Posterior spinal artery syndrome

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Posterior spinal artery syndrome
Gray770-vessels.png
5: posterior spinal arteries

Posterior spinal artery syndrome(PSAS), also known as posterior spinal cord syndrome, is a type of incomplete spinal cord injury. [1] PSAS is the least commonly occurring of the six clinical spinal cord injury syndromes, with an incidence rate of less than 1%.

Contents

PSAS originates from an infarct in the posterior spinal artery and is caused by lesions on the posterior portion of the spinal cord, specifically the posterior column, posterior horn, and posterolateral region of the lateral column. [2] These lesions can be caused by trauma to the neck, occlusion of the spinal artery, tumors, disc compression, vitamin B12 deficiency, syphilis, or multiple sclerosis. [3] Despite these numerous pathological pathways, the result is an interruption in transmission of sensory information and motor commands from the brain to the periphery.

Causes

Trauma to the spinal cord, such as neck hyperflexion injuries, are often the result of car accidents or sports-related injuries. In such injuries, posterior dislocations and extensions occur without the rupture of ligaments. This blunt trauma may be further complicated with subsequent disc compression. In addition to these complications, transient ischemic attacks could occur in the spinal cord during spinal artery occlusion. [4]

Common pathological sources of PSAS include Friedreich's Ataxia, an autosomal-recessive inherited disease, and tumors such as astrocytoma, ependymoma, meningioma, neurofibroma, sarcoma, and schwannoma. [ citation needed ]

Illustration of an axon with a degenerated myelin sheath Central Nervous System.png
Illustration of an axon with a degenerated myelin sheath

Cobalamin, commonly known as vitamin B12, plays a crucial role in the synthesis and maintenance of myelin in neurons found in the spinal cord. A deficiency of this essential vitamin results in demyelination, a deterioration of the axon's layer of insulation causing interrupted signal transmission, with a currently unknown specificity to the posterior region. [5]

PSAS may develop with the failure to treat syphilis. Symptoms typically appear during the tertiary phase of the disease, between twenty and thirty years after the initial syphilis infection. Failure to treat syphilis leads to progressive degeneration of the nerve roots and posterior columns. The bacteria Treponema pallidum that causes syphilis results in locomotor ataxia and tabes dorsalis. Further complications from tabes dorsalis include optic nerve damage, blindness, shooting pains, urinary incontinence, and degeneration of the joints. [6]

In most cases, lesions present bilaterally. However, in rare cases, lesions have been seen unilaterally. [2] Moreover, general symptoms of posterior spinal artery infarcts include ipsilateral loss of proprioceptive sensation, fine touch, pressure, and vibration below the lesion; deep tendon areflexia; and in severe circumstances, complete paralysis below the portion of the spinal cord affected. [1]

Diagnosis

Complete spinal imaging, X-rays, computed tomography (CT), or magnetic resonance imaging (MRI) can be used to identify infarctions on the dorsal columns. [6] Imaging alone is often inconclusive and does not present a full analysis of the affected columns. Clinical history, blood and cerebral spinal fluid (CSF) tests can also be used to make a full diagnosis. [1]

Treatment

Treatment for posterior spinal artery syndrome depends on the causes and symptoms, as well as the source of the infarction. The main goal of treatment is to stabilize the spine. Possible treatments include airway adjuncts; the use of ventilators; full spinal precautions and immobilization; and injections of dopamine. [6] [7] While there is no definitive cure for posterior cord syndrome, treatment and supportive care can be provided based on the patient's symptoms. Therapy and rehabilitative care including walking aids, physical, occupational, and psychotherapy can help ease the symptoms associated with PSAS. Acute therapy can include intensive medical care and analgesia. Corticosteroids are used to reduce any inflammation or swelling. Bracing or surgical repair can be done to stabilize the spinal fracture. [8]

Research

Protein PLAT (tissue plasminogen activator) PDB 1a5h Protein PLAT PDB 1a5h.png
Protein PLAT (tissue plasminogen activator) PDB 1a5h

It has been difficult to make any breakthroughs in diagnosis and/or treatment of PSAS as symptoms are not specific in nature and can vary based on the exact location of spinal cord lesions. In addition, the demographics of patients with PSAS are widespread as the onset of symptoms typically follows a traumatic event. Additionally, research has suffered setbacks because PSAS is rare with few documented cases, unlike anterior spinal artery syndrome. [1] [3] [9]

However, ongoing research has helped in differentiating PSAS from other brain injuries. Therefore, better therapies for PSAS treatment can be developed. For instance, one study suggests that a tissue plasminogen activator (tPA) therapy intervention, commonly used in stroke patients, [10] may aid in treating patients with symptoms of PSAS. [11]

