SPINAL CORD ISCHEMIA

Understanding the Epidemiology of Spinal Cord Ischemia

Spinal cord ischemia is a medical condition whose precise frequency remains uncertain. However, various studies provide insights into its occurrence:

• Hypoxic Ischemic Cases: Up to 45% of these cases may involve an ischemic event affecting the spinal cord. This highlights a notable association between low oxygen levels and spinal cord damage.
• Acute Myelopathies: Research suggests that about 8% of these sudden spinal cord disorders are linked to ischemia. However, this percentage indicates a significant, though not predominant, involvement of ischemic events in such conditions.
• Neurovascular Events: In events related to blood flow disruptions in the nervous system, approximately 1-2% show evidence of spinal cord ischemia. Although less common, it remains a critical area of concern.

The variability and potential severity of spinal cord ischemia underscore the need for further research to better understand its epidemiology and improve patient outcomes.

Spinal Cord Ischemia Causes:

Several factors can contribute to the development of spinal cord ischemia, each with its own underlying mechanism. The following are the different causes of spinal cord ischemia:

Atherosclerosis:

Atherosclerosis is a common cause of spinal cord ischemia, especially in older adults. It involves the buildup of plaque within the arteries supplying the spinal cord, leading to narrowing and reduced blood flow. Additionally, plaque formation can result from the accumulation of cholesterol, fatty deposits, and inflammatory cells in the arterial walls, ultimately restricting blood flow to the spinal cord.

Embolic Events:

Embolic events occur when blood clots or other debris dislodge from their site of origin and travel through the bloodstream.  When they become lodged in a smaller artery supplying the spinal cord, they stop blood from carrying oxygen. Also, these emboli can originate from various sources, including the heart (e.g., atrial fibrillation, endocarditis), large arteries (e.g., carotid artery disease), or other parts of the body (e.g., deep vein thrombosis). Finally, once lodged in a spinal artery, emboli can obstruct blood flow and cause ischemic injury to the spinal cord.

Aortic Pathologies:

Conditions affecting the aorta, the main artery of the body, can lead to spinal cord ischemia. Thus, aortic pathologies such as aortic dissection, aortic aneurysm, and atherosclerotic plaque formation can impair blood flow.  When this occurs, the spinal cord will become compromised because of vascular insufficiency in the arteries branching off the aorta.

Spinal Cord Trauma:

Traumatic injuries to the spine can disrupt the blood supply to the spinal cord, resulting in ischemia and subsequent neurological deficits. Overall, these injuries may include vertebral fractures, spinal cord contusions, or compression injuries caused by trauma-related hematoma or swelling. Therefore, the disruption of blood vessels supplying the spinal cord can lead to hemorrhage, thrombosis, or vasospasm. These conditions will ultimately compromise blood flow, causing ischemic damage.

Vascular Malformations:

Congenital or acquired vascular malformations in the spinal cord or adjacent structures can predispose individuals to spinal cord ischemia. Moreover, these malformations, such as arteriovenous malformations (AVMs), arteriovenous fistulas (AVFs), or cavernous malformations, disrupt normal blood flow patterns.  To summarize, these conditions may lead to localized ischemia if blood flow is diverted away from critical spinal cord regions.

Inflammatory Disorders:

Certain inflammatory conditions affecting the blood vessels, such as vasculitis, can result in inflammation and damage to the vascular walls. In addition, this condition can lead to impaired blood flow and ischemia. Inflammatory disorders like giant cell arteritis, systemic lupus erythematosus (SLE), and rheumatoid arthritis can affect both large and small vessels.  When these conditions affect the blood supply to the spinal cord, it can increase the risk of ischemic injury.

Thrombotic Disorders:

Thrombotic disorders, characterized by abnormal blood clotting within the vasculature, can occlude spinal arteries and cause ischemia. Meanwhile, conditions such as antiphospholipid syndrome, thrombophilias, and coagulopathies can predispose individuals to thrombotic events, resulting in vascular occlusion and subsequent spinal cord ischemia.

Surgical Complications:

In some cases, spinal cord ischemia may occur as a complication of spinal surgery or other surgical procedures involving the thoracic or abdominal aorta. In addition, surgical manipulation of the aorta or adjacent blood vessels can disrupt blood flow to the spinal cord, leading to ischemic injury.

