Spectrum of spinal cord involvement in COVID-19: A systematic review

  1. Ritwick Mondal
  2. Shramana Deb
  3. Gourav Shome
  4. Upasana Ganguly
  5. Durjoy Lahiri
  6. Julian Benito Leon

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Abstract

Background and aims

Recent reports reveal incidences of spinal cord involvement in form of para-infectious or post-infectious myelitis raising potential concerns about the possibilities of SARS-CoV-2 behind the pathogenesis of spinal cord demyelination. In this study, we intend to summarise so far available pieces of evidence documenting SARS-CoV-2 mediated spinal demyelination in terms of clinical, laboratory parameters and imaging characteristics.

Methodology

This review was carried out based on the existing PRISMA (Preferred Report for Systemic Review and Meta-analyses) consensus statement. Data was collected from four databases: Pubmed/Medline, NIH Litcovid, Embase and Cochrane library and Preprint servers up till 10 th September, 2020. Search strategy comprised of a range of keywords from relevant medical subject headings which includes “SARS-COV-2”, “COVID-19”, “demyelination” etc.

Results

A total of 21 cases were included from 21 case reports after screening from various databases and preprint servers. Biochemical analysis reveals that the majority of cases showed elevated CSF protein as well as lymphocytic pleocytosis. Interestingly, a majority of cases were found to be associated with long extensive transverse myelitis (LETM), and remaining cases were found to be associated with isolated patchy involvement or isolated short segment involvement or combined LETM and patchy involvement. Few cases were also found with significant co-involvement of the brain and spine based on the imaging data.

Conclusion

It can be interpreted that SARS-CoV-2 may play a potential role in spinal demyelinating disorders in both para-infectious and post-infectious forms.

Highlights

  • Imaging data reveals LETM, short and patchy involvements

  • Para infectious myelitis precedes post-infectious manifestation

  • Altered CSF parameters and myelitis-like symptoms at the onset of COVID-19

  • Similar spinal cord involvements in related HCoVs infections

Article activity feed

  1. ScreenIT

    SciScore for 10.1101/2020.09.29.20203554: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board Statementnot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    2.2 Search strategy: In this systemic review four databases: Pubmed/Medline, NIH LitCovid, Embase, and Cochrane Library were searched using pre-specified searching strategies, and this search was concluded on September 10, 2020.
    Embase
    suggested: (EMBASE, RRID:SCR_001650)
    Cochrane Library
    suggested: (Cochrane Library, RRID:SCR_013000)
    The search strategy consists of a variation of keywords of relevant medical subject headings (MeSH) and keywords, including “SARS-CoV-2”, “COVID-19”, “coronavirus”, “demyelinating disorders”, “Multiple sclerosis” and “Encephalomyelitis”.
    MeSH
    suggested: (MeSH, RRID:SCR_004750)
    We also hand-searched additional COVID-19 specific articles using the reference list of the selected studies, relevant journal websites, and renowned pre-print servers (medRxiv, bioRxiv, pre-preints.org) from 2019 to the current date for literature inclusion.
    bioRxiv
    suggested: (bioRxiv, RRID:SCR_003933)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    There are some implicit limitations in the present endeavor. Given the notable asymmetry between the total number of affected cases and reported cases of infection-related myelitis, it can be assumed that cases are presently under-reported which may be due to several reasons. Therefore, the present systematic review is based on a small number of cases even after an extensive search of available literature, both peer-reviewed, and pre-print. Also, several of the available reports do not describe the timeline of events in an organized manner making interpretation difficult. Laboratory features have also not been mentioned in detail in a few of the cases. In addition, there is considerable heterogeneity in the available data that may be considered a hindrance in advanced analysis. Despite these shortcomings, the present organized review will act as a preliminary guide for clinicians while dealing with suspected spinal cord demyelination in the context of SARS-CoV-2 infection.

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    About SciScore

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  2. Version published to 10.1101/2020.09.29.20203554v1 on medRxiv