Anterior spinal artery syndrome or Beck's syndrome or anterior cord syndrome is a rare neurovascular condition characterized by sudden ischemia with damage to the anterior 2/3rd of the spinal cord. The anterior spinal artery of Adamkiewicz which supplies this region of the spinal cord is susceptible to occlusion in the mid-lumbar region as the radicular artery supplying it is an end artery with no collateral circulation.
Presentation
Anterior spinal artery syndrome (ASAS) is a very rare condition which occurs following infarction of the anterior two-third of the spinal cord supplied by the anterior spinal artery. The cause of the infarction can be either iatrogenic or secondary to diseases. Common etiologies include mediastinal surgeries [1] [2], diabetes with atherosclerosis [3], diseases of the aorta [4], hematological disorders (sickle cell, polycythemia), cervical spine injury or spondylosis [5] [6] [7], infections (tuberculosis, N.meningitidis) [8] [9] [10], drugs (cocaine) [11], vasculitis, and idiopathic.
The common clinical presentation of ASAS is sudden onset, severe, pain along the spinal nerve roots radiating to the lower limbs with quadriparesis due to corticospinal tract involvement. The myelopathy can be associated with impaired bladder, bowel and sexual function depending upon the level at which the spinal cord is affected. Pain, as well as, temperature sensation are lost below the level of the infarction as the lateral spinothalamic tract is affected while the posterior column vibration and position sense are preserved. Orthostatic hypotension may be present due to autonomic dysfunction. Occasionally the spinal cord gray matter may be involved, preferentially with the preservation of sensory, bladder and bowel functions.
Entire Body System
- Lower Extremity Pain
The patient started complaining of spasmodic lower extremity pain and general weakness. She was unable to flex her knees upon request. [anesthesiology.pubs.asahq.org]
Respiratoric
- Hemoptysis
List the most common causes of massive hemoptysis. •. Discuss the roles of CT and bronchoscopy in the diagnosis of massive hemoptysis. •. [pubs.rsna.org]
This is the most feared, though rare complication of bronchial artery embolization done in massive hemoptysis.[6] Anatomy[edit] The anterior portion of the spinal cord is supplied by the anterior spinal artery. [en.wikipedia.org]
비록 흔치는 않으나 가장 위험스런상황으로 대량의 객혈(大量喀-hemoptysis)으로 인한 기관지동맥색전(氣管支動脈塞栓-bronchial artery embolization)이 된다. 치료 치료는 앞쪽척수동맥증후군을 일으키는 원인에 따라 달라지게 된다. 진단이 이루어졌다 해도 예후는 그리 좋은편은 아니라서 20%의 사망율을 보이게 되고 약간이나 거의 증상의 차도가 없는 앞쪽척수증후군은 50%까지 사망율이 나오게 된다. [m.blog.naver.com]
Cardiovascular
- Orthostatic Hypotension
Orthostatic hypotension may be present due to autonomic dysfunction. Occasionally the spinal cord gray matter may be involved, preferentially with the preservation of sensory, bladder and bowel functions. [symptoma.com]
hypotension due to involvement of lateral horn cells 6 bladder and bowel dysfunction and sexual dysfunction may arise depending on the level of the lesion Importantly 2-point discrimination, proprioception and vibratory senses are normal due to intact [radiopaedia.org]
hypotension), 성기능장애(性機能障碍-sexual dysfunction), 대소변장애등이 오게 된다. [m.blog.naver.com]
[…] spondylosis) Clinical features Acute (within hours) Back or chest pain Spinal shock Bilateral loss of temperature and pain sensation;, motor function (flaccid paraparesis or quadriparesis);, and autonomic function (bladder, bowel, and sexual dysfunction, orthostatic [amboss.com]
- Decompression Sickness
He was eventually diagnosed as having spinal cord decompression sickness along with a likely diagnosis of anterior spinal artery (artery of Adamkiewicz) syndrome. [ncbi.nlm.nih.gov]
Other causes include vasculitis, polycythemia, sickle cell disease, decompression sickness, and collagen and elastin disorders.[1] Any embolus or thrombus in largest feeder vessel known as the artery of Adamkiewicz, can lead to an anterior spinal syndrome [en.wikipedia.org]
그외에 다른 원인으로 혈관염(血管炎-vasculitis), 적혈구증가증(赤血球增加症-polycythemia), 겸상세포질환(兼床細胞疾患-sickle cell disease), 감압병(減壓病-decompression sickness), 콜라겐과 엘아스틴장애(collagen and elastin disorders)등이 있게 된다. [m.blog.naver.com]
