Working Diagnosis:
Anterior spinal syndrome with incomplete tetraparesis secondary to a C7 spinal cord infarction

Treatment:
Patient was admitted to the hospital and started on aspirin (ASA), clopidogrel, atorvastatin, enoxaparin, methylprednisolone x5 days, and norepinephrine until his blood pressure stabilized.

Outcome:
Patient was discharged to inpatient rehab on HD #4, he regained bowel and bladder function as well as b/l UE and left LE strength. As an outpatient, he continued physical therapy and occupational therapy rehabilitation. He followed up with PMR for ankle foot orthosis (AFO) bracing for right LE foot drop. His primary care provider (PCP) monitored for osteoporosis risk from reduced ambulatory weight bearing, weight loss, changes to his breathing/pneumonia (PNA) risk, and foot pain. He currently can complete activities of daily living (ADLs), is able to stand for short periods and uses a walker. He has a good prognosis for independent ambulation.

Author's Comments:
Anterior spinal syndrome occurs after infarction to the anterior spinal artery that supplies the anterior 2/3 of the spinal cord Case Photo #5 and leads to b/l loss of motor, pain/temperature sensation, and autonomic function after ischemia to the descending corticospinal, spinothalamic, and autonomic tracts respectively Case Photo #6 . The diagnosis was made based on acute/evolving symptoms, b/l neurologic deficits, intact CNs, and neurologic consultation. Dissociation between pain and tactile sensation of the C6-C7 dermatomes localized the lesion to the C7 spinal level. There were delayed findings on repeat MRI which are not uncommon and can help confirm the diagnosis (2). Infarction may occur in people with chronic spinal disease at the level of disease from mechanical triggering movements (3). TIAs have also been reported in patients prior to their spinal infarctions (3).

Editor's Comments:
Anterior cord syndrome is a rare disorder with incidence of 3.1 in 100,000 per year. Most common cause is iatrogenic during surgery due to clamping of aorta or hypotension. Also, embolic states, AV malformations, cocaine use, or hypotension due to illness such as cardiac arrest. Ischemia of the anterior spinal artery (ASA) causes decrease blood supply to the anterior 2/3 of the spinal cord. Presentation is usually bilateral with back pain and autonomic dysfunction due to involvement of the lateral horns at T1-L2. The cause is not clear in this case and the diagnosis was initially clouded by the patient’s histrionic presentation and psych history. However, stripped down, he has classic symptoms of acute onset bilateral upper extremity numbness and pain with progression to bowel and bladder dysfunction and back pain. The early MRI shows some signal changes and later progresses to multiple level T2 hyperintensity signal changes C6 to T6 with infarction at C7. Classic MRI findings would show T2 hyperintensities in anterior horns creating an "owl eye" appearance on axial cuts. His presentation and resolution with immunosuppression suggest a vasculitis etiology. Recovery depends on the cause and often carries significant morbidity and mortality. The mortality rate is between 9 and 23% and usually occurs within short period after initiation of symptoms. However, the cause of ischemia and autonomic dysfunction play a large role in outcome This patient did well with little blood pressure issues and relatively quick resolution of symptoms after initiation of treatment likely due to the treatable underlying etiology.

References:
(1) Willard F.H, Holt J., Medical Neuroanatomy: A Problem-Oriented Approach. V3.2
(2) Zalewski NL, Rabinstein AA, Krecke KN, Brown RD, Wijdicks EFM, Weinshenker BG, Kaufmann TJ, Morris JM, Aksamit AJ, Bartleson JD, Lanzino G, Blessing MM, Flanagan EP. Characteristics of Spontaneous Spinal Cord Infarction and Proposed Diagnostic Criteria. JAMA Neurol. 2019 Jan 01;76(1):56-63
(3) Novy J, Carruzzo A, Maeder P, Bogousslavsky J. Spinal cord ischemia: clinical and imaging patterns, pathogenesis, and outcomes in 27 patients. Arch Neurol 2006; 63:1113

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