Spinal cord infarction (ischemic myelopathy)

Spinal cord infarction is usually caused by damage to the extravertebral arteries. Symptoms include sudden and severe back pain, bilateral flaccid limb paresis, decreased (loss) sensitivity, particularly pain and temperature. Diagnosed by MRI. Treatment is symptomatic in most cases.

The posterior third of the spinal cord is supplied with blood by the posterior spinal artery, the anterior two thirds by the anterior spinal artery. The anterior spinal artery has several afferent arteries in the upper cervical region and one large afferent artery (the artery of Adamkiewicz) in the lower thoracic region. The afferent arteries arise from the aorta. Since the collateral blood supply of the anterior cerebral artery basin is scattered, there are segments of the spinal cord (e.g., from the 2nd to the 4th thoracic segments) that are especially sensitive to ischemia. Damage to the extravertebral afferent arteries or the aorta (e.g., due to atherosclerosis, dissection, prolonged clamping during surgery) causes infarction more often than damage to the spinal arteries themselves. Thrombosis is an uncommon cause, polyarteritis nodosa is rare.

Sudden back pain with encircling irradiation and a sensation of a constricting band, followed by segmental bilateral muscle weakness and sensory disturbances. Pain and temperature sensitivity decrease disproportionately, the most typical being damage to the anterior spinal artery, causing anterior spinal syndrome. Positional and vibration sensitivity transmitted along the posterior columns, and often tactile sensitivity, are relatively preserved. If the infarction is small and the tissues affected are at the greatest distance from the occluded artery, central spinal cord syndrome may develop. Neurological deficits may partially regress during the first few days.

Infarction may be suspected in the presence of acute, severe back pain in association with characteristic neurological deficits. Diagnosis requires MRI. Acute transverse myelitis, spinal cord compression, and demyelinating diseases may cause similar clinical symptoms, which usually develop gradually and are excluded by MRI and cerebrospinal fluid analysis. Rarely, the causes of infarction may be curable (eg, aortic dissection, polyarteritis nodosa), but most often treatment is symptomatic (supportive).

Spinal cord syndromes

Syndrome	Cause	Symptoms
Anterior spinal cord syndrome	Spinal cord involvement is disproportionate to anterior spinal artery involvement, usually caused by occlusion of the anterior spinal artery prior to infarction.	Tendency to dysfunction of all tracts except the posterior columns, with preservation of positional and vibration sensitivity
Central spinal cord syndrome	Lesion of the central spinal cord, primarily the central gray matter and crossed spinothalamic tracts; usually caused by trauma, syringomyelia, and tumors of the central spinal cord	Paresis more severe in the upper than in the lower limbs and sacral regions; a tendency toward decreased pain and temperature sensitivity in a jacket pattern, extending to the neck, shoulder, and lower torso, with relative preservation of tactile, positional, and vibration sensitivity (dissociated sensory disorder)
Conus medullaris syndrome	Lesion in the T12 vertebra area	Distal paresis of the legs, decreased sensitivity in the perianal area, erectile dysfunction, urinary retention, hypotension of the anal sphincter
Transverse myelopathy	Lesion of the entire transverse diameter of the spinal cord over at least one segment	Decreased function of all spinal cord functions (since all tracts are affected to varying degrees)
Brown-Sequard syndrome (rare)	Half (one-sided) spinal cord injury, usually caused by penetrating trauma	Ipsilateral paresis, ipsilateral loss of tactile, positional, vibration sensitivity, contralateral - loss of pain and temperature sensitivity (partial Brown-Sequard syndrome is possible)

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