Acute infarction of spinal cord

Neurology

Clinicals - History

Fact Explanation
Back pain Acute onset back pain is a common presenting complain of acute infarction of the spinal cord. This is due to ischemia of the spinal cord. However some patients may not manifest with pain. Back pain
Acute onset back pain is a common presenting complain of acute infarction of the spinal cord. This is due to ischemia of the spinal cord. However some patients may not manifest with pain.
Weakness Patient complains of bilateral symmetrical weakness (paraparesis or tetraparesis) or paralysis (paraplegia or tetraplegia) of the body. Weakness
Patient complains of bilateral symmetrical weakness (paraparesis or tetraparesis) or paralysis (paraplegia or tetraplegia) of the body.
Sensory loss There is bilateral and symmetrical sensory loss or impairment. Sensory loss
There is bilateral and symmetrical sensory loss or impairment.
Bladder dysfunction Depending on the area of the spinal cord involved, incontinence or retention of urine can also be associated with infarction. Bladder dysfunction
Depending on the area of the spinal cord involved, incontinence or retention of urine can also be associated with infarction.
Fecal incontinence Fecal incontinence develops with spinal infarction. Fecal incontinence
Fecal incontinence develops with spinal infarction.
Risk factors Diabetes, hypertension, coagulopathies and hypercholestrolemia are risk factors for the development of vascular infarctions.
Presence of arteriovenous fistula, polyarteritis nodosa, and carotid or vertebral artery dissection also put the patients at risk of spinal cord infarction. These conditions are common associations of spinal infarction among young patients.
Spinal surgery, cardiac surgery, surgery of the descending and thoracoabdominal aorta, arteriography and fibrocatilagenous embolism also increase the risk.
Presence of cardiac arrest and transient ischemic attacks also increases the risk of spinal cord infarction because of generalized hypotension.
Fibrocartilagenous emboli, arterial vascular malformations and syphilitic arteritis can also lead to spinal cord infarction.
Risk factors
Diabetes, hypertension, coagulopathies and hypercholestrolemia are risk factors for the development of vascular infarctions.
Presence of arteriovenous fistula, polyarteritis nodosa, and carotid or vertebral artery dissection also put the patients at risk of spinal cord infarction. These conditions are common associations of spinal infarction among young patients.
Spinal surgery, cardiac surgery, surgery of the descending and thoracoabdominal aorta, arteriography and fibrocatilagenous embolism also increase the risk.
Presence of cardiac arrest and transient ischemic attacks also increases the risk of spinal cord infarction because of generalized hypotension.
Fibrocartilagenous emboli, arterial vascular malformations and syphilitic arteritis can also lead to spinal cord infarction.
History of spinal disease Patients with a prior history of compression fractures of the spinal cord, spondylolisthesis, chronic arachonoiditis and chronic cervical disk protrusion can develop acute infarction of the spinal cord. History of spinal disease
Patients with a prior history of compression fractures of the spinal cord, spondylolisthesis, chronic arachonoiditis and chronic cervical disk protrusion can develop acute infarction of the spinal cord.

Clinicals - Examination

Fact Explanation
Body Mass Index (BMI) Obesity is an independent risk factor for the development of vascular infarctions. Body Mass Index (BMI)
Obesity is an independent risk factor for the development of vascular infarctions.
Features suggestive of metabolic syndrome Acanthosis nigricans, obesity, high blood pressure and pheripheral stigmata of hyperlipidemia (xantholesma, xanthomata) should be looked for. Features suggestive of metabolic syndrome
Acanthosis nigricans, obesity, high blood pressure and pheripheral stigmata of hyperlipidemia (xantholesma, xanthomata) should be looked for.
Muscle mass Muscle mass is not changed at the acute presentation. If muscle wasting, atrophy and fasciculations are evident other possible diagnosis should be considered of. However muscle wasting can be seen later, due to disuse atrophy in spinal cord infarction. Muscle mass
Muscle mass is not changed at the acute presentation. If muscle wasting, atrophy and fasciculations are evident other possible diagnosis should be considered of. However muscle wasting can be seen later, due to disuse atrophy in spinal cord infarction.
Muscle tone During the period of spinal shock, the muscles are flaccid. Once the spinal shock is recovered patient develops signs of upper motor neuron lesion. Muscle tone increases below the level of the infarct. Muscle tone
During the period of spinal shock, the muscles are flaccid. Once the spinal shock is recovered patient develops signs of upper motor neuron lesion. Muscle tone increases below the level of the infarct.
Muscle power Muscle power is markedly diminished. Muscle power
Muscle power is markedly diminished.
Tendon reflexes After the resolution of the spinal shock deep tendon reflexes become exaggerated below the level of the lesion. At the level of the lesion tendon reflexes are absent (lower motor neuron lesion). Tendon reflexes
After the resolution of the spinal shock deep tendon reflexes become exaggerated below the level of the lesion. At the level of the lesion tendon reflexes are absent (lower motor neuron lesion).
Vibration and proprioception Spinal cord infarction commonly involves the anterior columns with preserved posterior columns. So the vibration and proprioception, which is transmitted via the posterior column are usually preserved, so called dissociated sensory impairment. Vibration and proprioception
Spinal cord infarction commonly involves the anterior columns with preserved posterior columns. So the vibration and proprioception, which is transmitted via the posterior column are usually preserved, so called dissociated sensory impairment.
Touch, temperature and pain sensation Touch, temperature and pain sensation are absent below the level of the lesion. Touch, temperature and pain sensation
Touch, temperature and pain sensation are absent below the level of the lesion.