Overall, spinal cord ischemia can arise from a variety of causes, including vascular diseases, embolic events, traumatic injuries, vascular malformations, inflammatory disorders, thrombotic disorders, and surgical complications. Thus, identifying the underlying cause is essential for guiding treatment and preventing further neurological damage.

Spinal cord ischemia occurs when the blood supply to the spinal cord is compromised, leading to a range of neurological symptoms that can vary depending on the severity, location, and duration of the ischemic insult. The symptoms of spinal cord ischemia typically manifest as neurological deficits below the level of the affected spinal cord segment. Here are the different symptoms associated with spinal cord ischemia:

Symptoms of Spinal Cord Ischemia

Spinal cord ischemia happens when blood flow to the spinal cord is low, causing nerve-related symptoms. These vary based on how severe, where, and how long the blood flow is cut. Symptoms affect areas below the damaged part of the spinal cord. Here are the main symptoms:

Weakness and Paralysis

A key sign is weak or still limbs. Depending on the affected spine part, arms, legs, or both may be weak or paralyzed. Also, this can range from mild to severe, making it hard to move or function.

Sensory Issues

Low blood flow can cause numbness, tingling, or no feeling below the injury. Patients may lose sense of touch, heat, vibration, or body position. These issues can affect one or both sides, based on the damage.

Pain

Ischemia can cause nerve pain, like burning, shooting, or stabbing feelings. Pain may stay in the back or spread to areas linked to the harmed spine part. This pain can harm life quality.

Loss of Reflexes

Ischemia can stop reflexes below the injury, like the knee or ankle jerk. Weak or missing reflexes show spine issues and help pinpoint the damage.

Bowel and Bladder Issues

Low blood flow can affect nerves that control bowel and bladder. Patients may have leaks, trouble holding urine, or problems starting or keeping flow. These issues can hurt life quality and need treatment.

Sexual Issues

Ischemia can harm nerves tied to sexual function. Men and women may face issues like trouble with erections, low desire, or problems reaching climax. This can affect relationships and may need counseling or treatment.

Coordination and Balance Problems

Ischemia can make walking, coordination, or balance hard. Patients may feel clumsy, unsteady, or have trouble walking or standing. Unfortunately, this raises fall and injury risks.

Spasticity

In some cases, ischemia causes spasticity, with tight muscles, spasms, or strong reflexes. Ultimately, severe spasticity can limit movement and may require drugs or therapy.

Overall, spinal cord ischemia symptoms can greatly affect function and life quality. Therefore, spotting and treating these signs early is vital for better results and to stop more nerve harm.

Weakness and Paralysis:

One of the hallmark symptoms of spinal cord ischemia is weakness or paralysis in the affected regions of the body. Depending on which spinal cord segments are affected, individuals may experience weakness or paralysis in the arms, legs, or both. All in all, the weakness may range from mild to severe and can significantly impair mobility and function.

Sensory Disturbances:

Spinal cord ischemia can also lead to sensory disturbances, including numbness, tingling, or loss of sensation below the level of the injury. Patients may experience sensory deficits in various modalities, such as touch, temperature, vibration, and proprioception. These sensory abnormalities may be unilateral or bilateral, depending on the extent of spinal cord involvement.

Pain:

Spinal cord ischemia can cause pain, characterized by burning, shooting, or stabbing sensations in the affected areas. Also, the pain may be localized to the back or radiate to other parts of the body innervated by the affected spinal cord segments. Finally, pain can be debilitating and may impact the individual’s quality of life.

Loss of Reflexes:

Spinal cord ischemia can result in the loss of deep tendon reflexes below the level of the injury. Reflexes such as the patellar reflex (knee jerk) or Achilles reflex (ankle jerk) may be diminished or absent on physical examination. The loss of reflexes indicates spinal cord dysfunction and can help localize the level of the injury.

Bowel and Bladder Dysfunction:

Spinal cord ischemia may disrupt the autonomic nervous system pathways that control bowel and bladder function. However, patients may experience urinary or fecal incontinence, urinary retention, or difficulty initiating and maintaining voiding. This can significantly impact the individual’s quality of life and may require medical help for management.

