Spinal cord infarction: clinical and magnetic resonance imaging findings and short term outcome

Sildenafil-induced spinal cord infarction: a case report

Spinal cord infarction is a rare condition, accounting for only a small percentage of strokes. It can be classified into cervical and thoracolumbar infarctions, with various factors contributing to its occurrence. Sildenafil, a phosphodiesterase type 5 inhibitor commonly used for erectile dysfunction, has been associated with cardiovascular side effects, including transient hypotension. In this case report, we present the unusual occurrence of spinal cord infarction in a 65-year-old man who had self-administered high doses of sildenafil without a doctor's prescription. The patient experienced severe radicular pain in the lumbar region and subsequent weakness in the lower limbs. Evaluation revealed an anterior spinal cord infarction in the thoracic region, confirmed by MRI imaging. After excluding other potential causes, it was concluded that the intake of sildenafil likely led to systemic hypotension, resulting in spinal cord infarction. This case highlights the importance of considering sildenafil as a possible contributor to spinal cord infarction, particularly when used at high doses. Further studies are needed to better understand the relationship between sildenafil and vascular complications, including spinal cord infarction.

Anterior Spinal Cord Infarction: A Rare Diagnosis With an Uncommon Presentation

Spinal cord infarction (SCI) is a rare vascular event accounting for 1% of all strokes. Neurological syndromes may vary according to the arterial territory involved. This condition may differ in onset, severity, and recovery, making it a diagnostic challenge for clinicians. Diagnosis is made on a clinical basis, and neuroimaging (magnetic resonance imaging (MRI)) provides confirmatory evidence. A 72-year-old male, with a medical history of being overweight, hyperuricemia, dyslipidemia, and cigarette smoking presented to our emergency department (ED) with sudden-onset leg weakness. He reported chest pain with radiation to the back, followed by sudden arm and leg weakness, evolving to inferior limb plegia within four hours. He also noticed a loss of sensation below the breast region. On admission, vital signs were stable. Neurological examination demonstrated paraplegia of inferior limbs with absent deep tendon reflexes. Both pinprick, vibrational, and proprioceptive sensitivities were absent below T6. A diagnostic workup revealed lactescent serum suggesting severe hypertriglyceridemia. A clinical diagnosis of spinal cord infarction was made, which was later confirmed with MRI demonstrating an acute ischemic lesion in the anterior spinal artery (ASA) with the "owl's eye" sign, from T5 with extension to the cone. Neurological examination remained unaltered. He started aspirin and insulin perfusion. Since spinal cord injury is an uncommon cause of paraplegia, physicians should be extremely cautious. Despite the results of magnetic resonance imaging, the clinical picture was not consistent, which was finally explained by perilesional edema. To our knowledge, this is a rare case combining SCI with hypertriglyceridemia. Notwithstanding the lack of evidence linking reducing triglyceride levels to neurological recovery, insulin infusion was carried out given the hazards associated with sustaining such high levels of triglycerides. We aim to emphasize some characteristic MRI findings and the wealth of possible etiologies contributing to this clinical entity.

Clinical manifestations and magnetic resonance imaging features of spinal cord infarction

BACKGROUND AND OBJECTIVE

Spinal cord infarction (SCI) is a rare type of stroke, with no proposed classification or diagnostic criterium widely accepted and used in daily clinical practice currently. We try to explore the clinical manifestations and MRI features of SCI for improving the accurate diagnosis of SCI.

METHODS

Retrospectively analyzed the clinical data, MRI features, laboratory findings and outcomes of 40 patients who had been consecutively diagnosed with SCI in our hospital from June 2016 to January 2022.

RESULTS

Most of the SCI (92.5%) occurred at the level of T8-L2 and C4-T4. Transverse infarction (52.5%) and ASA territory infarction (27.5%) were the most common patterns. Longitudinally extensive lesions were noticed in 67.5% of the SCI and it might be a risk factor of poor prognosis (OR=21.11, 95%CI 2.14-208.29). Restricted diffusion of the SCI lesion occurred in 8h and a few lasted up to 60 days. All SCI showed spinal cord edema, accompanied by enhancement of the ventral cauda equina (13.8%), weakened enhancement of the dorsal venous plexus (44.8%), and vertebral infarction (25%). Most patients developed a stroke-like onset (92.5%) after movement (57.5%), with definite pain in the trunk or limbs (67.5%) and dissociative sensory disturbance (60.0%). The main etiologies of them include vascular abnormalities (45%) and iatrogenic injuries (15%).

CONCLUSION

An MRI classification of SCI based on the spinal cord blood supply was proposed. Restricted diffusion and co-existing abnormality of vertebral body and cauda equina may be the key neuroimaging feature for SCI diagnosis. Detailed history of vascular diseases or triggering factors are also helpful.

Spinal cord ischemia - from diagnosis to treatment

Purpose

The aim of the article is to outline the frequency of the occurrence, course, diagnosis and possible treatment of spinal cord ischemia (SCI) on the basis of a literature overview and to raise awareness of this rare yet devastating condition.

Views

SCI, when compared to cerebral stroke, is a relatively rare disease, being diagnosed 100 times less often. Our knowledge as to its root causes, proper treatment for it and long-term prognosis is still inconclusive. Magnetic resonance imaging with diffusion- weighted contrast is a main tool with which to confirm SCI and rule out a broad spectrum of possible alternative diagnoses. SCI is a condition in which prompt recognition, accurate diagnostic steps, and reperfusion therapy are essential to ensure a desirable functional outcome and reduce mortality and disability. Although there are no specific guidelines regarding treatment, the administration of rt-PA might be an effective therapy for acute ischemic stroke, preventing permanent spinal dysfunction. In surgical causes close cooperation between a neurologist and a neurosurgeon is necessary to provide combined appropriate management promptly.

Conclusions

Due to the relative rarity of SCI, multi-center studies of ischemia of the spinal cord and its treatment would be advisable in neurological practice to enhance current knowledge. A rapid diagnosis is crucial for appropriate care and desirable long-term outcomes.

Spontaneous spinal cord infarction: a systematic review

Background and objectives

Spontaneous spinal cord infarction (SCInf) is a rare condition resulting in acute neurological impairment. Consensus on diagnostic criteria is lacking, which may present a challenge for the physician. This review aims to analyse the current literature on spontaneous SCInf, focusing on epidemiology, the diagnostic process, treatment strategies and neurological outcomes.

Methods

The study was performed in accordance with a previously published protocol. PubMed, Web of Science and Embase were searched using the keywords 'spontaneous', 'spinal cord', 'infarction' and 'ischaemic'. The eligibility of studies was evaluated in two steps by multiple reviewers. Data from eligible studies were extracted and systematically analysed.

