Myelopathy due to fibrocartilaginous embolism: elephant in the room
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Myelopathy due to fibrocartilaginous embolism: elephant in the room K. P. Divya1 · Ajith Cherian1 · Naveen Kumar Paramasivan1 · Jaffar Vali Sayyed1 Received: 15 August 2020 / Accepted: 8 November 2020 © Belgian Neurological Society 2020
Keywords Nucleus pulposus · Anterior spinal artery infarct · Spinal cord infact · Myelopathy A 67-year-old gentleman had a sudden giveaway feeling of his left knee with dragging of the left lower limb, while carrying a heavy bag, necessitating support for ambulation. Six hours later, he experienced severe aching pain over the back, on either side of midline and had urinary retention requiring catheterization. Sensory dulling of either lower extremities, ascending till just above his umbilicus was noted, by 10 h. He had no upper limb or cranial nerve symptoms. His past history was unremarkable except for systemic hypertension since 35 years of age, which was well controlled. He had no cardiac symptoms or recent infection/vaccinations. General examination, cranial nerves and upper extremities were normal. Lower limbs were eutonic with an asymmetric pyramidal pattern of weakness. Right lower limb had Medical Research Council (MRC) grading of 5/5 at the hip and knee, while at the ankle, dorsiflexors and evertors were mildly weak (4+/5). Left lower limb was weaker with hip flexors (4/5) weaker than extensors (4+/5), hip abductors weaker (4+/5) than adductors (5/5) and knee flexors (4/5) weaker than extensors (4+/5). All movements at the left ankle joint were weak with dorsiflexors (4/5) being weaker than plantar flexors (4+/5) and evertors (4/5) being weaker than invertors (4+/5). Knee and ankle jerks were sluggish.
* Ajith Cherian [email protected] K. P. Divya [email protected] Naveen Kumar Paramasivan [email protected] Jaffar Vali Sayyed [email protected] 1
Department of Neurology, Sree Chitra Tirunal Institute of Medical Sciences and Technology, Trivandrum, Kerala 695011, India
Abdominal, cremasteric reflexes were absent and plantar response was mute. He had reduced pinprick and temperature sensation in the lower limbs and trunk extending till the T8 level, sparing the posterior column, vibratory and proprioceptive sensations. Magnetic resonance imaging (MRI) showed focal disc protrusion at T5–T6 intervertebral disc level with indentation of the anterior spinal cord. T2 hyperintensity was noted along with diffusion restriction in the anterior, paramedian cord extending more toward the left at the T6–T7 vertebral levels in the anterior spinal artery (ASA) distribution (Fig. 1a–e) suggestive of an acute infarct. In view of his typical clinical presentation, cord infarction in the ASA distribution and a thoracic disc protrusion at the same level, the possibility of a fibrocartilaginous embolism (FCE) from the disc was considered as he satisfied the criteria proposed by AbdelRazek et al. [1]. The ample extra-medullary space available posterior to the spinal cord negated direct compressive occlusion of the ASA by the prolapsed disc. An aortic disse
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