Sexual Dysfunction:

Dysfunction of the spinal cord pathways involved in sexual function can occur with spinal cord ischemia. Both men and women may experience erectile dysfunction, loss of libido, or difficulty achieving orgasm. Sexual dysfunction can have a profound effect on intimacy and may necessitate medical help.

Motor Coordination and Balance Issues:

Spinal cord ischemia can affect motor coordination and balance, leading to difficulties with walking, coordination, and balance. Patients may experience gait clumsiness or a feeling of unsteadiness when walking or standing. These motor deficits can increase the risk of falls and injuries.

Spasticity:

In some cases, spinal cord ischemia can lead to spasticity, characterized by involuntary muscle contractions and stiffness in the affected limbs. Spasticity may appear as muscle tightness, spasms, or exaggerated reflexes. Severe spasticity can interfere with mobility and may require treatment with medications or physical therapy.

Overall, the symptoms of spinal cord ischemia can impact an individual’s function and quality of life. Early recognition and management of these symptoms are essential for optimizing outcomes and preventing further problems.

Diagnosis:

Doctors diagnose spinal cord ischemia through a combination of medical history, physical examination, and diagnostic tests. Imaging studies such as MRI or CT scans can help identify abnormalities in the spinal cord and blood vessels. Furthermore, electrophysiological tests like electromyography (EMG) or nerve conduction studies may assess nerve function.

Understanding the Blood Supply Sources to the Spinal Cord

The spinal cord receives its blood supply from several critical arteries, ensuring it functions properly.

1. Anterior Spinal Artery:

• This artery is formed by the convergence of small branches originating from the vertebral arteries located at the top of the spinal column.
• It runs along the front side of the spinal cord and primarily supplies the anterior portion with essential nutrients and oxygen.

2. Radicular Arteries:

• These arteries play a crucial role in supplying blood to the spinal cord’s anterior section.
• They branch off from the aorta at several spinal levels and extend towards the spinal cord.
• Radicular arteries create connections, known as anastomoses, with smaller branches of the spinal cord, facilitating a comprehensive blood supply network.

3. Posterior Spinal Arteries:

• Although not detailed in the article, these arteries arise from the posterior inferior cerebellar arteries, providing the posterior aspect of the spinal cord with its blood supply.
• Their network complements the anterior spinal artery, ensuring the entire spinal cord remains well-supplied.

This intricate system of arteries, including their connections and origins, plays a vital role in maintaining the health and functionality of the spinal cord. By understanding these sources, medical professionals can better appreciate the complexities of spinal cord health and address issues related to its blood supply effectively.

Evidence for Treatment and Management of Spinal Cord Ischemia

General Reference

For those seeking a foundational understanding of spinal cord disorders, including ischemia, the June 2008 issue of Continuum is invaluable. Also, it comprehensively reviews spinal cord, root, and plexus disorders, focusing on spinal cord ischemia.

Epidemiology

A study from 1989 by Sandson and Friedman highlights the rarity of spinal cord ischemia, documenting it as constituting just 1% of stroke cases based on a four-year community study. Additionally, this offers context on the frequency and detection in clinical settings.

Causes of Cord Ischemia

Research by Novy et al. (2006) provides a detailed analysis of spinal cord ischemia types, giving insight into clinical and imaging patterns. Cheshire and colleagues (1996) further investigated the causes and outcomes, providing thorough data from university hospital case reviews. Duggal and Lach (2002) also contribute, focusing on lumbosacral spinal cord vulnerability post-cardiac arrest and hypotension, a critical consideration for patient risk assessments.

Diagnosis

Gass (2000) demonstrates the role of MRI in diagnosing spinal cord infarction through specific case images, which aids in identifying ischemic patterns and planning subsequent treatment steps.

Treatment and Management

Cheung et al. (2005) outline important strategies for managing paraplegia risk after thoracic aortic aneurysm repairs. In addition, methods include elevating mean arterial pressure and using lumbar drains to divert cerebrospinal fluid, underlining the importance of proactive vascular intervention techniques.

Venous Thrombosis Prevention

The American College of Chest Physicians provides guidelines on preventing venous thromboembolism (VTE) in non-orthopedic surgical patients, which include stroke sufferers. On the whole, these protocols are essential for minimizing secondary complications associated with spinal cord ischemia.

