Retroperitoneal approach for the treatment of diaphragmatic crus syndrome: technical note

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OBJECTIVE

Myelopathy selectively involving the lower extremities can occur secondary to spondylotic changes, tumor, vascular malformations, or thoracolumbar cord ischemia. Vascular causes of myelopathy are rarely described. An uncommon etiology within this category is diaphragmatic crus syndrome, in which compression of an intersegmental artery supplying the cord leads to myelopathy. The authors present the operative technique for treating this syndrome, describing their experience with 3 patients treated for acute-onset lower-extremity myelopathy secondary to hypoperfusion of the anterior spinal artery.

METHODS

All patients had compression of a lumbar intersegmental artery supplying the cord; the compression was caused by the diaphragmatic crus. Compression of the intersegmental artery was probably producing the patients’ symptoms by decreasing blood flow through the artery of Adamkiewicz, causing lumbosacral ischemia.

RESULTS

All patients underwent surgery to transect the offending diaphragmatic crus. Each patient experienced substantial symptom improvement, and 2 patients made a full neurological recovery before discharge.

CONCLUSIONS

Diaphragmatic crus syndrome is a rare or under-recognized cause of ischemic myelopathy. Patients present with episodic acute-on-chronic lower-extremity paraparesis, gait instability, and numbness. Angiography confirms compression of an intersegmental artery that gives rise to a dominant radiculomedullary artery. Transecting the offending diaphragmatic crus can produce complete resolution of neurological symptoms.

ABBREVIATIONS ASA = anterior spinal artery; ICG = indocyanine green.
Article Information

Contributor Notes

Correspondence Nicholas Theodore: Johns Hopkins School of Medicine, Baltimore, MD. theodore@jhmi.edu.INCLUDE WHEN CITING Published online March 20, 2020; DOI: 10.3171/2020.1.SPINE191455.Disclosures Dr. Jiang is a consultant for Longeviti Neuro Solutions, and receives grant funding from DePuy Synthes. Dr. Gailloud is a consultant for Cerenovus, and he receives an unrelated research grant from Siemens Medical. Dr. Wolinsky is a consultant for AO Foundation, Siemens, and Icotec. Dr. Theodore receives royalties and has an ownership interest in Globus Medical, and he is a consultant for Globus Medical and DePuy-Synthes.
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