Results

440 patients from 33 studies were included in this systematic review. Analysis of vascular risk factors showed that hypertension was present in 40%, followed by smoking in 30%, dyslipidaemia in 29% and diabetes in 16%. The severity of symptoms at admission according to the American Spinal Injury Association (ASIA) Impairment Scale was score A 19%, score B14%, score C36% and score D32%. The mean follow-up period was 34.8 (±12.2) months. ASIA score at follow-up showed score A 11%, score B 3%, score C 16%, score D 67% and score E 2%. The overall mortality during the follow-up period was 5%. When used, MRI with diffusion-weighted imaging (DWI) supported the diagnosis in 81% of cases. At follow-up, 71% of the patients were able to walk with or without walking aids.

Conclusion

The findings suggest a significant role for vascular risk factors in the pathophysiology of spontaneous SCInf. In the diagnostic workup, the use of DWI along with an MRI may help in confirming the diagnosis. The findings at follow-up suggest that neurological recovery is to be expected, with the majority of patients regaining ambulation. This systematic review highlights gaps in the literature and underscores the necessity for further research to establish diagnostic criteria and treatment guidelines.

Spinal Cord Infarction Thrombolysed at Seven Hours: A Case Report and Review of Literature

We report a case of acute spinal cord infarction treated with intravenous (IV) thrombolysis at seven hours from symptom onset. Nineteen previously thrombolysed cases are reviewed. The patient underwent a clinical assessment, followed by an MRI of the spine. He was thrombolysed with a recombinant tissue plasminogen activator. Neurological severity was assessed at presentation and 24 hours using the National Institute of Health Stroke Scale (NIHSS), and disability at three months was evaluated using a modified Rankin scale (mRS). A middle-aged man presented with acute-onset paraplegia (NIHSS 9). MRI with T2-weighted sagittal, axial, and diffusion-weighted images showed hyperintensity from D10 to LI vertebral levels. He was thrombolysed at 428 minutes, leading to mild clinical improvement at 24 hours (NIHSS 7). At three months, he could walk with support (mRS 3). Nineteen cases of acute spinal cord infarction treated with IV thrombolysis have been reported. Clinical outcome at three months is available for 16 patients: seven (44%) had a good outcome (mRS 0-2); this is the first reported case of spinal cord infarction treated with thrombolysis at seven hours. Clinical trials to confirm the efficacy and safety of thrombolysis in spinal cord infarcts are needed.

It Looks Like a Spinal Cord Tumor but It Is Not

Differentiating neoplastic from non-neoplastic spinal cord pathologies may be challenging due to overlapping clinical and radiological features. Spinal cord tumors, which comprise only 2-4% of central nervous system tumors, are rarer than non-tumoral myelopathies of inflammatory, vascular, or infectious origins. The risk of neurological deterioration and the high rate of false negatives or misdiagnoses associated with spinal cord biopsies require a cautious approach. Facing a spinal cord lesion, prioritizing more common non-surgical myelopathies in differential diagnoses is essential. A comprehensive radiological diagnostic approach is mandatory to identify spinal cord tumor mimics. The diagnostic process involves a multi-step approach: detecting lesions primarily using MRI techniques, precise localization of lesions, assessing lesion signal intensity characteristics, and searching for potentially associated anomalies at spinal cord and cerebral MRI. This review aims to delineate the radiological diagnostic approach for spinal cord lesions that may mimic tumors and briefly highlight the primary pathologies behind these lesions.

Unilateral Anterior Spinal Artery Syndrome following Spinal Anesthesia for Cesarian Section: A Case Report

Introduction

Spinal cord infarction is a rare but serious neurologic complication of spinal anesthesia. Direct vessel injury, intra-arterial anesthetic injection, and anesthetic-induced local hypotension are potential mechanisms of infarction during this procedure. The proximity of the artery of Adamkiewicz to the spinal levels used for spinal anesthesia may also play a role. This case of unilateral anterior spinal artery syndrome highlights the potential for an atypical pattern of injury and deficits due to the complexity of the spinal cord's anterior circulation.

Case Presentation

We present a 38-year-old female patient who presented with left lower extremity weakness, loss of temperature sensation, and urinary retention following spinal anesthesia for cesarian section. Magnetic resonance imaging of the spine demonstrated T2 hyperintensities in the left central spinal cord from T8 to the conus medullaris. A diagnosis of spinal cord infarction was made after lumbar puncture testing showed no evidence of inflammatory myelitis. The patient was treated with steroids empirically until lumbar puncture testing showed no inflammation. The patient was discharged on daily aspirin with persistent left lower extremity weakness and loss of temperature sensation. A plan for outpatient physical therapy was made for rehabilitation.

Conclusion

Awareness of the potential for spinal cord infarction secondary to spinal anesthesia must increase among anesthesiologists, obstetricians, and neurologists. The risk of systemic hypotension during and after spinal anesthesia is important to recognize for both primary and secondary prevention of this complication. The hyperacute onset of myelopathic symptoms should point neurologists to investigate an ischemic etiology in the proper clinical context.

Troublemaking Lesions: Spinal Tumor Mimics

There are various mass-like lesions that can mimic true neoplasms in the spine, including inflammatory, infectious, vascular, congenital, and degenerative etiologies. While some lesions have distinctive imaging features that suggest a correct diagnosis, others have overlapping characteristics that do not allow their differentiation based solely on their imaging findings. For entities with nonspecific imaging features, knowledge of the clinical and laboratory information is critical to provide an accurate diagnosis.

Spontaneous spinal cord infarctions: a systematic review and pooled analysis protocol

INTRODUCTION

Spinal cord infarction (SCInf) is a rare ischaemic event that manifests with acute neurological deficits. It is typically classified as either spontaneous, defined as SCInf without any inciting event, or periprocedural, which typically occur in conjunction with vascular surgery with aortic manipulations. While periprocedural SCInf has recently been the subject of intensified research, especially focusing on the primary prevention of this complication, spontaneous SCInf remains less studied.

METHODS AND ANALYSIS

Electronic databases, including PubMed, Web of Science and Embase, will be searched using the keywords "spinal cord", "infarction", "ischemia" and "spontaneous". The search will be set to provide only English studies published from database inception. Editorials, letters and reviews will also be excluded. Reference lists of relevant records will also be searched. Identified studies will be screened for inclusion, by one reviewer in the first step and then three in the next step to decrease the risk of bias. The synthesis will address several topics of interest including epidemiology, presentation, diagnostics, treatment strategies, outcomes and predictors. The review aims to gather the body of evidence to summarise the current knowledge on SCInf. This will lead to a better understanding of the condition, its risk factors, diagnosis and management. Moreover, the review will also provide an understanding of the prognosis of patients with SCInf with respect to neurological function, quality of life and mortality. Finally, this overview of the literature will allow the identification of knowledge gaps to help guide future research efforts.