Musculoskeletal
- Back Pain
Abstract Reported here is a 37-yr-old professional diving instructor who had developed complaints of back pain and weakness in the lower extremities after diving. [ncbi.nlm.nih.gov]
Infarction is suspected when severe back pain and characteristic deficits develop suddenly. Diagnosis of spinal cord infarction is by MRI. [merckmanuals.com]
Psychiatrical
- Fear
This is the most feared, though rare complication of bronchial artery embolization done in massive hemoptysis.[6] Anatomy[edit] The anterior portion of the spinal cord is supplied by the anterior spinal artery. [en.wikipedia.org]
People around you can’t fully understand the pain, fear, and distress of this condition. Just know you are not alone, and there are even support groups and organizations you can join for free. [webmd.com]
Urogenital
- Urinary Retention
Abstract Lower urinary tract function was studied in 10 patients with the anterior spinal artery syndrome. In the acute stage all patients had complete urinary retention. Cystometry in 3 patients showed detrusor areflexia. [ncbi.nlm.nih.gov]
Results: A 16-year-old girl with Down syndrome presented with urinary retention and acute complete flaccid paralysis of the legs with absent deep tendon and abdominal reflexes. [tandfonline.com]
retention and intestinal obstruction may also be present in individuals with anterior cord syndrome.[1] Symptoms usually occur very quickly and are often experienced within one hour of the initial damage. [en.wikipedia.org]
The disease is expressed with motor weakness accompanied by disturbance of temperature and superficial sensation, urinary retention or bowel disorder, with preserved position and vibration sense. [clinicaltrials.gov]
- Sexual Dysfunction
If an antidepressant increases serotonin concentrations, side effects can include nausea, changes in appetite and sexual dysfunction. [heretohelp.bc.ca]
Autonomic dysfunction may be present and can manifest as hypotension (either orthostatic or frank hypotension), sexual dysfunction, and/or bowel and bladder dysfunction. [oatext.com]
orthostatic hypotension due to involvement of lateral horn cells 6 bladder and bowel dysfunction and sexual dysfunction may arise depending on the level of the lesion Importantly 2-point discrimination, proprioception and vibratory senses are normal [radiopaedia.org]
[…] may be present and can manifest as hypotension (either orthostatic or frank hypotension), sexual dysfunction, and/or bowel and bladder dysfunction[4][5] Areflexia, flaccid internal and external anal sphincter, urinary retention and intestinal obstruction [en.wikipedia.org]
Neurologic
- Spinal Cord Syndrome
Central cord syndrome, anterior cord syndrome, posterior cord syndrome, and Brown-Séquard syndrome are the most common types of incomplete spinal cord syndromes. [amboss.com]
OBJECTIVE: To report a rare case of anterior spinal cord syndrome caused by a cement embolism in the anterior spinal artery after vertebroplasty. [ncbi.nlm.nih.gov]
Anterior cord syndrome is central diagram Specialty Neurosurgery Anterior spinal artery syndrome (also known as "anterior spinal cord syndrome") is syndrome caused by ischemia of the anterior spinal artery, resulting in loss of function of the anterior [en.wikipedia.org]
Spinal Cord Syndromes: Anterior Cord Syndrome Anterior cord syndrome often occurs as a result of flexion injury, or due to injury to the anterior spinal artery. [canadiem.org]
- Tremor
Atypical antipsychotics are less likely to produce extrapyramidal side effects (such as tremor and Parkinson's-like symptoms) and tardive dyskinesia (abnormal, repetitive facial movements). [drugs.com]
CN 3, 4) Weber's syndrome ventral peduncle, PCA Benedikt syndrome ventral tegmentum, PCA Parinaud's syndrome dorsal, tumor Nothnagel's syndrome Claude's syndrome Other Alternating hemiplegia Cerebellum lateral (Dysmetria Dysdiadochokinesia Intention tremor [en.wikipedia.org]
Common side effects of antipsychotic medications include: Blurred vision Dry mouth Drowsiness Muscle spasms or tremors Weight gain Note: Clozaril is not used often, despite its effectiveness for bipolar disorder. [webmd.com]
