Paraplegia with lumbar artery compression by the diaphragmatic crus

Retroperitoneal approach for the treatment of diaphragmatic crus syndrome: technical note

OBJECTIVE

Myelopathy selectively involving the lower extremities can occur secondary to spondylotic changes, tumor, vascular malformations, or thoracolumbar cord ischemia. Vascular causes of myelopathy are rarely described. An uncommon etiology within this category is diaphragmatic crus syndrome, in which compression of an intersegmental artery supplying the cord leads to myelopathy. The authors present the operative technique for treating this syndrome, describing their experience with 3 patients treated for acute-onset lower-extremity myelopathy secondary to hypoperfusion of the anterior spinal artery.

METHODS

All patients had compression of a lumbar intersegmental artery supplying the cord; the compression was caused by the diaphragmatic crus. Compression of the intersegmental artery was probably producing the patients' symptoms by decreasing blood flow through the artery of Adamkiewicz, causing lumbosacral ischemia.

RESULTS

All patients underwent surgery to transect the offending diaphragmatic crus. Each patient experienced substantial symptom improvement, and 2 patients made a full neurological recovery before discharge.

CONCLUSIONS

Diaphragmatic crus syndrome is a rare or under-recognized cause of ischemic myelopathy. Patients present with episodic acute-on-chronic lower-extremity paraparesis, gait instability, and numbness. Angiography confirms compression of an intersegmental artery that gives rise to a dominant radiculomedullary artery. Transecting the offending diaphragmatic crus can produce complete resolution of neurological symptoms.

Focal compression of the upper left thoracic intersegmental arteries as a potential cause of spinal cord ischemia

BACKGROUND AND PURPOSE

This study was prompted by recurrent angiographic observations of focal stenoses involving the proximal segment of the left upper thoracic intersegmental arteries, a few centimeters distal to their origin. The purpose was to investigate the nature and prevalence of this anomaly.

MATERIALS AND METHODS

The existence of non-ostial thoracic intersegmental artery stenoses was evaluated in 50 angiograms; the contribution of stenosed branches to the anterior spinal artery was recorded. Angiograms performed in 3 patients with right-sided aortas were also reviewed. The topographic relationships of the upper thoracic intersegmental artery with surrounding structures were investigated in 3 cadavers.

RESULTS

Thirty-seven non-ostial stenoses were found in 26 patients (52%), predominantly on the left side (92%), between T3 and T8, most frequently at T4 and T5 (54%). Severe lesions were observed in 10% of cases. Patients with stenoses had fewer detectable anterior radiculomedullary arteries between T3 and T5 (35% versus 54%). Upper intersegmental artery stenoses, documented on the left side of all 3 specimens, appeared to be caused by the recurrent path of these intersegmental arteries related to the leftward position of the thoracic aorta, and by their course around reinforced paramedian longitudinal strands of the endothoracic fascia.

CONCLUSIONS

Upper thoracic intersegmental artery stenoses are frequent. They result from the leftward deviation of the descending aorta and the existence of a fixed point along the course of the intersegmental arteries related to the endothoracic fascia. Because contributors to the spinal vascularization often originate at similar levels, these stenoses may play a role in the susceptibility of the upper and midthoracic spinal cord to ischemia.