ETHICS AND DISSEMINATION

Ethics approval was not required for our review as it is based on existing publications. The final manuscript will be submitted to a peer-reviewed journal.

Spinal Cord Infarct Due to Fibrocartilaginous Embolism in an Adolescent Boy: A Case Report and Literature Review

Fibrocartilaginous embolism (FCE) is one of the rare causes of acute spinal cord infarction. We report the case of a previously healthy 14-year-old boy with this condition. A few hours after lifting heavy objects, he developed sudden quadriparesis. On examination, he had asymmetric hypotonic quadriparesis and normal dorsal column function but absent spinothalamic function in all limbs with sensory level to shoulder. Magnetic resonance imaging (MRI) of the spine confirmed the diagnosis of spinal infarction secondary to FCE. The patient initially received methylprednisolone and plasma exchange. A follow-up visit after neurorehabilitation showed improvement but with residual neurological deficit. Although FCE is rare, it should be kept as one of the differential diagnoses of an acute neurological deficit of the spinal cord.

Spontaneous conus infarction with "snake-eye appearance" on magnetic resonance imaging: A case report and literature review

BACKGROUND

Infarction of the conus medullaris is a rare form of spinal cord infarction. The first symptom is usually acute non-characteristic lumbar pain, followed by lower limb pain, saddle numbness, fecal incontinence, and sexual dysfunction. Spontaneous conus infarction with "snake-eye appearance" on magnetic resonance imaging has rarely been reported.

CASE SUMMARY

We report a 79-year-old male patient with spontaneous conus infarction who had acute lower extremity pain and dysuria as the first symptoms. He did not have any recent history of aortic surgery and trauma. Magnetic resonance imaging revealed a rare "snake-eye appearance." In addition, we reviewed the literature on 23 similar cases and summarized the clinical features and magnetic resonance manifestations of common diseases related to the "snake-eye sign" to explore the etiology, imaging findings, and prognosis of spontaneous conus infarction.

CONCLUSION

We conclude that acute onset of conus medullaris syndrome combined with "snake-eye appearance" should be strongly suspected as conus medullaris infarction caused by anterior spinal artery ischemia. This special imaging manifestation is helpful in the early diagnosis and treatment of conus infarction.

Correlation between "Snake-Eyes" Sign and Role of Surgery with a Focus on Postoperative Outcome: A Systematic Review

(1) Background: The "snake-eyes" sign represents a unique finding characterized by bilateral hyperintense symmetric, circular, or ovoid foci on T2-weighted MRI sequences in the anterior horn cells of the spinal cord. There are conflicting opinions as some authors affirm that it does not affect the prognosis of cervical myelopathy while other papers emphasize the opposite, stating how the "snake-eyes" sign constitutes an irreversible lesion and a predictor of poor prognosis. This systematic review evaluates the correlation between the "snake-eyes" sign and the prognosis of cervical myelopathy after surgery including anterior and/or posterior approaches; (2) Methods: A systematic literature review was conducted following the PRISMA statement and a total of seven papers were included; (3) Results: A total of 419 patients were evaluated, with a mean age of 55.72 ± 14.38 years. After surgery, 26.01% of patients experienced a significant clinical improvement, while in 61.81%, there was no significant improvement. In particular, 144 of 196 patients (73.5%) treated through an anterior approach and 114 of 223 (51.1%) that underwent a posterior approach, did not present a significant improvement. Furthermore, in 12.17% of patients, the postoperative outcome was not reported, leading to a high risk of bias in the assessment of the prognostic significance of the "snake-eyes" appearance; (4) Conclusions: The "snake-eyes" sign is usually considered as an unfavorable predictive marker for myelopathic surgical patients, but the pathophysiology is still unclear, and the results have not yet reached unified levels of evidence.

Postpartum Spinal Cord Infarction: A Case Report and Review of the Literature

Background: Postpartum spinal cord infarction is a very rare disease. Only two cases have been reported in the English literature. Methods: We reported a 26 year old female who received second doses of the mRNA-1273 vaccine 52 days before delivery. She presented as sudden onset of paraplegia, sensory level, and sphincter incontinence at postpartum period. No history of heparin exposure was noted. Imaging findings confirmed the T10-11 level infarction and her anti-human heparin platelet factor 4 (anti-PF4) antibody was positive. After 7 days of dexamethasone therapy, her paraplegia and urinary incontinence gradually improved. Results: The CT angiography (CTA) of the artery of Adamkiewicz (Aka) showed tandem narrowing, most conspicuous at the T10-11 level, which was presumably due to partial occlusion of the arteriolar lumen. The thoracolumbar spine magnetic resonance imaging with contrast medium showed owl's eyes sign at the T10 and T11 levels. We compared our case with two other case reports from the literature. Conclusions: Post-partum spinal cord infarction with positive anti-PF4 antibody and relatively thrombocytopenia are the characteristics of our case.

Neurosarcoidosis presenting as longitudinally extensive myelitis: Diagnostic assessment, differential diagnosis, and therapeutic approach

Neurosarcoidosis is an uncommon and multiform clinical entity. Its presentation as an isolated longitudinal extensive transverse myelitis (LETM) is rare and challenging to identify. We report a case of LETM in a 60-year-old patient with no significant systemic symptoms nor relevant medical history. The peculiar spinal magnetic resonance imaging finding characterized by a posterior and central canal subpial contrast enhancement, the so-called “trident sign,” together with chest computed tomography scan and lymph node biopsy led to the diagnosis of sarcoidosis. We also discuss the main differential diagnoses of LETM and therapeutic options for sarcoidosis-related myelitis.

Spontaneous spinal cord infarction: a practical approach

Spontaneous spinal cord infarction is significantly less common than cerebrovascular disease. Because of the tight anatomical distribution of pathways in the cord, small spinal cord infarcts usually give more obvious symptoms and signs than similar lesions in the brain. Large epidemiological stroke studies have generally not included spinal cord stroke and so the incidence of vascular syndromes in the spinal cord is unknown. Management and prevention strategies for spontaneous spinal cord infarcts stem from small case series and case reports. Patient outcomes from spinal cord infarction are better with prompt recognition, timely management and prevention of associated medical complications arising from paraplegia, tetraplegia, neurogenic bladder and bowel dysfunction. The process of rehabilitation following spinal cord infarction is an evolving area.

