Ischemic Spinal Cord Infarction in Children Without Vertebral Fracture

Abstract

Spinal cord infarction in children is a rare condition which is becoming more widely recognized. There are few reports in the pediatric literature characterizing etiology, diagnosis, treament and prognosis. The risk factors for pediatric ischemic spinal cord infarction include obstruction of blood flow associated with cardiovascular compromise or malformation, iatrogenic or traumatic vascular inujury, cerebellar herniation, thrombotic or embolic disease, infection, and vasculitis. In many children the cause of spinal cord ischemia in the absence of vertebral fracture is unknown. Imaging diagnosis of spinal cord ischemia is often difficult due to the small transverse area of the cord, cerebrospinal fluid artifact and inadequate resolution of MRI. Physical therapy is the most important treatment option. The prognosis is dependent on the level of spinal cord damage, early identification and reversal of ischemia, and follow-up with intensive physical therapy and medical support. In addition to summarizing the literature regarding spinal cord infarction in children without vertebral fracture, this review article adds two cases to the literature which highlight the difficulties and controversies in the management of this condition.

Fibrocartilaginous embolism: a cause of acute ischemic myelopathy

“…1,2 The abruptness of symptom onset in this case suggests a vascular etiology. Ischemic spinal cord infarction can be caused by decreased blood flow due to hypotension, vascular injury, compression, other impairment or thromboembolism to spinal arteries.…”

“…Ischemic spinal cord infarction can be caused by decreased blood flow due to hypotension, vascular injury, compression, other impairment or thromboembolism to spinal arteries. 1 Acute transverse myelitis is unlikely, as the diagnostic criteria were not fulfilled. 3 Occasionally, acute myelopathy may be misdiagnosed as Guillain-Barre syndrome, as acute spinal shock may present with flaccid paraparesis.…”

“…Prognosis is favorable (54% of patients with spinal cord infarction show improvement) as seen in our patient. 1 …”

“…Imaging of spinal cord ischemia is often difficult because of its small transverse area, cerebrospinal fluid artifact and inadequate resolution of magnetic resonance imaging (MRI). 1 We report a case of ischemic myelopathy secondary to presumptive fibrocartilaginous embolism (FCE) on the basis of the typical clinical and radiological features.…”

Case 2: Acute paralysis in a 10-year-old girl

“…Risk factors for this condition were outlined after a recent review of 108 case reports; the most common etiologies were found to be bacterial meningitis, fibrocartilaginous embolism, umbilical arterial catheters and minor trauma (3). There are a small number of case reports describing children with SCIWORA following minor trauma; the exact etiology of spinal cord infarction following minor trauma is not well understood (3). A proposed mechanism is that the relatively inelastic spinal cord is strained inside the more flexible spinal column during either hyperflexion or hyperextension resulting in reactive vasospasm or compression of vertebral and/or spinal arteries.…”