Investigations - Diagnosis

Fact Explanation
Full blood count Full blood count is helpful in diagnosing an infective etiology for the spinal infarction. White blood cell count is elevated in infections. Thrombocytopenia can be the causative factor for hemorrhagic infarction. Full blood count
Full blood count is helpful in diagnosing an infective etiology for the spinal infarction. White blood cell count is elevated in infections. Thrombocytopenia can be the causative factor for hemorrhagic infarction.
Serum electrolytes Elevated potassium levels can cause periodic paralysis and even acute flaccid paralysis. Hypokalemia is also associated with paralysis. Serum electrolytes
Elevated potassium levels can cause periodic paralysis and even acute flaccid paralysis. Hypokalemia is also associated with paralysis.
Fasting blood sugar Fasting blood sugar should be assessed in order to diagnose diabetes mellitus. Fasting blood sugar
Fasting blood sugar should be assessed in order to diagnose diabetes mellitus.
Lipid profile Hypercholestrolemia is a risk factor for the development of vascular infarcts. Lipid profile
Hypercholestrolemia is a risk factor for the development of vascular infarcts.
Cerebro-spinal fluid (CSF) full report In vasculitic etiologies, the opening pressure of CSF is increased. CSF protein and lymphocyte count are elevated. CSF sugar can be reduced in the presence of bacterial infection. Cerebro-spinal fluid (CSF) full report
In vasculitic etiologies, the opening pressure of CSF is increased. CSF protein and lymphocyte count are elevated. CSF sugar can be reduced in the presence of bacterial infection.
Autoantibodies Antineutrophil cytoplasmic antibody (ANCA) is strongly associated with the presence of vasculitis. Autoantibodies
Antineutrophil cytoplasmic antibody (ANCA) is strongly associated with the presence of vasculitis.
CT CT scan can detect the presence of arterial thrombi which favors the diagnosis of ischemic infarction. CT
CT scan can detect the presence of arterial thrombi which favors the diagnosis of ischemic infarction.
MRI MRI is useful to exclude other sinister and potentially reversible causes like epidural hematoma, vertebral fracture and other space occupying lesions. MRI
MRI is useful to exclude other sinister and potentially reversible causes like epidural hematoma, vertebral fracture and other space occupying lesions.
Spinal angiography Spinal angiography is useful in detecting the site of the lesion. Spinal angiography
Spinal angiography is useful in detecting the site of the lesion.

Investigations - Management

Fact Explanation
Activated partial thromboplastin time (aPTT) aPTT should be monitored in patients who are anticoagulated. Activated partial thromboplastin time (aPTT)
aPTT should be monitored in patients who are anticoagulated.
Psychiatric follow up Mood disorders, especially depression can be commonly occur after stroke due to sudden transition of life from being healthy to immobile and bed bound. Presence of mood disorders may adversely influence on physical, functional, and cognitive recovery. Early detection and treatment of mood disorders are really important in further management of patient. Psychiatric follow up
Mood disorders, especially depression can be commonly occur after stroke due to sudden transition of life from being healthy to immobile and bed bound. Presence of mood disorders may adversely influence on physical, functional, and cognitive recovery. Early detection and treatment of mood disorders are really important in further management of patient.
Group therapy Group therapy is one treatment modality used in rehabilitation of stroke patients. This enables emotional ventilation and encourages to do more physical activities with lesser stress. Group therapy can be combined with music and simple games to make it more interesting. Group therapy
Group therapy is one treatment modality used in rehabilitation of stroke patients. This enables emotional ventilation and encourages to do more physical activities with lesser stress. Group therapy can be combined with music and simple games to make it more interesting.
Physiotherapy Physiotherapy should be continued till the patient achieves adequate functional recovery. Physiotherapy
Physiotherapy should be continued till the patient achieves adequate functional recovery.