Spontaneous spinal cord infarction in Austria: a two-center comparative study

Background:

Spinal cord infarction (SCI) is a neurological emergency associated with high rates of persistent neurological deficits. Knowledge about this rare but potentially treatable condition needs to be expanded.

Objective:

To describe the characteristics of spontaneous SCI in a large retrospective series of patients treated at two tertiary care centers in Austria.

Methods:

We performed a descriptive and comparative analysis of spontaneous SCI treated at the University Hospitals of Salzburg and Graz between the years 2000 and 2020. The analysis included pre- and in-hospital procedures, clinical presentation, etiology, diagnostic certainty, reperfusion therapy, and functional outcome at discharge.

Results:

We identified 88 cases, 61% were ascertained in the second half of the study period. The median age was 65.5 years [interquartile range (IQR) = 56–74], 51.1% were women. Anterior spinal artery infarction was the predominant syndrome (82.9%). Demographics, vascular comorbidities, and clinical presentation did not differ between the centers. The most frequent etiology and level of diagnostic certainty were distinct, with atherosclerosis (50%) and definite SCI (42%), and unknown (52.5%) and probable SCI (60%) as front runners in Salzburg and Graz, respectively. Patients arrived after a median of 258.5 min (IQR = 110–528) at the emergency room. The first magnetic resonance imaging (MRI) of the spinal cord was performed after a median of 148 min (IQR = 90–312) from admission and was diagnostic for SCI in 45%. Two patients received intravenous thrombolysis (2.2%). The outcome was poor in 37/77 (48%).

Conclusion:

Demographics, clinical syndromes, and quality benchmarks for spontaneous SCI were consistent at two Austrian tertiary care centers. Our findings provide the foundation for establishing standards for pre- and in-hospital care to improve outcomes.

Acute spinal cord infarction after multilevel en bloc corpectomy: a case report and literature review

Spinal cord infarction (SCI) is a catastrophic neurologic deficit following spine surgery. Because of the opposite management regimens used for SCI and acute epidural hematoma, accurate diagnosis of SCI is of great importance to maximally reserve neurologic functions and improve outcomes. A 21-year-old man developed acute paralysis and sensory deficits of the bilateral lower limbs shortly after undergoing two-stage combined posterior and anterior multilevel en bloc corpectomy. An emergency second-look surgery revealed wide-spectrum blackness of the thecal sac with no signs of an epidural hematoma. The patient underwent anticoagulation therapy, ventilation support, microcirculation perfusion, and fluid optimization. He regained an ambulatory status without other severe complications. Upon discharge, his muscle strength had returned to grade 4 and his Eastern Cooperative Oncology Group performance score had decreased to 0. At the final 48-month follow-up, the implants were in good position without local recurrence, and the patient was able to lead an independent life and work in his full capacity. An epidural hematoma did not appear to be the cause of SCI after spinal tumor surgery in this case; however, SCI was a possible reason for the acute paralysis. Anticoagulation treatment with adjuvant therapies may be an effective option in managing SCI.

Role of the Cervical Anterior Spinal Artery in the Endovascular Treatment of Vascular Diseases: Bystander, Accomplice, Victim, or Friend?

The cervical anterior spinal artery (ASA) is a very important artery arising from the intracranial vertebral artery (VA). It can play different roles in endovascular treatment (EVT) of spinal vascular diseases. The current understanding of these roles is incomplete; therefore, we performed this review. We found that cervical ASA can be involved in many spinal vascular diseases, such as arteriovenous fistula (AVF), arteriovenous malformation (AVM), and aneurysm, and can serve as a collateral channel in proximal VA occlusion. In AVF and AVM, when the cervical ASA is involved, it often plays the role of an accomplice or victim because it acts as the feeder or as a bystander that does not provide blood flow to the AVF and AVM. In cervical ASA aneurysm, the ASA is a victim. During EVT of VA aneurysms or stenoses, the cervical ASA ostia can be covered or occluded, resulting in ASA ischemia. In this situation, the ASA is a victim. In VA occlusion or the subclavian steal phenomenon, the cervical ASA can serve as a collateral channel to provide blood flow to the posterior circulation. In this case, the ASA plays the role of a friend. According to the role of the cervical ASA in spinal vascular diseases, EVT should be determined “case by case.” Most importantly, when EVT is performed to treat these diseases, the cervical ASA axis must be preserved. Therefore, understanding the role of the cervical ASA in spinal vascular diseases is crucial.

Spinal Cord Ischemia Secondary to Aortic Dissection: Case Report with Literature Review for Different Clinical Presentations, Risk Factors, Radiological Findings, Therapeutic Modalities, and Outcome

Aortic dissection (AD) is a serious condition that causes transient or permanent neurological problems that include spinal cord ischemia (SCI), which occurs when AD extends into the descending aorta resulting in insufficient perfusion of segmental arteries that supplies the spinal cord. We report a 64-year-old male, presented with severe back pain, asymmetrical paresthesia, and weakness of both limbs, more in the left lower limb with loss of pinprick, temperature, and fine touch sensation on the lower left lower limb below the level of T5 with preserved proprioception and vibration and urine hesitancy. Computed tomography showed AD, Stanford type A, and spinal magnetic resonance imaging (MRI) showed hyperintense owl's eye sign at T5. The patient was diagnosed as anterior spinal artery syndrome secondary to an AD and referred for aortic surgical repair with good functional outcome. In our review to cases of SCI due to AD, it was more common in males above 55 years, pain only found in 47.8% of patients, with anterior cord syndrome on top of the clinical presentations, and hypertension is the most common risk factor. MRI spine showed thoracic location predominance. Surgical or endovascular repair especially for type A and complicated type B should be considered to avoid complications, and cerebrospinal fluid drainage is a very useful tool in reversing SCI specially if done early with favorable outcome. Only the old age is associated with increased risk of mortality. Early diagnosis and appropriate management are crucial for better outcome.

Spinal cord infarction in a young adult: What is the culprit?

Context: Non-traumatic spinal cord infarction in the young adult is usually associated with a single or multiple genetic mutations. There are certain gene mutations that are more commonly associated with spinal cord infarctions. Homozygous or heterozygous mutations, and single mutations or polymorphism, do not seem to determine the probability of spinal cord infarction.Findings: We add another case of spinal cord infarction in a young adult to the few reported in the literature, and discuss the value of genetic studies and genetic counseling.Conclusion: Non-traumatic spinal cord infarction is usually caused by a genetic mutation. Early recognition of this entity and definition of the mutation will limit unnecessary and invasive procedures and allows early rehabilitation, preventive measures for complications and genetic counseling.

