Spinal cord infarction following minor trauma in children: fibrocartilaginous embolism as a putative cause

Report of 3 cases

Restricted access

Spinal cord infarctions following seemingly innocuous trauma in children are rare, devastating events. In the majority of these cases, the pathophysiology is enigmatic. The authors present 3 cases of pediatric spinal cord infarction that followed minor trauma. An analysis of the clinical, radiographic, and laboratory features of these cases suggests that thromboembolism of the nucleus pulposus into the spinal cord microcirculation is the likely mechanism. A review of the human and veterinary literature supports this notion. To the authors' knowledge, this is the largest pediatric series of myelopathy due to thromboembolism of the nucleus pulposus reported to date, and it is the first report of this condition occurring in an infant.

Abbreviations used in this paper:ASIA = American Spinal Injury Association; DWI = diffusion-weighted imaging; FCE = fibrocartilaginous embolism.

Article Information

Address correspondence to: Andrew Reisner, M.D., 5455 Meridian Mark Road NE, Suite 540, Atlanta, Georgia 30342. email: andrew.reisner@choa.org.

Please include this information when citing this paper: published online February 15, 2013; DOI: 10.3171/2013.1.PEDS12382.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Case 1. A and B: Sagittal (A) and axial (B) T2-weighted MR images obtained at admission. There is C2–T1 central cord hyperintensity localized to the central gray matter. There is diminished signal in the C3–4 disc space. C and D: One-year follow-up sagittal (C) and axial (D) T2-weighted MR images of the cervicothoracic spine revealing cord atrophy and cystic myelomalacia of the spinal cord.

  • View in gallery

    Case 2. A and B: Sagittal (A) and axial (B) T2-weighted MR images obtained at admission, revealing spinal cord swelling and hyperintensity from C-1 to T-1. Note the hyperintensity involving the entire cord on axial images. There are diminished signals in multiple disc spaces (C2–3, C4–5, C5–6, and C6–7 spaces). C and D: Follow-up sagittal (C) and axial (D) T2-weighted MR images of the cervicothoracic spine revealing cord atrophy and cystic myelomalacia of the spinal cord.

  • View in gallery

    Case 3. A and B: Sagittal (A) and axial (B) T2-weighted MR images obtained at admission, revealing C1–4 spinal cord swelling and hyperintensity involving the anterior and central spinal cord. There is mild kyphosis and diminished signal in the C3–4 disc space. C: Diffusion-weighted image indicating restricted diffusion and infarction. D: Apparent diffusion coefficient map demonstrating restricted diffusion in the cervical cord.

References

1

Ahmann PASmith SASchwartz JFClark DB: Spinal cord infarction due to minor trauma in children. Neurology 25:3013071975

2

Bandyopadhyay SSheth RD: Acute spinal cord infarction: vascular steal in arteriovenous malformation. J Child Neurol 14:6856871999

3

Banerjee AKDeodhar SD: Cartilage embolism of spinal cord. J Neurol Neurosurg Psychiatry 52:120112021989. (Letter)

4

Bastian HCSpinal cord softening. Quain R: Dictionary of Medicine LondonLongmans Green1882. 1479

5

Benson JESchwartz KJ: Ischemic myelomalacia associated with fibrocartilaginous embolism in multiple finishing swine. J Vet Diagn Invest 10:2742771998

6

Bots GTWattendorff ARBuruma OJSRoos RAEndtz LJ: Acute myelopathy caused by fibrocartilaginous emboli. Neurology 31:125012561981

7

Caplan LRMcKee AC: Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises Case 5-1991. A 61-year-old woman with an abrupt onset of paralysis of the legs and impairment of the bladder and bowel function. N Engl J Med 324:3223321991

8

Cauzinille L: Fibrocartilaginous embolism in dogs. Vet Clin North Am Small Anim Pract 30:1551672000

9

Cheshire WPSantos CCMassey EWHoward JF Jr: Spinal cord infarction: etiology and outcome. Neurology 47:3213301996

10

Choi JUHoffman HJHendrick EBHumphreys RPKeith WS: Traumatic infarction of the spinal cord in children. J Neurosurg 65:6086101986

11

Cook JR Jr: Fibrocartilaginous embolism. Vet Clin North Am Small Anim Pract 18:5815921988

12

Cooper DMagilner DCall J: Spinal cord infarction after weight lifting. Am J Emerg Med 24:3523552006

13

Coradini MJohnstone IFilippich LJArmit S: Suspected fibrocartilaginous embolism in a cat. Aust Vet J 83:5505512005

14

Davis GAKlug GL: Acute-onset nontraumatic paraplegia in childhood: fibrocartilaginous embolism or acute myelitis?. Childs Nerv Syst 16:5515542000