Management - Supportive

Fact Explanation
Initial monitoring Once the spinal cord infarction is suspected, initial imaging should be done to diagnose spinal infarction.
Initial neuroprotective strategies include, avoidance of hypotension as this can aggravate spinal ischemia.
Initial monitoring
Once the spinal cord infarction is suspected, initial imaging should be done to diagnose spinal infarction.
Initial neuroprotective strategies include, avoidance of hypotension as this can aggravate spinal ischemia.
Health education Patient education is important in managing spinal cord infarction, as immobility related to spinal infarction can lead to various complications like, urinary tract infections, pressure sores and muscle contractures.
Family members should also be educated about the prevention of possible complications of spinal cord infarction (maintenance of bladder care, skin care, and necessity of limb physiotherapy).
Dietary modifications that should be adhered to include, avoidance of high fat diet (fried food, processed meat, margarine) and increment of food and vegetables in diet.
Health education
Patient education is important in managing spinal cord infarction, as immobility related to spinal infarction can lead to various complications like, urinary tract infections, pressure sores and muscle contractures.
Family members should also be educated about the prevention of possible complications of spinal cord infarction (maintenance of bladder care, skin care, and necessity of limb physiotherapy).
Dietary modifications that should be adhered to include, avoidance of high fat diet (fried food, processed meat, margarine) and increment of food and vegetables in diet.
Psychological Support Spinal cord infarction results in significant psychological stress to the victim and to the family. Enough psychological support should be provided with empathy, encouraging patients to face the acute stress in their life. Patients should be referred to councilors, peer discussions and psychotherapy where necessary. Psychological Support
Spinal cord infarction results in significant psychological stress to the victim and to the family. Enough psychological support should be provided with empathy, encouraging patients to face the acute stress in their life. Patients should be referred to councilors, peer discussions and psychotherapy where necessary.
Occupational therapy Patients should be referred to occupational therapy to make them independent in their day-to-day activities. Occupational therapy
Patients should be referred to occupational therapy to make them independent in their day-to-day activities.
Deep vein thrombosis (DVT) prophylaxis Compression stockings and low molecular weight heparin can be used in DVT prophylaxis. Deep vein thrombosis (DVT) prophylaxis
Compression stockings and low molecular weight heparin can be used in DVT prophylaxis.
Bladder care Intermittent catheterization is superior to indwelling catheters in minimizing the risk of catheter associated urinary tract infection. A closed catheter drainage system should me maintained always and indwelling catheters should be changed on time. Bladder care
Intermittent catheterization is superior to indwelling catheters in minimizing the risk of catheter associated urinary tract infection. A closed catheter drainage system should me maintained always and indwelling catheters should be changed on time.
Skin care Pressure sores can occur secondary to prolonged immobilization. Patient should be turned every 2 hours to maintain adequate skin perfusion. Skin care
Pressure sores can occur secondary to prolonged immobilization. Patient should be turned every 2 hours to maintain adequate skin perfusion.
Peptic ulcer prophylaxis Use of H2 receptor antagonists or proton-pump inhibitors for 6 weeks reduces the incidence of stress related peptic ulcerations. Peptic ulcer prophylaxis
Use of H2 receptor antagonists or proton-pump inhibitors for 6 weeks reduces the incidence of stress related peptic ulcerations.

Management - Specific

Fact Explanation
Limb physiotherapy Limb physiotherapy is indicated for every patient. This is helpful to prevent the occurrence of contractures and improves the final functional outcome. Limb physiotherapy
Limb physiotherapy is indicated for every patient. This is helpful to prevent the occurrence of contractures and improves the final functional outcome.
Aspirin Aspirin is an antiplatelet drug used only in ischemic spinal infarction. It inhibits platelet aggregation and prevent the progression of thrombus. Low dose aspirin (75 mg daily) is effective in reducing the risk of recurrent ischemic events. Aspirin
Aspirin is an antiplatelet drug used only in ischemic spinal infarction. It inhibits platelet aggregation and prevent the progression of thrombus. Low dose aspirin (75 mg daily) is effective in reducing the risk of recurrent ischemic events.
Clopidogrel Similar to aspirin clopidogrel also inhibits the activation of platelets, and inhibits the progression of the already formed thrombus. Combination of aspirin and clopidogrel can also be used in the treatment of ischemic strokes. However since this significantly increase the risk of bleeding combined treatment should only be given to patients with very low risk of spontaneous bleeding and hemorrhagic stroke. Clopidogrel
Similar to aspirin clopidogrel also inhibits the activation of platelets, and inhibits the progression of the already formed thrombus. Combination of aspirin and clopidogrel can also be used in the treatment of ischemic strokes. However since this significantly increase the risk of bleeding combined treatment should only be given to patients with very low risk of spontaneous bleeding and hemorrhagic stroke.
Low molecular weight heparin Anticoagulation is indicated for the treatment of ischemic infarction of the spinal cord. (It should not be used for the hemorrhagic strokes) Low molecular weight heparin
Anticoagulation is indicated for the treatment of ischemic infarction of the spinal cord. (It should not be used for the hemorrhagic strokes)

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