Presentation
Rapid onset lower back pain, bilateral lower limb weakness and reduced sensation over the S1-3 dermatomes.
Patient Data
Poorly-defined, non-contiguous foci of high T2w signal within the lower cord and conus medullaris, predominantly located anteriorly. A characteristic 'owl eye' appearance is demonstrated at the T12 level. There is associated expansion of the cord. No clear evidence of increased T1w signal to indicate hemorrhage and no enhancement of the lesions post-contrast. The discontinuous nature of the lesions is against an ischemic etiology, while the lack of contrast-enhancement is against an intramedullary tumor. Demyelination or myelitis cannot be excluded based on current imaging.
Incidental degenerative spondylotic changes at L4/L5 and L5/S1, accompanied by Modic type 1 changes.
Follow-up imaging was performed.
Largely unchanged appearances of the high T2w signal foci within the lower spinal cord. The axial sequences demonstrate that these foci are located centrally within the cord. Previously, the largest focus was relatively ill-defined and anteriorly located. The current appearances are of a well-defined lesion with extension to the anterior margin of the cord and central CSF intensity gliosis, suggestive of a mature infarct. These findings are in keeping with multiple spinal cord infarcts that have now matured in appearance.
Case Discussion
Spinal cord ischemia presents with acute onset back pain, bilateral weakness and paresthesia. Loss of sphincter control and inability to void or defecate may develop later. Differential diagnoses include acute transverse myelopathy, myelitis, Guillain-Barré syndrome and mass lesions. However, these conditions usually develop with an acute but slower evolution than spinal cord infarction.
The etiology for spinal cord ischemia is the same as that for stroke. Atherosclerotic thromboembolic disease and primary hemorrhage are the most common causes, with aneurysms, AVMs and hemangiomas also responsible for a minority of cases.
The spinal cord is supplied by the anterior spinal artery and the paired posterior spinal arteries, which form anastomoses. The anterior spinal artery is formed at the foramen magnum by branches from the vertebral arteries and receives further segmental radicular arteries from the aorta along its length, with the largest radicular artery being the artery of Adamkiewicz.
Anterior cord syndrome is the most common presentation of spinal ischemia, with posterior cord syndrome being very rare. Anterior cord syndrome is characterized by loss of motor function and loss of sensations carried by the anterior columns of the spinal cord (pain and temperature) below the level of injury with preservation of sensations carried by the posterior columns (fine touch, vibration and proprioception).
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