15

Feigin IPopoff NAdachi M: Fibrocartilaginous venous emboli to the spinal cord with necrotic myelopathy. J Neuropathol Exp Neurol 24:63741965

16

Foix CAlajouanine T: La myelite necrotique subaigue. Rev Neurol 33:1421926

17

Foo DRossier AB: Anterior spinal artery syndrome and its natural history. Paraplegia 21:1101983

18

Fuentealba ICWeeks BRMartin MTJoyce JRWease GS: Spinal cord ischemic necrosis due to fibrocartilaginous embolism in a horse. J Vet Diagn Invest 3:1761791991

19

Gandini GCizinauskas SLang JFatzer RJaggy A: Fibrocartilaginous embolism in 75 dogs: clinical findings and factors influencing the recovery rate. J Small Anim Pract 44:76802003

20

Han JJMassagli TLJaffe KM: Fibrocartilaginous embolism— an uncommon cause of spinal cord infarction: a case report and review of the literature. Arch Phys Med Rehabil 85:1531572004

21

Kestle JRWResch LTator CHKucharczyk W: Intervertebral disc embolization resulting in spinal cord infarction. Case report. J Neurosurg 71:9389411989

22

Küker WWeller MKlose UKrapf HDichgans JNägele T: Diffusion-weighted MRI of spinal cord infarction—high resolution imaging and time course of diffusion abnormality. J Neurol 251:8188242004

23

Lenn NJ: Spinal cord infarction due to minor trauma. Neurology 27:9991977. (Letter)

24

Liao CCLui TNChen LRChuang CCHuang YC: Spinal cord injury without radiological abnormality in preschool-aged children: correlation of magnetic resonance imaging findings with neurological outcomes. J Neurosurg 1 Suppl103:17232005

25

Manara RCalderone MSeverino MSCitton VToldo ILaverda AM: Spinal cord infarction due to fibrocartilaginous embolization: the role of diffusion weighted imaging and short-tau inversion recovery sequences. J Child Neurol 25:102410282010

26

Masson CPruvo JPMeder JFCordonnier CTouzé EDe La Sayette V: Spinal cord infarction: clinical and magnetic resonance imaging findings and short term outcome. J Neurol Neurosurg Psychiatry 75:143114352004

27

Mikulis DJOgilvy CSMcKee ADavis KROjeman RG: Spinal cord infarction and fibrocartilagenous emboli. AJNR Am J Neuroradiol 13:1551601992

28

Naiman JLDonohue WLPrichard JS: Fatal nucleus pulposus embolism of spinal cord after trauma. Neurology 11:83871961

29

Nance JRGolomb MR: Ischemic spinal cord infarction in children without vertebral fracture. Pediatr Neurol 36:2092162007

30

Pang DWilberger JE Jr: Spinal cord injury without radiographic abnormalities in children. J Neurosurg 57:1141291982

31

Raghavan AOnikul ERyan MMPrelog KTaranath AChennapragada M: Anterior spinal cord infarction owing to possible cartilaginous embolism. Pediatr Radiol 30:5035062004

32

Riché MCModenesi-Freitas JDjindjian MMerland JJ: Arteriovenous malformation (AVM) of the spinal cord in children: a review of 38 cases. Neuroradiology 22:1711801982

33

Salvador de la Barrera SBarca-Buyo AMontoto-Marqués AFerreiro-Velasco MECidoncha-Dans MRodriguez-Sotillo A: Spinal cord infarction: prognosis and recovery in a series of 36 patients. Spinal Cord 39:5205252001

34

Srigley JRLambert CDBilbao JMPritzker KPH: Spinal cord infarction secondary to intervertebral disc embolism. Ann Neurol 9:2963011981

35

Stedman NLBrown TPRowland GN: Intravascular cartilaginous emboli in the spinal cord of turkeys. Avian Dis 42:4234281998

36

Tosi LRigoli GBeltramello A: Fibrocartilaginous embolism of the spinal cord: a clinical and pathogenetic reconsideration. J Neurol Neurosurg Psychiatry 60:55601996

37

Transverse Myelitis Consortium Working Group: Proposed diagnostic criteria and nosology of acute transverse myelitis. Neurology 59:4995052002

38

Wilmshurst JMWalker MCPohl KRE: Rapid onset transverse myelitis in adolescence: implications for pathogenesis and prognosis. Arch Dis Child 80:1371421999

39

Yousef OMAppenzeller PKornfeld M: Fibrocartilagenous embolism: an unusual cause of spinal cord infarction. Am J Forensic Med Pathol 19:3953991998

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 159 159 56
Full Text Views 100 100 19
PDF Downloads 116 116 20
EPUB Downloads 0 0 0

PubMed

Google Scholar