Fibrocartilaginous Embolism of the Spinal Cord in Children: A Case Report and Review of Literature

Abstract

Fibrocartilaginous embolism (FCE) is assumed to be caused by the migration of fibrocartilaginous nucleus pulposus components through retrograde embolization to the spinal cord artery. FCE is currently not well recognized among pediatricians due to its rarity. We present the case of a previously healthy 15-year-old soccer player who, after kicking a ball, developed progressive weakness in both legs and ischuria the next day. Magnetic resonance imaging revealed T2 hyperintensity in the anterior horn of the spinal cord at the Th12/L1 level with Schmorl's node at the level of L1/2. We also reviewed previous literature of FCE of the spinal cord in children (<18 years of age), and a total of 25 pediatric patients, including our case, were reviewed. The median age was 14 years and 64% of the reviewed patients were female. The most common trigger event was intense exercise or sports (52%). The neurological symptoms started within 1 day in most cases and time to symptom peak varied from a few hours to 2 weeks. The most common initial neurologic symptoms were weakness or plegia (100%), followed by paresthesia or numbness (44%). Affected areas of the spinal cord were distributed evenly from the cervical to thoracolumbar regions. Although steroids and anticoagulants were most commonly used, the prognosis was quite poor (mostly mild to severe sequelae and 3 patients died). Although FCE is a very rare condition, pediatricians should be aware of the characteristics and include FCE of the spinal cord in their differential diagnosis, especially for physically active patients.

Pediatric fibrocartilaginous spine embolism induced by trauma

“…There is no well-defined treatment for fibrocartilaginous emboli within the spinal cord. Previous patients have been treated with anticoagulation therapy, corticosteroids, or even emergent surgery, however, there was no significant improvement in patients clinically [3] . Patients have also been managed in the long term with blood pressure control, physical therapy, and supportive care [3] .…”

“…Previous patients have been treated with anticoagulation therapy, corticosteroids, or even emergent surgery, however, there was no significant improvement in patients clinically [3] . Patients have also been managed in the long term with blood pressure control, physical therapy, and supportive care [3] . Our patient has been following physical therapy and occupational therapy as well as recommendations of physical rehabilitation specialists to develop strength in her distal upper extremities.…”

“…Fibrocartilaginous embolic infarction is a rare and often undiagnosed cause of spinal cord infarctions. It is a clinical diagnosis limited by definitive correlation via postmortem examination of the vascular supply to the spinal cord [3] . However, the diagnosis of fibrocartilaginous embolism should remain on the differential for acute paralysis or weakness from minor trauma or physical activity immediately preceding symptom onset [4] .…”

“…Diagnosing fibrocartilaginous emboli based on MRI is difficult as early stages of the infarction will present normally. The presence of a narrowed disk or Schmorl nodes in addition to expanding spinal cord with increased signal on T2 weighted image (T2WI) without early contrast enhancement is highly suggestive of a fibrocartilaginous embolus [3] . Repeat MRI with a T2WI sequence or enhanced MRI may be important.…”

Spinal Cord Infarct Due to Fibrocartilaginous Embolism

“…The proposed mechanism is increased intradisc or intravertebral body pressure by axial loading forces applied to the spine that propels the fibrocartilaginous nucleus pulposus into the spinal vasculature. [1][2][3] Diagnostic clues include acute bilateral weakness…”