IS YOUR PRACTICE PICTURE PERFECT? A special deal for GLMS Members
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obtained and demonstrated( drum roll, please) ischemia vs. infarct from approximately C2-T5 with predominance in the anterior horns.
The literature review of non-traumatic spinal cord infarction is as rare as the pathology itself in the pediatric population and predominately consists of case studies. Causes typically include but are not limited to hypotension, vascular injury, thrombus, embolus or compression. Considering that many of these etiologies are already scarce in the pediatric population, finding cause proves to be a difficult task. Pain in neck, back or legs, weakness, tingling and numbness are commonly described symptoms in pediatric case studies and were present in the patient that presented to us. Prognosis studies have been performed on primarily adult patients; one such study demonstrated > 40 percent recovery in ambulation amongst the 37 patients that left the hospital wheelchair-bound through aggressive physical therapy and rehabilitation programs. [ 1 ] Poor prognostic factors include female sex, advanced age, severity of symptoms and lack of improvement within 24 hours after infarction.[ 2 ]
It appears as though outcomes are primarily dependent on access to physical therapy and supportive care including psychological treatment. Workup and treatment recommendations if suspicious of atraumatic spinal cord infarct include obtaining an MRI for definitive diagnosis, followed by autoimmune, hypercoagulable and infectious evaluations. Treatment in the emergency department is mostly supportive and includes addressing any contributory conditions and the management of respiratory concerns.[ 3 ]
On follow up, I found that the patient required intubation after exhibiting respiratory decompensation after the MRI was obtained. Initial treatment with highdose steroids and IVIG were discontinued when infectious and immunologic workups were unrevealing. The hospital course was complicated by neurogenic bowel and bladder, neuropathic pain, anxiety, intermittent autonomic instability with hypotension, pneumonia and a urinary tract infection. The patient required tracheostomy and percutaneous gastric tube placement during his hospital stay. The patient continued to exhibit flaccid paralysis of all four extremities and ventilator dependence on discharge to acute rehabilitation.
Per my own investigation, I was relieved to find that Frazier has had success managing these cases and has many unique resources that may positively impact this patient’ s course. See some video evidence https:// www. youtube. com / watch? v = 8o _ w174rI3s).
Needless to say, my differential for motor weakness, particularly in pediatrics, will forever be haunted by this case.
Dr. Hayes is an Emergency Medicine resident at the University of Louisville
[ 1 ] Robertson CE, Brown RD Jr, Wijdicks EF, et al. Recovery after spinal cord infarcts: long-term outcome in 115 patients. Neurology. 2012; 78: 114 – 121.
[ 2 ] Cheshire WP, Santos CC, Massey EW, Howard JF Jr. Spinal cord infarction: etiology and outcome. Neurology. 1996; 47( 2): 321.
[ 3 ] Spencer, Sandra P. MD; Brock, Timothy D. MD; Matthews, Rebecca R. MD; Stevens, Wendy K. MD. Three Unique Presentations of Atraumatic Spinal Cord Infarction in the Pediatric Emergency Department Pediatric Emergency Care. 30( 5): 354-357, May 2014.
This blog entry was featured on Room 9 Blogs, a blog for ER Residents. You can view other entries at www. room9er. com
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