Prognosis

Masson et al. (2004) explore the prognosis of spinal cord infarction, noting the imaging characteristics and factors affecting patient outcomes. Studies by Nedeltchev et al. (2004) and Pelser and van Gijn (1993) deliver insights on long-term outcomes, highlighting key prognostic indicators and potential improvements in motor function, albeit often accompanied by significant pain.

By synthesizing this vast array of studies, clinicians can gain a nuanced understanding of spinal cord ischemia, enabling informed decision-making around diagnosis, management, and patient care strategies.

Emergency Management Steps for Spinal Cord Ischemia

Handling spinal cord ischemia promptly is crucial to prevent long-term damage. Here’s a structured approach to managing this emergency:

Address Hypotension

• Ensure that the patient’s Mean Arterial Pressure (MAP) remains above 65 mm Hg.
• If not contraindicated, administer intravenous fluids and vasopressor agents to maintain a MAP greater than 85 mm Hg for at least 24 hours.

Therapeutic Interventions Post-Surgery

• For ischemia following thoracoabdominal surgery, consider installing a lumbar drain to help relieve cerebrospinal fluid pressure.
• Though there are no universal guidelines for drainage rates, aim for 10-15 ml per hour or adjust based on neurological assessments.

Manage Embolic Origins

• If the ischemia is believed to be caused by an embolism, consider using intravenous tissue plasminogen activator (tPA), following established criteria for its administration.
• In cases with a known embolic source, interventional neuroradiology procedures like embolectomy or intra-arterial thrombolytic therapy may be viable options.

Temperature Regulation

• During the initial 24 to 48 hours of treatment, maintain normal body temperature using standard procedures to address hyperthermia.

Implementing these steps quickly can significantly influence patient outcomes, emphasizing the importance of immediate and appropriate intervention.

Nonsurgical Treatment:

Nonsurgical treatments for spinal cord ischemia aim to improve blood flow and manage symptoms. This may include medications such as anticoagulants to prevent blood clots, vasodilators to widen blood vessels, and pain relievers to alleviate discomfort. Physical therapy and rehabilitation can help restore function and mobility.

Managing Venous Thrombosis Prophylaxis in Spinal Cord Ischemia Cases

Managing venous thrombosis prophylaxis is a critical aspect of treating spinal cord ischemia. Here’s a structured guide to understanding the process:

Initial Steps

• Begin with mechanical methods, such as using sequential compression devices (SCDs), immediately upon diagnosis. This non-invasive approach helps improve blood circulation and reduce the risk of clot formation.
• Introduction of Chemical Prophylaxis:  Once it’s medically safe, introduce chemical prophylaxis. This usually follows the stabilization of any initial bleeding concerns. However, if hemorrhage is present at the time of diagnosis, it’s advisable to delay chemical prophylaxis for about 5 to 7 days to allow for proper assessment and management of bleeding risks.
• Use of Drains:  In scenarios where surgical drains are utilized, it’s important to inject heparin 24 hours after the drain placement. Heparin administration should ideally continue until 12 hours before the drain is scheduled for removal.
• Preferred Pharmacological Agents:  Post-drain removal, low molecular weight heparin (e.g., Enoxaparin) is generally preferred for ongoing venous thrombosis prevention. This can typically be administered as either a 40 mg dose once daily or a 30 mg dose twice daily, based on patient needs and medical advice.
• Duration of Chemical Prophylaxis:  For comprehensive protection, continue the anticoagulation treatment for a period of six months. This duration significantly mitigates the risk of venous thromboembolism during the recovery phase.

By scheduling timely interventions and using a mix of mechanical and chemical prophylaxis, healthcare providers can effectively minimize the risk of venous thrombosis in patients with spinal cord ischemia. Each step requires careful consideration of the patient’s unique medical condition and any concurrent complications.

Surgical Treatment:

Surgical treatment for spinal cord ischemia aims to address the underlying cause of reduced blood flow to the spinal cord and restore adequate circulation to prevent further damage and improve neurological function. The specific approach to surgery depends on the underlying cause of ischemia and the extent of spinal cord injury. Whenever possible, the surgeons at the Southwest Scoliosis and Spine Institute will employ Minimally Invasive Spine Surgery.