- Hyperreflexia
Detrusor hyperreflexia was noted in 8 patients, a normal bladder in 1 and detrusor areflexia in 1. External urethral sphincter electromyography revealed detrusor-sphincter dyssynergia in 4 patients and normal findings in 6. [ncbi.nlm.nih.gov]
At first the lower limb paralysis was flaccid and areflexic but after several weeks spasticity, hyperreflexia, and Babinski signs appeared. After an initial period of incontinence bowel and bladder control was regained. [lksom.temple.edu]
The acute stages are characterized by flaccidity and loss of deep tendon reflexes; spasticity and hyperreflexia develop over ensuing days and weeks. [oatext.com]
Initially areflexia is present due to spinal shock but, hyperreflexia and spasticity appear later The most common form is anterior spinal artery syndrome. [sci-recovery.org]
- Dystonia
[…] syndrome ventral tegmentum, PCA Parinaud's syndrome dorsal, tumor Nothnagel's syndrome Claude's syndrome Other Alternating hemiplegia Cerebellum lateral (Dysmetria Dysdiadochokinesia Intention tremor) medial (Cerebellar ataxia) Basal ganglia Chorea Dystonia [en.wikipedia.org]
Laryngeal dystonia Lorazepam 4 mg IV over 10 min, then 1–2 mg IV slowly Intubation may be needed. [merckmanuals.com]
- Neglect
Following topics are gynaecology and obstetrics, care of the newborn, paediatrics, care of the older persons, abuse and neglect, and patients with long-term health conditions and palliative care The book ends with chapters concerning major incidents, [books.google.nl]
Dysmetria Dysdiadochokinesia Intention tremor) medial (Cerebellar ataxia) Basal ganglia Chorea Dystonia Parkinson's disease Cortex ACA syndrome MCA syndrome PCA syndrome frontal lobe: Expressive aphasia Aboulia parietal lobe: Receptive aphasia Hemispatial neglect [en.wikipedia.org]
Workup
ASAS should be suspected in any adult or child presenting with acute onset painful quadriparesis with preservation of posterior column sensations. History may indicate the etiology but a thorough physical and neurological examination are vital for diagnosis of the condition as well a to detect the level and extent of the neurological deficits. Routine laboratory tests such as complete blood count with differential, serum blood glucose, erythrocyte sedimentation rate (ESR), antinuclear antibody (ANA) levels, complement assay, nuclear antibody assays, serum lipids, serum electrolytes, and serology for syphilis should be ordered. An infectious etiology is indicated by leukocytosis while inflammatory markers may be elevated in infections as well as vasculitis. Besides diabetes, it is important to exclude coagulation disorders with tests like activated partial thromboplastin time, antiphospholipid antibody titer, protein C and protein S levels and platelet count [12] [13]. Cerebrospinal fluid analysis (CSF) is performed to look for infectious and autoimmune conditions while blood and CSF polymerase chain reaction (PCR) may be required to exclude viral etiologies.
However, the diagnosis of ASAS can only be confirmed with a magnetic resonance (MRI) scan of the spinal cord. This can detect all the causative lesions within or outside the spinal cord [14] [15] [16] [17] [18] [19]. Ideally, it should be performed at the earliest to avoid complications such as renal failure from developing [1]. A concomitant brain MRI may be useful in identifying lesions of multiple sclerosis, sarcoid, and other infections. A computed tomography (CT) scan and plain radiography do not have a significant role in the diagnosis of ASAS. If MRI is not available then CT myelography can help to detect tumors. Spinal angiography (arteriography) may be performed to identify an arteriovenous malformation
Other supportive tests in ASAS include electromyography (EMG) and nerve conduction velocity (NCV) tests to document neurological deficits and denervation changes. They also help to differentiate ASAS from polyneuropathy.
Temporal artery biopsy is indicated only if confirmation of giant cell arteritis as the underlying etiology of ASAS is suspected.