Pediatric Spinal Cord Diseases

Spinal cord diseases in pediatric patients are highly variable in terms of presentation, pathology, and prognosis. Not only do they differ with respect to each other but so too with their adult equivalents. Some of the most common diseases are autoimmune (ie, multiple sclerosis, acute disseminated encephalomyelitis, and acute transverse myelitis), congenital (ie, dysraphism with spina bifida, split cord malformation, and tethered cord syndrome), tumor (ie, juvenile pilocytic astrocytoma, ependymoma, and hem-angioblastoma), and vascular (ie, cavernous malformations, arteriovenous malformations, and dural arteriovenous fistulas) in nature. These each require their own niche treatment paradigm and prognosis. Furthermore, presentation of different spinal cord diseases in children can be difficult to discern without epidemiologic and imaging data. Interpretation of these data is crucial to facilitating a timely and accurate diagnosis. Correspondingly, the aim of this review was to highlight the most pertinent features of the most common spinal cord diseases in the pediatric population.

Isolated Infarctions of the Conus Medullaris: Clinical Features and Outcomes

OBJECTIVE

This study aims to describe the clinical features and outcomes of patients with isolated infarctions of the conus medullaris, and to identify factors associated with poor functional outcomes.

MATERIALS AND METHODS

We performed a systematic review and retrospective analysis on the clinical characteristics and outcomes of patients with isolated conus medullaris infarctions reported in literature over the past 30 years.

RESULTS

We analyzed a total of 19 cases; 18 identified in literature from January 1991 to June 2021, together with our patient. Their median age was 56 years (range 28-79), with twice as many females as males. Pain was prominent at onset (15/19, 79%), only a third had vascular risk factors (7/19, 37%), and half had no significant preceding activities or events (9/19, 47%). Almost all experienced paraplegia or paraparesis (16/19, 84%), in which upper motor neuron features were rare (3/19, 16%). The underlying cause was unknown in half (10/19, 53%). Functional outcomes appeared fair, with nearly half being capable of unassisted ambulation (9/11, 82%). Patients with vascular risk factors (67% vs 13%, p = 0.024) or with identified underlying causes (78% vs 13%, p = 0.007) were less likely to walk unassisted.

CONCLUSION

Isolated conus medullaris but should be considered in patients with acute cauda equina syndrome, especially in females. Patients with vascular risk factors, or with known causes of infarction, are less likely to walk unassisted. DWI sequences should be included in conventional MRI sequences when evaluating patients with acute cauda equina syndrome.

Postoperative spinal cord ischaemia: magnetic resonance imaging and clinical features

OBJECTIVES

Ischaemic spinal cord injury (SCI) is one of the most serious complications of aortic surgery. Ischaemic SCIs occur due to various aetiologies, and prediction of the risk is difficult. Magnetic resonance imaging (MRI) is useful to detect the details of spinal cord infarction. There are few studies about MRI for evaluating ischaemic SCI after cardiovascular surgery and aortic events. We report 9 cases of postoperative ischaemic SCI and analyse their MRI features.

METHODS

T2-weighted MRI scans of 9 patients who developed ischaemic SCI due to cardiovascular surgery and aortic events between 2012 and 2017 were evaluated.

RESULTS

In all patients, high-intensity areas were observed on T2-weighted magnetic resonance images. The site of infarction was the thoracic spinal cord level (9 cases) and additionally at the lumbar spinal cord level (5 cases). The area of infarction area was categorized based on the arterial territory: anterior spinal artery territory (3 cases), posterior spinal artery territory (2 cases), spinal sulcal artery territory (1 case) and artery of Adamkiewicz territory (3 cases).

CONCLUSIONS

MRI revealed the infarction sites in all cases and the differences in the infarction patterns in each case. MRI could thus be useful for investigating the aetiology of ischaemic SCI following aortic surgeries and events.

Non-traumatic spinal cord infarction of the conus medullaris in a child: a case report

INTRODUCTION

The etiologies of pediatric spinal cord infarction are commonly cardiovascular problems resulting from hypotensive events from trauma and abdominal aortic surgery. Non-traumatic spinal cord infarction in children is rare and remains difficult to diagnose. We report a case of non-traumatic spinal cord infarction of the conus medullaris in a child who recovered after receiving only rehabilitative treatment.

CASE PRESENTATION

A 12-year-old female patient experienced sudden low back pain for 2 days, followed by weakness in the lower extremities and difficulties in micturition. On admission, magnetic resonance imaging indicated spinal cord infarction of the conus medullaris. After initial treatment with prednisone and mannitol, a few weeks of intensive rehabilitation was recommended. Physical therapy focused on improving lower limb strength. A plastic solid ankle-foot orthosis was used with Lofstrand crutches throughout the period of rehabilitation. After 2 months of rigorous therapy, she was able to walk independently.

DISCUSSION

Non-traumatic spinal cord infarction of the conus medullaris in children is extremely rare. The current case is unique because it involves a patient who presented with pediatric spinal cord infarction of the conus medullaris and showed remarkable neurological recovery after rehabilitation. The case describes a rare spinal cord infarction in a pediatric patient and emphasizes the importance of providing an accurate diagnosis and treatment.

Acute Myelopathy: Vascular and Infectious Diseases

Vascular and infectious causes are rare but important causes of spinal cord injury. High suspicion for these processes is necessary, as symptoms may progress over hours to days, resulting in delayed presentation and diagnosis and worse outcomes. History and clinical examination findings can assist with localization of the affected vascular territory and spinal level, which will assist with focusing spinal imaging. Open and/or endovascular surgical management depends on the associated vascular abnormality. Infectious myelopathy treatment consists of targeted antimicrobial therapy when possible, infectious source control, and again, close monitoring for systemic complications.

Anti-MOG antibody associated long segment myelitis presenting as anterior cord syndrome

A patient having clinical features reminiscent of anterior cord syndrome (ACS) was found to have long segment myelitis on MRI. Investigations revealed serum anti-myelin oligodendrocyte glycoprotein (MOG) antibody positivity. He was treated with pulse methylprednisolone followed by immunosuppressant therapy with mycophenolate mofetil, which led to clinical recovery. Anterior cord syndrome has so far not been reported in the context of anti-MOG antibody associated disease.