Vascular Bypass Surgery:

In cases where there is a blockage or narrowing of major blood vessels supplying the spinal cord, vascular bypass surgery may be performed. During this procedure, a vascular surgeon creates a new pathway for blood flow by grafting a healthy blood vessel from another part of the body or using artificial graft material to bypass the blocked or narrowed segment. By rerouting blood flow around the obstruction, this surgery helps restore adequate blood supply to the spinal cord.

Endovascular Procedures:

The endovascular techniques involve accessing the blood vessels through minimally invasive methods, typically via catheterization through the arteries. Endovascular procedures may include angioplasty, where a balloon catheter is used to widen narrowed blood vessels, or stent placement to keep the vessels open. In cases of embolism, where a blood clot has lodged in a spinal artery, thrombectomy or clot retrieval procedures may be performed to remove the clot and restore blood flow.

Spinal Decompression Surgery:

In some cases, spinal cord ischemia may result from compression of the spinal cord due to conditions like spinal stenosis or herniated discs. Spinal decompression surgery aims to relieve pressure on the spinal cord by removing bone or tissue that is compressing the nerves. This may involve procedures such as laminectomy, discectomy, or spinal fusion to stabilize the spine and alleviate compression.

Blood Flow Repair Techniques

In rare cases of long-term spinal cord ischemia with very low blood flow, advanced methods to fix blood flow may be used. These can include artery bypass using natural or man-made grafts to make new blood paths or complex procedures to tie off or rebuild spinal arteries.

Nerve Protection Methods

Along with surgeries to restore blood flow, nerve protection steps can help limit spinal cord damage. These may include drugs like steroids or antioxidants to reduce swelling and stress, plus ways to improve spinal cord blood flow and aid tissue healing.

Steroids given through a vein can be one option, possibly helping with injury-related swelling in spinal cord damage. But they must be used carefully due to a higher risk of infection from steroid use.

Steroids can be harmful in cases of stroke or swelling from head injuries, as they may worsen outcomes. This shows the need for careful checks and custom treatment plans.

By knowing when these therapies help or harm, doctors can make smart choices to boost recovery and lower risks.

The choice of surgery depends on factors like the cause of ischemia, the severity of nerve issues, and the patient’s overall health. Surgery is often part of a full treatment plan that includes drugs, rehab, and regular checks to improve results and life quality for those with spinal cord ischemia.

Benefits of Surgery

Surgery for spinal cord ischemia offers several benefits to ease symptoms, restore blood flow, and prevent more nerve harm. These benefits depend on the ischemia cause, the extent of spinal cord injury, and the surgery type. Here are some key benefits:

Restoring Blood Flow

Surgery aims to bring back good blood flow to the spinal cord. By fixing issues like blocked arteries or pressed vessels, it improves blood to affected areas. This helps prevent more injury and supports tissue healing.

Nerve Function Improvement

Surgery done soon after symptoms start can improve nerve function. By easing pressure on the spinal cord, freeing nerve roots, or fixing blood vessels, it can reduce pain, weakness, numbness, and mobility issues. Sometimes, surgery stops nerve problems from worsening and aids recovery.

Preventing Lasting Damage

Quick surgery can stop permanent spinal cord harm and reduce the risk of lasting nerve issues. By fixing the ischemia cause and restoring blood flow, surgery limits tissue damage and keeps spinal cord function. This approach is key to reducing long-term disability and improving outcomes.

Pain Relief

Surgery can ease pain from spinal cord ischemia, especially if caused by nerve pressure or irritation. By freeing nerves, removing bad discs, or stabilizing the spine, surgery reduces pain and improves life quality.

Avoiding Complications

Spinal cord ischemia can cause issues like paralysis, loss of bladder or bowel control, and poor sensation. Surgery tackles vessel or structural problems to lower these risks. By restoring blood flow and easing spinal cord pressure, it reduces the chance of further issues and improves the patient’s outlook.

Improved Functional Outcomes:

For patients experiencing neurological deficits due to spinal cord ischemia, surgery offers the potential for improved functional outcomes and enhanced mobility. By optimizing spinal cord perfusion and addressing contributing factors such as spinal stenosis or vascular abnormalities, surgical treatment can help patients regain strength, sensation, and coordination, enabling them to resume daily activities and improve their quality of life.

