Pain in the Back? It Could Be Spinal Cord Infarction
Pain in the Back? It Could Be Spinal Cord Infarction
Abstract & Commentary
By John J. Caronna, MD, Professor of Clinical Neurology, Weill Cornell Medical College. Dr. Caronna reports no financial relationships relevant to this field of study.
Synopsis: Although rare, spinal cord infarction should be considered in any patient with acute back or neck pain associated with paraparesis.
Source: Cheng MY, Lyu RK, Chang YJ, et al. Concomitant spinal cord and vertebral body infarction is highly associated with aortic pathology: A clinical and magnetic resonance imaging study. J Neurol [E-pub ahead of print, April 28, 2009].
Spinal cord infarction (SCI) is uncommon compared to cerebral stroke, and accounts only for about 1% of all strokes.1 SCI due to occlusion of the anterior spinal artery (ASA) characteristically presents with sudden back pain and bilateral leg weakness. On neurological examination, there is flaccid paraplegia, areflexia, loss of pain and temperature sensation below the level of the lesion with sparing of proprioception and vibration sense, and autonomic dysfunction involving the bladder and bowel. Atherosclerosis and hypertension occur in approximately 50% of cases of SCI, and disease of the aorta is the most common location of pathology.2
The authors previously reviewed the clinical features, risk factors, imaging, and prognosis of these Chinese patients with SCI.3 In the present report, they investigated the relationship between the clinical features and imaging characteristics of SCI.
Twenty patients (11 women, nine men) with SCI were diagnosed at a university hospital in Taiwan between 1993 and 2007. Their average age was 56.6 ± 15.5 years. The cause of SCI was found in 16 patients (80%), including eight with a high risk of atherosclerosis (40%), and five (25%) with aortic disease (dissection [3], aneurysm and atheroma [2]). Three patients (15%) had adjacent spinal diseases that might be related to their SCI: One had an odontoid fracture after chiropractic manipulation, another had traumatic T2-T3 spondylolisthesis, and the other developed a conus medullaris syndrome after heavy lifting. In four patients (20%), the cause of SCI could not be determined. All SCI patients had acute monophasic symptoms, and 14 (70%) described pain with SCI. Among these patients, lower cervical (6/14) and thoracolumbar infarctions (5/14) were more likely to present with pain.
Cervicothoracic SCI occurred in 10/20 (50%) patients, thoracolumbar lesions in eight (40%) and midthoracic SCI in two (10%). Most cervical SCIs were at C4-C7, while the thoracolumbar infarcts were at T9-T12. Nineteen patients (95%) had SCI in the distribution of the ASA. No posterior spinal artery distribution infarcts were observed.
Abnormal signal and enhancement on MRI produced a double dot or "owl's eyes" pattern in the region of the anterior horns in 13/14 cases of bilateral anterior SCI. In 2/3 cases of unilateral anterior SCI and in one half of patients with central SCI, only one "owl's eye" was present.
Seven (35%) patients had concomitant vertebral body infarction, usually in the thoracolumbar region. Hypertension and aortic disease greatly increased the risk of developing vertebral body infarction.
Twelve patients (60%) had poor outcomes (death, inability to walk, or ability to walk only with two aides), younger patients (≤ 55 years old) with long-cord lesions (≥ 3 vertebral segments) had poorer outcomes than older patients with short cord lesions.
Commentary
Patients in this series had acute monophasic symptoms, reaching nadir in < 24 hours. None had spinal TIAs or intermittent spinal claudication manifested by painless paraparesis or drop attacks.2 Many of these patients had acute neck or back pain near the level of their SCI that resolved spontaneously within days. In addition to neck pain, patients with SCI at lower cervical levels also reported chest, scapular, or even abdominal pain that could be mistaken for symptoms of cardiac or gastrointestinal origin. Patients with thoracolumbar SCI had back pain especially if an aortic dissection was present.
The patient who presents with acute paraparesis is a medical emergency that requires prompt evaluation and diagnosis to exclude the presence of spinal cord compression. Once the differential diagnosis is narrowed to ischemia, the treatment of SCI is similar to that employed in acute cerebral infarction. Extrapolation from the current management of cerebral stroke suggests that inhibition of platelet aggregation might be beneficial.
Unfortunately, because of its relative rarity, no study has yet addressed the role of anticoagulation or tPA in acute SCI.
References
1. Masson C, Psuro JP, Meder JF, et al. J Neurol Neurosurg Psychiatry 2004;75:1431-1435.
2. Cheshire WP, Santos CC, Massey EW, et al. Neurology 1996;47:321-330.
3. Cheng MY, Lyu RK, Chang YJ, et al. Cerebrovasc Dis 2008;26:502-508.
Although rare, spinal cord infarction should be considered in any patient with acute back or neck pain associated with paraparesis.Subscribe Now for Access
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