Spinal cord infarction. A case report and narrative review

Spinal cord infarction is a rare but severe disorder, consistently less frequent than ischemic brain injury. It constitutes only 1-2% of all neurological vascular emergencies. Here we describe a case of spinal cord infarction in a 68-year-old Caucasian man without any neurological problem in his clinical history. The patient presented to the Emergency Department complaining for sudden onset of lower limbs weakness, as well as pain and mild loss of sensitivity in both legs. These symptoms suddenly arose after a 10 minutes bicycle race. He underwent a CT angiography, which confirmed the presence of a fusiform aneurysm of infra-renal abdominal aorta with thrombotic apposition on right lateral side and some ulcerated thrombi. As such, the patient underwent a spinal cord Magnetic Resonance Imaging, that showed images compatible with an acute ischemic injury (infarction) from D11 to medullary cone. He was then treated with low molecular weight heparin, aspirin, and methylprednisolone, and was then admitted to the Stroke Unit. He gradually regained lower limbs sensitivity totally, but the strength was only partially restored. Although a rare entity, Emergency Physicians should always keep in mind this possibility when evaluating patients with sudden loss of sensitivity and/or strength in their lower limbs. (www.actabiomedica.it)

Normal anterior-posterior diameters of the spinal cord and spinal canal in healthy term newborns on sonography

BACKGROUND

There are no published normal values for spinal cord and canal diameters in newborns. Spinal cord and spinal canal diameters are assessed subjectively by radiologists without any objective values for the upper limit of normal.

OBJECTIVE

To determine normal values for anteroposterior (AP) diameters of the spinal cord and spinal canal on sonography in healthy term newborns.

MATERIALS AND METHODS

We performed ultrasound of the entire spine on 37 healthy newborns (23 male, 14 female). The AP diameters of the spinal canal and spinal cord were measured at representative levels of the cervical (C4, C5, C6), thoracic (T5, T6, T7, T8) and lumbar spine (lumbar enlargement and above and below the lumbar enlargement level). Statistical analysis was performed to determine the mean and standard deviation of the spinal canal and spinal cord AP diameter at each aforementioned vertebral level, and their correlations with birth weight, length and head circumference.

RESULTS

The mean AP spinal cord diameter was 4.1±0.5 mm at the cervical level, 3.3±0.3 mm at the thoracic level and 4.4±0.6 mm at the lumbar level. The mean AP spinal canal diameter was 7.7±0.7 mm at the cervical level, 6.2±0.8 mm at the thoracic level, and 8.4±0.7 mm at the lumbar level.

CONCLUSION

In this prospective study, we have determined normal values for AP diameters of the spinal cord and spinal canal on sonography in healthy newborns at representative cervical, thoracic and lumbar levels. This data may assist in evaluating the neonatal spine in clinical situations such as suspected spinal cord injury.

Sulcal artery syndrome: A Three-patient series and review of literature

OBJECTIVE

This study aims to describe the clinical characteristics of patients with sulcal artery syndrome, and between those with vertebral artery dissection against those without.

METHODS

We report three cases of sulcal artery syndrome without vertebral artery dissection, performed a systematic review and retrospective analysis of the characteristics of patients with sulcal artery syndrome in available literature, and compared the clinical features of those with vertebral artery dissection against those without.

RESULTS

We report 3 patients with sulcal artery syndrome, and analysed them with 17 other cases identified in literature between January 1990 till April 2020. The mean age was 47 years (range 10-80), with twice as many males as females. Pain at onset was a prominent feature (17/18, 94.4%). Preceding trauma occurred in less than half (7/18, 38.9%). Most had cervical cord infarctions (18/20, 90%), often over the high cervical cord (16/18, 88.9%). Good functional recovery (mRS 0-2) was observed in 86.7% (13/15). While vertebral artery dissection was the leading aetiology (11/20, 55.5%), about half of the cases were due to other causes. Cervical cord involvement was significantly associated with vertebral artery dissection (p = 0.026).

CONCLUSION

Sulcal artery syndrome should be suspected in patients with acute hemicord syndrome, especially in males with cervical cord involvement or pain at onset. High cervical cord involvement was strongly suggestive of underlying vertebral artery dissection. Additionally, DWI sequences are useful when evaluating acute myelopathies, and its inclusion in conventional MRI sequences is supported in prevailing literature.

Spinal infarcts

Compared to cerebral ischaemia, the frequency of spinal cord ischaemia is rare. Spinal infarcts lead to various types of neurological deficits, usually consisting of an abrupt and complete tetra- or paraplegia. Magnetic resonance imaging is the most valuable tool to show the infarct and to rule out other causes of acute spinal cord syndromes., such as myelitis or acute compressions. Nowadays, in western countries, most spinal cord infarcts are due to aortic diseases (atherosclerosis, aneurysm, dissection) or are of iatrogenic origin (mainly aortic surgery and interventional radiology), while other causes are rare. There is no specific treatment, besides prevention of complications, treatment of the underlying cause and rehabilitation.

Diffusion Tensor Imaging of the Spinal Cord

Spinal cord often is regarded as one of the last territories in the central nervous system where diffusion tensor imaging (DTI) can be used to probe white matter architecture. This article reviews current progress in spinal cord DTI, starting with anatomic properties and technical challenges that make spinal cord DTI a difficult task. Several possibilities offered by advanced pulse sequences that might overcome the difficulties are addressed, with associated trade-offs and limitations. Potential clinical assistance also is discussed in various spinal cord pathologies, such as myelopathy due to external compression, spinal cord tumors, acute ischemia, traumatic injury, and so forth.

Unilateral Upper Cervical Cord Infarction: A Report of Two Cases with Mild Neurological Symptoms Accompanying a Small Ischemic Lesion Detected by Brain MRI

Spinal cord infarction (SCI) is rare, difficult to diagnose, and often fails to be detected by diffusion-weighted imaging (DWI) of spinal cord magnetic resonance imaging (MRI). Because the clinical features of SCI can vary widely, diagnosis during the acute phase of SCI is often challenging for clinicians. Although SCI shares similar etiologies with cerebral infarction, the characteristics of SCI without vessel dissection remain largely unknown. We present two older patients with mild neurological symptoms who each presented with a small, unilateral, upper cervical cord lesion, which was detected by thin-section, coronal DWI of brain MRI. Both unilateral small lesions were localized in the right lateral funiculus, and each patient showed good prognosis. The anatomical findings suggested that the pial collateral network surrounding the cervical cord contributed to lesion formation. Small and localized lesions have been associated with mild neurological symptoms and better short-term prognosis. The present report indicated that the use of thin-section coronal DWI when performing brain MRI may be helpful for the diagnosis of small, unilateral, upper cervical cord infarctions.

