Spinal Cord Infarction

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Spinal Cord Infarction

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A basic knowledge of the signs and symptoms of acute spinal cord dysfunction are required in order to perform a relevant history and physical examination. A spinal sensory level is classically found, but sensory complaints and findings limited to the distal extremities can also be seen early in the course of spinal infarction. Typically onset is apoplectic, evolving in minutes or a few hours to produce severe dysfuction of sensory and motor systems.

Occlusive vascular lesions affecting the spinal cord (spinal stroke) are diagnostic challenges. As is the case for the more common cerebrovascular accident affecting cerebral circulation, an acute onset is a clue to the diagnosis. The circulation to the spinal cord has unique features related to the rich anastomotic anatomy of the cord that result in relative rarity of spinal cord infarction in comparison to cerebral infarction, as described in the images below.

The anterior spinal artery is a single long anastomotic channel that lies at the mouth of the anterior central sulcus and supplies the circulation to the anterior two thirds of the spinal cord, shown below.

It gives origin to sulcal arteries that take an arching course to one or the other anterior gray horns. The posterior spinal arteries are smaller paired arteries lying just medial to the dorsal roots. The arterial supply of the spinal cord arises from the aorta and at its cephalad and caudal ends from tributaries of the subclavian and iliac arteries. Eight to ten unpaired anterior medullary arteries are branches of the larger afferent aorta and vertebral and iliac arteries. The largest anterior medullary artery, the great anterior medullary artery of Adamkiewicz, which is susceptible to occlusion with neurologic deficit, is located at the lumbar enlargement, usually at L2 on the left side (but may be at any point from T8 to L2).

United States

Spinal cord infarction is not common, but only fragmentary or indirect data are available on incidence or prevalence. A large study showed that only 9 of 3784 autopsies revealed spinal cord infarction, with a rate of occurrence of 0.23% at death. Conversely, if spinal stroke is approximately 1.2% of strokes, an overall annual incidence of 12 in 100,000 can be estimated.

International

International incidences are also unclear. Recent reports that describe patients developing spinal cord infarction in an increasing number of situations and pathologies would influence this because procedures ranging from major surgery to injections for epidural anesthesia, infections and especially meningitis, and medications vary in different countries.

The risk to life and its quality from spinal cord infarction is substantial because of the disability, which can be severe, with paraplegia, risk of pulmonary emboli, and risk of infection (eg, bladder, lungs, decubiti). However, no epidemiologic studies are available because of the relatively small number of patients affected.

Published series of reports of spinal cord infarction are relatively small, ranging up to 36-44 patients. [1] They find a mortality rate in the vicinity of 20-25% for patients admitted to hospital with spinal cord infarction. [2]  No relationship to age is reported. However, the reported series do have a median age of 52 years.

Although prognosis is guarded, with many or most patients remaining severely weak and with with severe bladder dysfunction, up to one-third to one-half of patients experience slow recovery of at least a moderate nature.

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Thomas F Scott, MD Professor, Program Director, Department of Neurology, Drexel University College of Medicine; Director, Allegheny MS Treatment Center

Thomas F Scott, MD is a member of the following medical societies: American Academy of Neurology, American Neurological Association, Consortium of Multiple Sclerosis Centers, National Multiple Sclerosis Society Advisory Board, Allegheny Chapter

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Howard S Kirshner, MD Professor of Neurology, Psychiatry and Hearing and Speech Sciences, Vice Chairman, Department of Neurology, Vanderbilt University School of Medicine; Director, Vanderbilt Stroke Center; Program Director, Stroke Service, Vanderbilt Stallworth Rehabilitation Hospital; Consulting Staff, Department of Neurology, Nashville Veterans Affairs Medical Center

Howard S Kirshner, MD is a member of the following medical societies: Alpha Omega Alpha, American Neurological Association, American Society of Neurorehabilitation, American Academy of Neurology, American Heart Association, American Medical Association, National Stroke Association, Phi Beta Kappa, Tennessee Medical Association

Disclosure: Nothing to disclose.

Helmi L Lutsep, MD Professor and Vice Chair, Department of Neurology, Oregon Health and Science University School of Medicine; Associate Director, OHSU Stroke Center

Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology, American Stroke Association

Disclosure: Medscape Neurology Editorial Advisory Board for: Stroke Adjudication Committee, CREST2; Executive Committee for the NINDS-funded DEFUSE3 Trial; Physician Advisory Board for Coherex Medical.

Norman C Reynolds, Jr, MD Neurologist, Veterans Affairs Medical Center of Milwaukee; Clinical Professor, Medical College of Wisconsin

Norman C Reynolds, Jr, MD is a member of the following medical societies: American Academy of Neurology, Association of Military Surgeons of the US, International Parkinson and Movement Disorder Society, Sigma Xi, Society for Neuroscience

Disclosure: Nothing to disclose.

Spinal Cord Infarction

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