Pearls & Oy-sters: Fibrocartilaginous embolism myelopathy

Abstract

CLINICAL PEARL Fibrocartilaginous embolism myelopathy is a stroke syndrome, characterized by rapidly progressive paraplegia (hours to 2-3 days) following an episode of back pain (mostly after a minor trauma).1 CSF studies are normal and MRI shows T2 hyperintensity in the spinal cord with associated swelling, diffusion restriction, and often presence of Schmorl's nodes at the level of injury.1 CASE REPORT A 25-year-old man with no significant past medical history and an active lifestyle presented to the hospital with a complaint of bilateral lower extremity numbness and weakness. Three days prior, the patient slipped while getting out of his truck and fell into a split position. Immediately afterwards he felt a sudden pain in his left groin with associated paraesthesia and weakness initially in his left thigh. Within several hours, the weakness and paraesthesia spread over the entire left leg and 24 hours later to the right leg. He also felt his bladder was full and lost control of his flatulence.The patient was a well-developed man in mild distress with normal vital signs. On neurologic examination, mental status and cranial nerves were normal. Manual motor testing of his upper extremities was unremarkable. Testing of his lower extremities revealed increased tone bilaterally. In the right lower extremity his iliopsoas was 4/5, hamstrings were 4ϩ/5, quadriceps were 4ϩ/5, tibialis anterior was 5/5, and gastrocnemius was 5/5. In the left lower extremity, his iliopsoas was 1/5, hamstrings were 4Ϫ/5, quadriceps were 4Ϫ/5, tibialis anterior was 4/5, and gastrocnemius was 4ϩ/5. Muscle bulk was normal. Rectal sphincter tone was diminished. He had no adventitial movements. Deep tendon reflexes were 2ϩ/4 in the upper extremities and 4ϩ/4 in the lower extremities bilaterally, with several beats of ankle clonus and bilateral extensor response in the toes. Sensory examination revealed intact vibration, proprioception, and pain and temperature sensation in the upper extremities bilaterally. There was an L1 sensory level involving pinprick and temperature testing. Proprioception and vibration were intact. Light touch elicited dysesthesias in the left lower extremity. Coordination was intact. The patient was able to sit up with assistance but was not able to bear any weight on his legs.The patient was admitted to a telemetry unit and had a thoracolumbar spine MRI, which showed a hyperintense T2 signal in the central and left posterior aspect of the cord from T9 through T11, slightly greater in the craniocaudal dimension. There were Schmorl's nodes at the inferior T10, superior T11, inferior T11, and superior T12 end plates (figure). Axial and sagittal MRI T1 pre-and post-gadolinium images did not show any evidence of enhancement at the level corresponding to the T2 hyperintensity. A lumbar puncture revealed an opening pressure of 29 cm of water with CSF analysis showing leukocytes 2/L, erythrocytes 4/L, glucose 63 mg/dL, and protein 44 mg/dL. CSF Lyme antibody was negative. CSF myelin basic protein was elevated at 307 ng/mL. CS...

Fibrocartilaginous Embolism of The Spinal Cord - A Case Report

“…Fibrocartilaginous embolism is a rare clinical entity, having only a few cases reported in the literature [1,2,5]. Little is known about the condition, and disseminating knowledge about it is important so as to improve diagnostic accuracy and make it possible for specific therapies to be developed [1,6].…”

“…The first case was reported in 1961 by Naiman et al [1,3,5,7]. After that, only a few cases were reported in the literature and most of those patients died of neurologic complications [1][2][3][4][5].…”

“…This entity is characterized by a sudden onset of clinical signs following a traumatic episode, with a peak of neurologic deficit in the first hours / days and usually normal CSF tests. Radiologically, it presents typical imaging findings (on MRI) that lead to the presumptive diagnosis of spinal cord ischemia caused by fibrocartilaginous emboli [5].…”

“…Its incidence is bimodal, affecting both adolescents and older adults [1,3,5] due to the characteristics of spinal cord vascularization in each of these age groups [3,5]. Low-energy traumas can cause rupture of the annulus fibrosus, with subsequent displacement of emboli from the nucleus pulposus of intervertebral discs to the inside of the arterial branches that supply the spinal cord parenchyma, causing arterial occlusion and subsequent spinal cord ischemia [1][2][3]5].…”

“…Low-energy traumas can cause rupture of the annulus fibrosus, with subsequent displacement of emboli from the nucleus pulposus of intervertebral discs to the inside of the arterial branches that supply the spinal cord parenchyma, causing arterial occlusion and subsequent spinal cord ischemia [1][2][3]5].…”