Acute Spinal Cord Infarction with Preferential Involvement of Ventral Gray Matter: An Autopsy Report

Herein, we report abdominal aortic thrombosis as a rare cause of acute spinal cord infarction. A 78-year-old man with multiple vascular risk factors developed acute paraplegia with sensory and urinary disturbances and signs of ischemia in both lower limbs. The post-mortem study done 3 days after the onset of symptoms revealed a large coagulum in the abdominal aorta, distal to the renal arteries and extending to bilateral common iliac arteries; in addition, marked atherosclerosis was present in most large blood vessels. Premature incomplete necrotic foci were seen in the ventral gray matter of the spinal cord from T6 through S5; the surrounding white matter and dorsal gray matter were spared. Considering our autopsy case, spinal cord gray matter may be more vulnerable to ischemia than the white matter.

Etiology and Outcomes of Spinal Cord Infarct: A Case Series From a Level 1 Trauma Center

STUDY DESIGN

Retrospective study.

OBJECTIVES

To evaluate the demographics, prevalence, etiology, severity, and outcomes of spinal cord injuries (SCIs) resulting from ischemic infarction.

METHODS

All patients with SCI and a diagnosis of cord infarct who were admitted to the inpatient rehabilitation unit at a level 1 trauma center from January 2003 to January 2014 were identified using an administrative billing database. Outcomes measures were evaluated.

RESULTS

Among 685 unique SCI patients who were identified, 30 (4.4%) had SCI due to spinal ischemic infarction. The mean age was 59 years (range 17-80 years). Fifty percent of patients had ASIA (American Spinal Injury Association) A and B severity. Most common causes were the following: 6 (20%) abdominal aortic aneurysm (AAA) repairs, 6 (20%) arteriovenous fistulas, and 6 (20%) with an unknown cause. Surgical complications led to 4 (13.3%) cord infarcts and was associated with a higher severity of injury (P = .02) compared with other etiologies. Other causes included systemic hypotension, AAA rupture, trauma, diabetic ketoacidosis, and after radiation therapy. At follow-up, 6 (20%) of patients were able to ambulate normally without assistance, 7 (23.3%) were ambulating with assistance, and 17 (56.7%) were still wheelchair bound. Clinical improvement in ambulatory status was noted in 6 (20%) patients and was associated with less severe initial injury (P = .02).

CONCLUSIONS

While the existing literature associates spinal cord infarction with aortic pathologies and surgery, these caused less than 30% of cases, while nonaortic surgical complications were associated with the most severe injuries. Outcomes were worse than previously reported in the literature.

Diagnostic Approach to Intrinsic Abnormality of Spinal Cord Signal Intensity

Intramedullary cord hyperintensity at T2-weighted MRI is a common imaging feature of disease in the spinal cord, but it is nonspecific. Radiologists play a valuable role in helping narrow the differential diagnosis by integrating patient history and laboratory test results with key imaging characteristics. The authors present an algorithmic approach to evaluating intrinsic abnormality of spinal cord signal intensity (SI), which incorporates clinical evaluation results, time of onset (acute vs nonacute), cord expansion, and pattern of T2 SI abnormality. This diagnostic approach provides a practical framework to aid both trainees and practicing radiologists in workup of myelopathy.^©RSNA, 2019.

Anterior Spinal Artery Syndrome: Rare Precedented Reason of Postoperative Plegia After Spinal Deformity Surgery: Report of 2 Cases

BACKGROUND

Complications in spinal deformity surgery vary from insignificant to severe. Apart from direct mechanical insult, ischemia can also cause spinal cord injury. Ischemic injury may be detected during surgery or may manifest itself postoperatively. We present 2 cases of anterior spinal artery syndrome.

CASE DESCRIPTION

In the first case, a 12-year-old girl developed anterior spinal artery syndrome resulting in total quadriplegia 8 hours after spinal deformity surgery. She was treated with a steroid, immunoglobulin, and low-molecular-weight heparin. She showed complete recovery at 1 year postoperatively both clinically and radiographically. In the second case, a 62-year-old woman experienced sudden loss of motor evoked potentials intraoperatively during dural tear repair after sagittal and coronal alignment was established. The paraplegic patient was diagnosed with anterior spinal artery syndrome at the thoracic level postoperatively. She was treated with a steroid and heparin. At 1 year postoperatively, she has gained much of her strength and has myelomalacia in her spinal cord.

CONCLUSIONS

Anterior spinal artery syndrome is a serious condition with a generally poor prognosis. Though treatment should be directed at the underlying cause, the best strategy is to prevent it from occurring. Peroperative blood pressure control, intraoperative neuromonitoring, avoidance from mechanical stress during surgery, and close neurologic and hemodynamic monitorization postoperatively should be performed.

Clinically suspected concomitant spinal cord and vertebrobasilar infarctions caused by fibrocartilaginous embolism

Fibrocartilaginous embolism (FCE) is a rare and probably under diagnosed cause of spinal cord infarction presumably due to acute embolization of nucleus pulposus fragments into the spinal circulation. Concomitant cerebral involvement is much rarer and often asymptomatic. Although the definitive diagnosis is histologic, certain criteria have been proposed to support the diagnosis in living patients, such as absence of vascular risk factors, acute onset or antecedent of valsalva maneuver before the episode and the exclusion of potential differential diagnoses. A 56 years-old patient, without any medical history was referred for sudden back pain while carrying heavy load at work. Clinical examination showed a Brown-Sequard syndrome. Brain and spine MRI disclosed spinal cord infarction at the C4-C5 level associated with brain infarctions involving exclusively the vertebrobasilar circulation. The exhaustive etiological assessment was normal. In our case, the acute symptoms onset, the clinical and imaging data and lack of evidence for other plausible diagnoses in the setting of a valsalva-like maneuver are highly suggestive of FCE diagnosis.

Clinical, Radiologic, and Prognostic Features of Myelitis Associated With Myelin Oligodendrocyte Glycoprotein Autoantibody

Importance

Recognizing the characteristics of myelin oligodendrocyte glycoprotein autoantibody (MOG-IgG) myelitis is essential for early accurate diagnosis and treatment.

Objective

To evaluate the clinical, radiologic, and prognostic features of MOG-IgG myelitis and compare with myelitis with aquaporin-4-IgG (AQP4-IgG) and multiple sclerosis (MS).

Design, Setting, and Participants

We retrospectively identified 199 MOG-IgG-positive Mayo Clinic patients from January 1, 2000, through December 31, 2017, through our neuroimmunology laboratory. Fifty-four patients met inclusion criteria of (1) clinical myelitis; (2) MOG-IgG positivity; and (3) medical records available. We excluded 145 patients without documented myelitis. Myelitis of AQP4-IgG (n = 46) and MS (n = 26) were used for comparison.