Related Research Articles

<span class="mw-page-title-main">Transverse myelitis</span> Medical condition of the spinal cord

Transverse myelitis (TM) is a rare neurological condition wherein the spinal cord is inflamed. Transverse implies that the inflammation extends horizontally across the spinal cord. Partial transverse myelitis and partial myelitis are terms sometimes used to specify inflammation that only affects part of the width of the spinal cord. TM is characterized by weakness and numbness of the limbs, deficits in sensation and motor skills, dysfunctional urethral and anal sphincter activities, and dysfunction of the autonomic nervous system that can lead to episodes of high blood pressure. Signs and symptoms vary according to the affected level of the spinal cord. The underlying cause of TM is unknown. The spinal cord inflammation seen in TM has been associated with various infections, immune system disorders, or damage to nerve fibers, by loss of myelin. As opposed to leukomyelitis which affects only the white matter, it affects the entire cross-section of the spinal cord. Decreased electrical conductivity in the nervous system can result.

Tetraplegia, also known as quadriplegia, is paralysis caused by illness or injury that results in the partial or total loss of use of all four limbs and torso; paraplegia is similar but does not affect the arms. The loss is usually sensory and motor, which means that both sensation and control are lost. The paralysis may be flaccid or spastic.

<span class="mw-page-title-main">Lateral medullary syndrome</span> Medical condition

Lateral medullary syndrome is a neurological disorder causing a range of symptoms due to ischemia in the lateral part of the medulla oblongata in the brainstem. The ischemia is a result of a blockage most commonly in the vertebral artery or the posterior inferior cerebellar artery. Lateral medullary syndrome is also called Wallenberg's syndrome, posterior inferior cerebellar artery (PICA) syndrome and vertebral artery syndrome.

<span class="mw-page-title-main">Medial medullary syndrome</span> Medical condition

Medial medullary syndrome, also known as inferior alternating syndrome, hypoglossal alternating hemiplegia, lower alternating hemiplegia, or Dejerine syndrome, is a type of alternating hemiplegia characterized by a set of clinical features resulting from occlusion of the anterior spinal artery. This results in the infarction of medial part of the medulla oblongata.

<span class="mw-page-title-main">Spinal cord injury</span> Injury to the main nerve bundle in the back of humans

A spinal cord injury (SCI) is damage to the spinal cord that causes temporary or permanent changes in its function. Symptoms may include loss of muscle function, sensation, or autonomic function in the parts of the body served by the spinal cord below the level of the injury. Injury can occur at any level of the spinal cord and can be complete, with a total loss of sensation and muscle function at lower sacral segments, or incomplete, meaning some nervous signals are able to travel past the injured area of the cord up to the Sacral S4-5 spinal cord segments. Depending on the location and severity of damage, the symptoms vary, from numbness to paralysis, including bowel or bladder incontinence. Long term outcomes also range widely, from full recovery to permanent tetraplegia or paraplegia. Complications can include muscle atrophy, loss of voluntary motor control, spasticity, pressure sores, infections, and breathing problems.

Lhermitte phenomenon, also called the barber chair phenomenon, is an uncomfortable "electrical" sensation that runs through the back and into the limbs. The sensation can feel like it goes up or down the spine. It is painful for some, although others might simply feel strange sensations.

<span class="mw-page-title-main">Cerebral infarction</span> Medical condition

A cerebral infarction is the pathologic process that results in an area of necrotic tissue in the brain. It is caused by disrupted blood supply (ischemia) and restricted oxygen supply (hypoxia), most commonly due to thromboembolism, and manifests clinically as ischemic stroke. In response to ischemia, the brain degenerates by the process of liquefactive necrosis.

<span class="mw-page-title-main">Conus medullaris</span> Lower part of the spinal cord

The conus medullaris or conus terminalis is the tapered, lower end of the spinal cord. It occurs near lumbar vertebral levels 1 (L1) and 2 (L2), occasionally lower. The upper end of the conus medullaris is usually not well defined, however, its corresponding spinal cord segments are usually S1-S5.

<span class="mw-page-title-main">Neurosyphilis</span> Infection of the central nervous system in a patient with syphilis

Neurosyphilis refers to infection of the central nervous system in a patient with syphilis. In the era of modern antibiotics the majority of neurosyphilis cases have been reported in HIV-infected patients. Meningitis is the most common neurological presentation in early syphilis. Tertiary syphilis symptoms are exclusively neurosyphilis, though neurosyphilis may occur at any stage of infection.