Treatment
The treatment has generally been supportive. We believe thrombolysis should be considered in the acute phase of this condition, and present a case with ASAS who experienced partial recovery after treatment given 4.5 h after symptom onset. [ncbi.nlm.nih.gov]
Diagnosis[edit] MRI Treatment[edit] Treatment is determined based on the primary cause of anterior cord syndrome. When the diagnosis of anterior cord syndrome is determined, the prognosis is unfortunate. [en.wikipedia.org]
The treatment has generally been supportive. We believe thrombolysis should be considered in the acute phase of this condition, and present a case with ASAS who experienced partial recovery after treatment given 4.5 h after symptom onset. [casereports.bmj.com]
Prognosis
In our opinion, CMAP could be seen a marker of prognosis for ASAS patients, and absent CMAP might forecast the bad prognosis. [ncbi.nlm.nih.gov]
10–15% functional recovery; if no recovery is evident and progressive after 24 hours, prognosis is poor Vibration and proprioception are typically spared because of an intact dorsal column! [amboss.com]
Treatment and prognosis Prognosis of anterior cord syndrome is worst among all other spinal cord injury syndromes 5. It is associated with high mortality and poor functional outcome in terms of poor recovery of motor power and coordination. [radiopaedia.org]
Etiology
Spinal cord infarction is a well-described, but rare, etiology of myelopathy, especially in children. [ncbi.nlm.nih.gov]
A spine MRI is the diagnostic modality of choice to determine the etiology, level, and extent of the lesion. Treatment depends on the underlying etiology. [amboss.com]
Temporal artery biopsy is indicated only if confirmation of giant cell arteritis as the underlying etiology of ASAS is suspected. [symptoma.com]
Background: Spinal cord infarction is a well-described, but rare, etiology of myelopathy, especially in children. [tandfonline.com]
Epidemiology
References:[11][13][14][15][16][17][18] Posterior cord syndrome Definition: injury of the posterior spinal cord affecting the posterior column (fine touch, vibration, pressure, and proprioception) Epidemiology: very rare Etiology: occlusion of the posterior [amboss.com]
Thoracic (Lower) & Lumbar: 90% Sacral: 4% Cervical 3% Left > Right: 2:1 Feeding vessels Location: Often lumbar Number: Usually 1; Occasionally 2 or 3 Fistula in dorsolateral root sleeve High venous pressure in spinal cord Reduced spinal cord perfusion Epidemiology [neuromuscular.wustl.edu]
However, no epidemiologic studies are available because of the relatively small number of patients affected. [emedicine.com]
Summary Epidemiology To date, there have been more than 500 cases reported worldwide. Individuals of European and Asian descent are most often affected, with most case reports emerging from Japan. A slight male predominance has been reported. [orpha.net]
Hardoon et al17 determined that the prevalence of SMI in THIN is similar to that of epidemiological studies. [bmjopen.bmj.com]
Pathophysiology
The clinical features, treatment and proposed pathophysiology for this condition are presented. [ncbi.nlm.nih.gov]
Anterior Uveitis <ul><li>Prevalence </li></ul><ul><li>Symptoms </li></ul><ul><li>Diagnostic techniques and signs </li></ul><ul><li>Pathophysiology </li></ul><ul><li>Associated conditions </li></ul><ul><li>Management </li></ul> 3. [slideshare.net]
[…] carcinomas documented in 15% - 25% of cases ( J Clin Pathol. 2014;67:891 ) Sites Polyps affect entire gastrointestinal tract, except the esophagus Also associated with ectodermal changes including alopecia, nail atrophy and cutaneous hyperpigmentation Pathophysiology [pathologyoutlines.com]
Pathophysiological classification of human spinal cord ischemia. J Spinal Cord Med. 1997 Jan. 20(1):74-87. [Medline]. Cheng MY, Lyu RK, Chang YJ, Chen CM, Chen ST, Wai YY, et al. [emedicine.com]
Prevention
For this reason avoidance of prolonged aortic cross clamp time, hypotension, and its associated low flow to the spinal cord, paying attention to prevent atheromatous embolization of Adamkiewicz artery and pelvic circulation can prevent this complication [ncbi.nlm.nih.gov]
Data Do Not Support Routine Use for Prevention In the first of two reviews, Esther S. [medscape.com]
References
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- Liblau R, Chiras J, Orssaud C, et al. Spinal infarction in the anterior spinal territory with possible relation with bilharziasis. J Rev Neurol (Paris) 1991;147(8–9):605–608.
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- Luo CB, Chang FC, Teng MM. Magnetic resonance imaging as a guide in the diagnosis and follow-up of spinal cord infarction. J Chin Med Assoc. 2003 Feb; 66(2):89-95.
- Weber P, Vogel T, Bitterling H, et al. Spinal cord infarction after operative stabilization of the thoracic spine in a patient with tuberculous spondylodiscitis and sickle cell trait. Spine. 2009 Apr 15; 34(8): E294-7.
- Joseph G, Santosh C, Marimuthu R. Spinal cord infarction due to a self-inflicted needle stick injury. Spinal Cord. 2004 Nov; 42(11):655-8.
- Hogan EL, Romanul FC. Spinal cord infarction occurring during insertion of aortic graft. Neurology. 1966 Jan; 16(1):67-74.
- Ross RT. Spinal cord infarction in disease and surgery of the aorta. Can J Neurol Sci. 1985 Nov; 12(4):289-95.
- Faivre A, Bonnel S, Leyral G, et al. Essential thrombocythemia presenting as spinal cord infarction.Presse Med. 2009 Apr 22.
- Lyders EM, Morris PP. A Case of Spinal Cord Infarction Following Lumbar Transforaminal Epidural Steroid Injection: MR Imaging and Angiographic Findings. AJNR Am J Neuroradiol. 2009 Oct;30(9):1691-3