Overall, surgery for spinal cord ischemia plays a crucial role in addressing the underlying causes of ischemia, relieving symptoms, and promoting neurological recovery. While the specific benefits may vary depending on individual patient factors and the nature of the underlying condition, surgical intervention offers a proactive and targeted approach to managing spinal cord ischemia and optimizing patient outcomes.

Recovery Period:

Recovery from spinal cord ischemia depends on the severity of the condition, the extent of neurological damage, and the effectiveness of treatment. Rehabilitation efforts, including physical therapy, occupational therapy, and assistive devices, play a crucial role in the recovery process. Recovery periods can vary widely among individuals.

Rehabilitation:

Rehabilitation after spinal cord ischemia focuses on maximizing function, independence, and quality of life. This may involve a multidisciplinary approach, including physical therapy, occupational therapy, speech therapy, and psychological support. Assistive devices and adaptive techniques can help individuals manage daily activities and improve mobility.

Initiating Physical Therapy Early

Physical therapy should begin as soon as possible to optimize outcomes. If surgical stabilization is required, or if drains and pressers are in use, it’s crucial to start rehabilitation therapy immediately after these are removed. Early intervention not only aids in maintaining muscle strength but also enhances the range of motion, even while the patient is still in bed.

Comprehensive Rehabilitation Approach

A multidisciplinary team tailors the rehabilitation process to the patient’s unique needs. Occupational therapists work on daily living skills, while speech therapists may address communication challenges. Psychological support is essential to help patients and their families cope with the emotional aspects of recovery.

Leveraging Assistive Devices

Incorporating assistive devices and adaptive techniques can significantly improve mobility and independence. Whether through walkers, wheelchairs, or specialized equipment, these tools are vital in helping patients navigate their environments safely and effectively. By integrating these strategies, spinal cord ischemia patients can achieve better rehabilitation outcomes, leading to enhanced quality of life and greater independence.

The Prognosis of Spinal Cord Ischemia

The prognosis for spinal cord ischemia varies depending on factors such as the extent of the ischemic injury. In addition, the rapidity of treatment and the underlying cause will affect treatment. Some patients may experience partial or complete recovery of neurological function with appropriate treatment and rehabilitation. However, others may experience difficulties in recovery. Your doctor will discuss your individual prognosis based on your specific circumstances and guide what to expect.

Importance of Early Intervention

The rapidity of treatment is critical. Early and effective medical intervention can significantly influence recovery outcomes. Understanding the severity and timing of symptoms can aid in setting realistic expectations for recovery.

By considering these factors, healthcare providers can better tailor treatment and rehabilitation plans to improve recovery chances. Always consult with your healthcare professional to understand how these statistics might relate to your personal medical situation.

Key Indicators of Prognosis

• Motor Improvement: According to one study, the absence of motor improvement in the first 24 hours can be a predictor of poor long-term outcomes. This early phase is crucial in determining the likely trajectory of recovery.
• Severity of Motor Deficits:
  • If motor deficits are not severe at their peak, nearly 50% of patients may regain the ability to walk.
  • In cases of moderate severity, about 30% of patients might still require a wheelchair at four years post-injury.

Reasons to Choose The Southwest Scoliosis and Spine Institute:

The Southwest Scoliosis and Spine Institute, led by renowned spine surgeons Doctors Richard A. Hostin, Devish Ramnath, and Ishaq Syed, offers comprehensive care for spinal cord ischemia. With state-of-the-art facilities and a multidisciplinary team, they provide personalized treatment plans tailored to each patient’s needs. Their expertise, experience, and commitment to excellence make them a trusted choice for individuals seeking top-quality spinal care. Located in Dallas, Plano, and Frisco, Texas, their convenient locations ensure accessible and compassionate care for patients with spinal cord ischemia.

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Citation: National Institute of Health – Spinal Cord Ischemia

The medical content on this page has been carefully reviewed and approved for accuracy by the Southwest Scoliosis and Spine Institute’s qualified healthcare professionals, including our board-certified physicians and Physician Assistants. Our team ensures that all information reflects the latest evidence-based practices and meets rigorous standards of medical accuracy, with oversight from our expert spine doctors to guarantee reliability for our patients.