Dissociated sensory loss is a pattern of neurological damage caused by a lesion to a single tract in the spinal cord which involves preservation of fine touch and proprioception withselective loss of pain and temperature.

<span class="mw-page-title-main">Carotid artery dissection</span> Human disease

Carotid artery dissection is a separation of the layers of the artery wall supplying oxygen-bearing blood to the head and brain and is the most common cause of stroke in young adults.

<span class="mw-page-title-main">Radiculopathy</span> Medical condition

Radiculopathy, also commonly referred to as pinched nerve, refers to a set of conditions in which one or more nerves are affected and do not work properly. Radiculopathy can result in pain, weakness, altered sensation (paresthesia) or difficulty controlling specific muscles. Pinched nerves arise when surrounding bone or tissue, such as cartilage, muscles or tendons, put pressure on the nerve and disrupt its function.

<span class="mw-page-title-main">Lacunar stroke</span> Medical condition

Lacunar stroke or lacunar cerebral infarct (LACI) is the most common type of ischemic stroke, resulting from the occlusion of small penetrating arteries that provide blood to the brain's deep structures. Patients who present with symptoms of a lacunar stroke, but who have not yet had diagnostic imaging performed, may be described as having lacunar stroke syndrome (LACS).

<span class="mw-page-title-main">Anterior spinal artery syndrome</span> Human spinal cord disorder

Anterior spinal artery syndrome is syndrome caused by ischemia of the anterior spinal artery, resulting in loss of function of the anterior two-thirds of the spinal cord. The region affected includes the descending corticospinal tract, ascending spinothalamic tract, and autonomic fibers. It is characterized by a corresponding loss of motor function, loss of pain and temperature sensation, and hypotension.

<span class="mw-page-title-main">Central cord syndrome</span> Human spinal cord disorder

Central cord syndrome (CCS) is the most common form of cervical spinal cord injury. It is characterized by loss of motion and sensation in arms and hands. It usually results from trauma which causes damage to the neck, leading to major injury to the central corticospinal tract of the spinal cord. The syndrome is more common in people over the age of 50 because osteoarthritis in the neck region causes weakening of the vertebrae. CCS most frequently occurs among older persons with cervical spondylosis, however, it also may occur in younger individuals.

<span class="mw-page-title-main">Brown-Séquard syndrome</span> Human spinal cord disorder

Brown-Séquard syndrome is caused by damage to one half of the spinal cord, i.e. hemisection of the spinal cord resulting in paralysis and loss of proprioception on the same side as the injury or lesion, and loss of pain and temperature sensation on the opposite side as the lesion. It is named after physiologist Charles-Édouard Brown-Séquard, who first described the condition in 1850.

Dejerine–Roussy syndrome or thalamic pain syndrome is a condition developed after a thalamic stroke, a stroke causing damage to the thalamus. Ischemic strokes and hemorrhagic strokes can cause lesioning in the thalamus. As initial stroke symptoms dissipate, an imbalance in sensation causes these later syndromes, characterizing Dejerine–Roussy syndrome. Although some treatments exist, they are often expensive, chemically based, invasive, and only treat patients for some time before they need more treatment, called "refractory treatment".

Vascular myelopathy refers to an abnormality of the spinal cord in regard to its blood supply. The blood supply is complicated and supplied by two major vessel groups: the posterior spinal arteries and the anterior spinal arteries—of which the Artery of Adamkiewicz is the largest. Both the posterior and anterior spinal arteries run the entire length of the spinal cord and receive anastomotic (conjoined) vessels in many places. The anterior spinal artery has a less efficient supply of blood and is therefore more susceptible to vascular disease. Whilst atherosclerosis of spinal arteries is rare, necrosis in the anterior artery can be caused by disease in vessels originating from the segmental arteries such as atheroma or aortic dissection.

<span class="mw-page-title-main">Spinal cord</span> Long, tubular central nervous system structure in the vertebral column

The spinal cord is a long, thin, tubular structure made up of nervous tissue, which extends from the medulla oblongata in the brainstem to the lumbar region of the vertebral column (backbone). The backbone encloses the central canal of the spinal cord, which contains cerebrospinal fluid. The brain and spinal cord together make up the central nervous system (CNS). In humans, the spinal cord begins at the occipital bone, passing through the foramen magnum and then enters the spinal canal at the beginning of the cervical vertebrae. The spinal cord extends down to between the first and second lumbar vertebrae, where it ends. The enclosing bony vertebral column protects the relatively shorter spinal cord. It is around 45 cm (18 in) long in adult men and around 43 cm (17 in) long in adult women. The diameter of the spinal cord ranges from 13 mm in the cervical and lumbar regions to 6.4 mm in the thoracic area.

