Case Diagnosis: Vertebral Body Infarction associated with Conus Medullaris Ischemia
A 56-year-old male with no significant past medical history presented with acute onset paraplegia with loss of bowel and bladder function. These symptoms rapidly progressed within an hour while patient was at work. Angiogram studies ruled out aortic dissection and aneurysm. Hypercoagulable panel was negative. Inflammatory markers were within normal limits, excluding a vasculitis process. Cerebrospinal fluid studies were grossly abnormal but cultures were negative. Thoracic magnetic resonance imaging (MRI) revealed an abnormal T2 signal in the T12 vertebral body with edema as well as abnormal enhancement within the conus medullaris. These findings were consistent with T12 vertebral body bone marrow infarction and conus medullaris ischemia.
Upon admission to rehabilitation, patient was functionally limited due to his diagnosis of complete T4 ASIA A spinal cord injury. Initially, he required moderate to maximal assistance with bed mobility and transfers. He worked intensively with physical and occupational therapy for four weeks, significantly benefitting from seated ergometer, truncal strengthening, and locomotor gait training. Upon discharge, the patient progressed to modified independent with wheelchair mobility, manually propelling 1,000 feet. The presence of vertebral body infarctions are very rarely found along with spinal cord infarctions due to regional arterial anastomosis.
This patient was found to have a conus medullaris infarct adjacent to the T12 vertebral body. Symptoms often include back pain, paresthesias, paraplegia, radiculopathy, bowel and bladder dysfunction, and gait imbalance. It is imperative to thoroughly review MRI imaging for surrounding anatomical infarctions in patients who suffer from spinal cord infarctions. Vertebral body infarctions are directly related to increased pain and debility in the paraplegic population. Although rare, it should always be on the differential diagnosis as early recognition allows for timely evaluation and initiation of secondary preventative therapies.
Varun Goswami– Resident Physician, East Carolina University/Vidant Medical Center
Justin Virk– Medical Student, Aureus University School of Medicine
Raymund Millan– Attending Physician, East Carolina University
Jonathan LeCrone– Medical Student, Brody School of Medicine