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Malignant chordoma
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Stab wound from the flank
Syringomyelia formation
Thoracic aortic dissection
Vitamin B12 deficiency
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This patient who presents with bilateral flaccid paralysis and loss of pain/temperature sensation in his lower extremities with intact dorsal column function (vibration sensation) most likely has anterior cord syndrome. Given his chest pain that radiates downward, this was most likely caused by dissection of a thoracic aortic aneurysm. Anterior spinal cord injury syndromes typically involve all the tracts in the anterior 2/3 of the spinal cord, including the corticospinal tracts, spinothalamic tracts, and descending autonomic tracts. This results in muscle paralysis due to impairment of the corticospinal tracts, bilateral loss of pain and temperature sensation distally due to dysfunction of the spinothalamic tracts, and urinary incontinence due to dysfunction of the descending autonomic tracts. Notably, the dorsal columns are spared so patients will have preserved sensation to vibration, light touch, and proprioception. The underlying cause of anterior spinal cord injury syndromes is infarction of the anterior spinal artery, which can occur secondary to aortic dissection (injury to the artery of Adamkeiwicz), compression injury, vertebral burst fracture, intervertebral disk herniation, or radiation myelopathy. The management of anterior cord syndrome depends on etiology but surgical decompression (e.g., laminectomy) may be required for any compressive lesions. For aortic dissection, the initial step in work-up is a computed tomography angiogram of the chest and reduction in blood pressure if the patient is hypertensive. Elshony et al. discuss the presentation and prognostic factors for patients with anterior spinal cord syndrome due to aortic dissection. They found that older men are the most likely demographic to experience this complication. They recommended that early diagnosis and management are essential for improved outcomes. Incorrect Answers: Answer 1: A malignant chordoma would present with cauda equina syndrome due to compression of the sacral nerve roots. This manifests as low back pain, ataxia, bladder incontinence, pain in a sciatic distribution, and saddle anesthesia. Cauda equina syndrome is a surgical emergency requiring decompression. Answer 2: Stab wound from the flank can result in Brown-Sequard syndrome due to hemi-transection of the spinal cord. This syndrome would present with an ipsilateral loss of motor and vibratory sensation and a contralateral loss of pain and temperature sensation. Answer 3: Syringomyelia is a cause of central cord syndrome, which would present with loss of pain and temperature sensation in the upper extremities at the level of the lesion. Patients may also experience symmetric weakness of the upper extremities in a "cape-like" distribution. Answer 5: Vitamin B12 deficiency can cause subacute combined degeneration of the dorsal columns of the spinal cord. This disorder would present with decreased vibratory sense and proprioception in the lower extremities bilaterally. This typically presents in malnourished patients, vegans, and alcoholics. Bullet Summary: Anterior cord syndrome would present with bilateral flaccid paralysis and loss of pain/temperature sensation below the level of the injury with intact proprioception and vibration sensation.
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