Spinal cord stroke is a rare type of stroke with compromised blood flow to any region of spinal cord owing to occlusion or bleeding, leading to irreversible neuronal death. It can be classified into two types, ischaemia and haemorrhage, in which the former accounts for 86% of all cases, a pattern similar to cerebral stroke. The disease is either arisen spontaneously from aortic illnesses or postoperatively. It deprives patients of motor function or sensory function, and sometimes both. Infarction usually occurs in regions perfused by anterior spinal artery, which spans the anterior two-thirds of spinal cord. Preventions of the disease include decreasing the risk factors and maintaining enough spinal cord perfusion pressure during and after the operation. The process of diagnosing the ischemic and hemorrhagic spinal cord stroke includes applying different MRI protocols and CT scan. Treatments for spinal cord stroke are mainly determined by the symptoms and the causes of the disease. For example, antiplatelet and corticosteroids might be used to reduce the risk of blood clots in ischaemic spinal stroke patients, while rapid surgical decompression is applied to minimize neurological injuries in haemorrhagic spinal stroke patients instead. Patients may spend years for rehabilitation after the spinal cord stroke.

References

  1. 1 2 3 4 "Incomplete Spinal Cord Injury". Spinal Cord.com. Spinal Cord.com. Retrieved 27 March 2018.
  2. 1 2 Richard, Sebastien; Abdallah, Chifaou; Chanson, Anne; Foscolo, Sylvain; Baillot, Pierre-Alexandre; Ducroucp, Xavier (2014). "Unilateral posterior cervical spinal cord infarction due to spontaneous vertebral artery dissection". The Journal of Spinal Cord Medicine. J Spinal Cord Med. 37 (2): 233–236. doi:10.1179/2045772313Y.0000000125. PMC   4066433 . PMID   24090478.
  3. 1 2 Mascalchi, Mario; Cosottini, Mirco; Giampiero, Ferrito; Salvi, Fabrizio; Nencini, Patrizia; Quilici, Nello (1998). "Posterior Spinal Artery Infarct" (PDF). AJNR. American Journal of Neuroradiology. 19 (2): 361–3. PMC   8338164 . PMID   9504495 . Retrieved 27 March 2018.
  4. ↑ "Posterior cord syndrome - OrthopaedicsOne Articles - OrthopaedicsOne". www.orthopaedicsone.com. Retrieved 2018-04-25.
  5. ↑ Pandey, Shuchit; V Holla, Vikram; Rizvi, Imran; Qavi, Abdul; Shukla, Rakesh (2016-07-07). "Can vitamin B12 deficiency manifest with acute posterolateral or posterior cord syndrome?". Spinal Cord Series and Cases. 2 (1): 16006–. doi:10.1038/scsandc.2016.6. ISSN   2058-6124. PMC   5129416 . PMID   28053750.
  6. 1 2 3 "Medical Definition of Tabes dorsalis". MedicineNet.com. MedicineNet.com. Retrieved 27 March 2018.
  7. ↑ McKinley, William; Santos, Katia; Meada, Michelle; Brooke, Karen (2007). "Incidence and Outcomes of Spinal Cord Injury Clinical Syndromes". The Journal of Spinal Cord Medicine. J Spinal Cord Med. 30 (3): 215–224. doi:10.1080/10790268.2007.11753929. PMC   2031952 . PMID   17684887.
  8. ↑ "Complete spinal cord injury – Knowledge for medical students and physicians". www.amboss.com. Retrieved 2018-04-25.
  9. ↑ Murata, Kiyoko; Ikeda, Ken; Muto, Mitsuaki; Hirayama, Takeshisa; Kano, Osamu; Iwasaki, Yasuo (2012). "A case of Posterior Spinal Artery Syndrome in the Cervical Cord: A Review of the Clinicoradiological Literature". Internal Medicine (Tokyo, Japan). Internal Medicine. 51 (7): 803–7. doi: 10.2169/internalmedicine.51.6922 . PMID   22466844 . Retrieved 27 March 2018.
  10. ↑ "Tissue Plasminogen Activator" (PDF). Stroke Association. The Stroke Collaborative. Archived from the original (PDF) on 28 March 2018. Retrieved 27 March 2018.
  11. ↑ Sakurai, Takeo; Wakida, Kenji; Nishida, Hiroshi (2016). "Cervical Posterior Spinal Artery Syndrome: A Case Report and Literature Review". Journal of Stroke and Cerebrovascular Diseases. 25 (6): 1552–6. doi:10.1016/j.jstrokecerebrovasdis.2016.02.018. PMID   27012218 . Retrieved 27 March 2018.
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