Diagnostic Considerations

The top priority is to exclude spinal cord compression by a mass lesion. The pathologies associated with spinal cord infarction are numerous and include neoplasm, spinal epidural or subdural abscess, granuloma, spinal epidural or subdural hematoma, extramedullary spinal tumor (including meningioma, neurofibroma, extradural lymphoma, metastasis), and herniated intervertebral disk. Compressive lesions are "surgical" causes and require prompt diagnosis because of the urgent clinical need for decompression.

Differentiate spinal cord infarction from acute inflammatory demyelinating polyradiculopathy (AIDP, Guillain-Barré syndrome) by following the diagnostic criteria for AIDP. The ADIP radiculopathy usually does not involve sphincter dysfunction and has a different pattern of sensory deficit (typical of peripheral neuropathy), with distal loss in the extremities and lacking a sensory level on the body.

Intraspinal hemorrhage (hematomyelia): Consider the possibility of an underlying arteriovenous malformation of the spinal cord. This is especially important because surgical extirpation may prevent recurrence of hemorrhage and/or progression to more severe disability such as complete paraplegia.

Acute myelopathy

Acute transverse myelopathy

Viral myelitis

Demyelinating disease

Neurosarcoidosis

Tuberculosis

Neurosyphilis

Parasitic diseases (schistosomiasis, cysticercosis)

Differential Diagnoses

Acute Disseminated Encephalomyelitis
Acute Inflammatory Demyelinating Polyradiculoneuropathy
Atlantoaxial Instability in Down Syndrome
Compressive mass lesions/neoplasms
Dissection Syndromes
Epidural Hematoma Management in the ED
Leptomeningeal Carcinomatosis (Metastasis) Imaging
Neurosarcoidosis
Neurosyphilis
Paraneoplastic Encephalomyelitis
Polyarteritis Nodosa
Spinal Cord Hemorrhage
Spinal Metastasis
Syringomyelia
Tuberculous Meningitis
Varicella Zoster
Vascular Surgery for Arteriovenous Malformations
Vasculitis
Viral Meningitis

Workup

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Media Gallery

Transverse section of spinal cord showing location of main pathways. The lamination of fibers in posterior columns and in lateral spinothalamic and lateral corticospinal tracts is indicated (C, cervical; T, thoracic; L, lumbar; S, sacral).
Simplified representation of course of major sensory pathways in the spinal cord. Decussation of the spinothalamic tracts occurs within one or two segments of their entry.
Pattern of arterial supply to spinal cord and (left) territories of the anterior and posterior spinal arteries.
Guide to clinical determination of the segmental spinal cord level.
Transverse section of spinal cord at T12-L1 showing infarction of central cord. The patient became paraplegic following resection of a ruptured abdominal aortic aneurysm. During surgery, prolonged occlusion of the abdominal aorta and great anterior radicular artery was necessary.

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Author

Thomas F Scott, MD Professor, Program Director, Department of Neurology, Drexel University College of Medicine; Director, Allegheny MS Treatment Center

Thomas F Scott, MD is a member of the following medical societies: American Academy of Neurology, American Neurological Association, Consortium of Multiple Sclerosis Centers, National Multiple Sclerosis Society Advisory Board, Allegheny Chapter

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Howard S Kirshner, MD Professor of Neurology, Psychiatry and Hearing and Speech Sciences, Vice Chairman, Department of Neurology, Vanderbilt University School of Medicine; Director, Vanderbilt Stroke Center; Program Director, Stroke Service, Vanderbilt Stallworth Rehabilitation Hospital; Consulting Staff, Department of Neurology, Nashville Veterans Affairs Medical Center

Howard S Kirshner, MD is a member of the following medical societies: Alpha Omega Alpha, American Neurological Association, American Society of Neurorehabilitation, American Academy of Neurology, American Heart Association, American Medical Association, National Stroke Association, Phi Beta Kappa, Tennessee Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Helmi L Lutsep, MD Professor and Vice Chair, Department of Neurology, Oregon Health and Science University School of Medicine; Associate Director, OHSU Stroke Center

Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology, American Stroke Association

Disclosure: Medscape Neurology Editorial Advisory Board for: Stroke Adjudication Committee, CREST2; Physician Advisory Board for Coherex Medical; National Leader and Steering Committee Clinical Trial, Bristol Myers Squibb; Abbott Laboratories, advisory group.

Additional Contributors

Norman C Reynolds, Jr, MD Neurologist, Veterans Affairs Medical Center of Milwaukee; Clinical Professor, Medical College of Wisconsin

Norman C Reynolds, Jr, MD is a member of the following medical societies: American Academy of Neurology, Association of Military Surgeons of the US, International Parkinson and Movement Disorder Society, Sigma Xi, The Scientific Research Honor Society, Society for Neuroscience

Disclosure: Nothing to disclose.