Main Outcomes and Measures

Outcome variables included modified Rankin score and need for gait aid. A neuroradiologist analyzed spine magnetic resonance imaging of patients with MOG-IgG and control patients blinded to diagnosis.

Results

Of 54 included patients with MOG-IgG myelitis, the median age was 25 years (range, 3-73 years) and 24 were women (44%). Isolated transverse myelitis was the initial manifestation in 29 patients (54%), and 10 (19%) were initially diagnosed as having viral/postviral acute flaccid myelitis. Cerebrospinal fluid-elevated oligoclonal bands occurred in 1 of 38 (3%). At final follow-up (median, 24 months; range, 2-120 months), 32 patients (59%) had developed 1 or more relapses of optic neuritis (n = 31); transverse myelitis (n = 7); or acute disseminated encephalomyelitis (n = 1). Clinical features favoring MOG-IgG myelitis vs AQP4-IgG or MS myelitis included prodromal symptoms and concurrent acute disseminated encephalomyelitis. Magnetic resonance imaging features favoring MOG-IgG over AQP4-IgG or MS myelitis were T2-signal abnormality confined to gray matter (sagittal line and axial H sign) and lack of enhancement. Longitudinally extensive T2 lesions were of similar frequency in MOG-IgG and AQP4-IgG myelitis (37 of 47 [79%] vs 28 of 34 [82%]; P = .52) but not found in MS. Multiple spinal cord lesions and conus involvement were more frequent with MOG-IgG than AQP4-IgG but not different from MS. Wheelchair dependence at myelitis nadir occurred in one-third of patients with MOG-IgG and AQP4-IgG but never with MS, although patients with MOG-IgG myelitis recovered better than those with AQP4-IgG.

Conclusions and Relevance

Myelitis is an early manifestation of MOG-IgG-related disease and may have a clinical phenotype of acute flaccid myelitis. We identified a variety of clinical and magnetic resonance imaging features that may help clinicians identify those at risk in whom MOG-IgG should be tested.

Clinical, neuroimaging, and nerve conduction characteristics of spontaneous Conus Medullaris infarction

Background

Spontaneous conus medullaris infarction is a rare disease. We describe two patients with spontaneous conus medullaris infarction presenting as acute cauda equina syndrome and their unique electromyography (EMG) findings.

Case presentation

Two patients developed acute low back pain with mild asymmetric paraparesis, loss of perianal sensation and sphincter dysfunction. Ankle deep tendon reflexes were reduced in bilaterally. Neither patient had cardiovascular risk factors. Magnetic Resonance imaging showed infarction in the conus medullaris. Functional recovery was good in both patients, but progressive asymmetric calf wasting and sphincter dysfunction remained. EMG studies at follow-up of at least 3 years demonstrate active denervation at the muscles innervated by the first sacrum anterior horn cells.

Conclusion

Spontaneous conus medullaris infarction can occur in healthy individuals and presents as cauda equina syndrome. Findings of needle EMG studies indicate a progressive course of sacrum anterior horn cell disorder during long-term follow-up.

Historical setting and neuropathology of lathyrism: Insights from the neglected 1944 report by Oliveras de la Riva

Lathyrism is a central motor system disorder recognized since antiquity resulting from prolonged dietary dependence on the grasspea (Lathyrus sativus). The neuropathology underlying the characteristic spastic paraparesis of lathyrism is sketchy. Described here is a landmark but little-known Spanish-language neuropathological study of two patients with lathyrism of recent onset. Due to erroneous interpretations of Filimonov's influential work in 1926, it was assumed that spastic paraparesis of lathyrism was explained by destruction of Betz's pyramidal cells in the motor cortex. Contrary to present understanding, Betz cells and anterior horn cells were preserved, and pathological findings dominated by myelin loss were largely limited to pyramidal tracts in the lumbar cord. Thickening of the adventitia of capillaries and arterioles, together with proliferation of perivascular astrocytes, was found along the length of the spinal cord. Oliveras de la Riva proposed that the segmental spinal pathology arose because distal regions of elongate pyramidal tract axons are distant from their trophic center in the motor cortex, a view not far from the current distal axonopathy concept of lathyrism. In addition, we review the historical circumstances of Filimonov's work in Russia, a summary of the epidemic of lathyrism in Spain following its Civil War (1936-1939), and some historical aspects of the Cajal Institute in Madrid, where Oliveras de la Riva's work was carried out under the supervision of Fernando de Castro, one of Cajal's favorite students.

Acute Spinal Cord Infarction Presenting With Chest Pain and Neurogenic Shock: A Case Report

BACKGROUND

Spinal cord infarction (SCI) is rare, accounting for approximately 1% of strokes.

CASE REPORT

We present the case of a 63-year-old male who presented to the emergency department (ED) with chest pain and acute-onset generalized weakness and was ultimately diagnosed with SCI secondary to suspected occlusion of the artery of Adamkiewicz. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: SCI may present diagnostic challenges, with its predilection for mimicking other major emergency conditions, such as acute aortic dissection, aortic aneurysm rupture, spinal cord compressive myelopathy, or transverse myelitis. Its consequences are often significantly disabling initially, though patients may experience subsequent clinical improvement. It is important to include SCI in the differential for patients with chest or back pain coupled with neurologic symptoms.

Spinal cord ischemia/infarct after cauda equina syndrome from disc herniation - A case study and literature review

Background

Spinal cord infarction is rare and occurs in 12/100,000; it represents 0.3%-2% of central nervous system infarcts. Here, we present a patient who developed recurrent bilateral lower extremity paraplegia secondary to spinal cord infarction 1 day after a successful L4-5 microdiscectomy in a patient who originally presented with a cauda equina syndrome.

Case Description

A 56-year-old patient presented with an acute cauda equina syndrome characterized by severe lower back pain, a right foot drop, saddle anesthesia, and acute urinary retention. When the lumbar magnetic resonance imaging (MRI) revealed a large right paracentral lumbar disc herniation at the L4-L5 level, the patient underwent an emergency minimally invasive right-sided L4-5 discectomy. Immediately, postoperatively, the patient regained normal function. However, 1 day later, while having a bowel movement, he immediately developed the recurrent paraplegia. The new lumbar MRI revealed acute ischemia and an infarct involving the distal conus medullaris. Further, workup was negative for a spinal cord vascular malformation, thus leaving an inflammatory postsurgical vasculitis as the primary etiology of delayed the conus medullaris infarction.

Conclusions

Acute neurologic deterioration after spinal surgery which does not neurologically correlate with the operative level or procedure performed should prompt the performance of follow-up MR studies of the neuraxis to rule out other etiologies, including vascular lesions versus infarctions, as causes of new neurological deficits.