Further Outpatient Care
Treat persisting spasticity, which may be manifest by painful cramps and/or spasms, with oral baclofen, tizanidine, or occasionally diazepam. If the spasticity is unrelieved and remains symptomatic with manifestations such as stiffness, limited gait, spasms, cramps, and pain, proceed to interventional measures; the most successful are intramuscular injection of botulinum toxin and intrathecal baclofen by subarachnoid pump.
Impotence may respond to oral sildenafil (or related phosphodiesterase-5 inhibitors). The dose of sildenafil is 50 mg (not to exceed 100 mg) taken 30-45 minutes before sexual activity. Intervention by intraurethral alprostadil or intracavernous injection of alprostadil also may be effective.
One can manage urinary incontinence and urgency with oral oxybutynin. It is also available as a slow-release capsule (Ditropan XL). Detrol (tolterodine) or Detrol LA is a newer drug effective in the treatment of overactive bladder.
Further Inpatient Care
The patient is evaluated by the rehabilitation or physiatry service. Episodes of infarction are usually single or monophasic with a low frequency of recurrence, although this can depend on the etiology of the ischemic cord lesion. The prognosis for functional recovery should be guarded in light of the series in the medical literature. A minority of patients improve; rarely (< 10%), patients achieve a remarkable recovery of function, particularly of motor control and ability to walk. A transition to semi-independent living is accomplished through intense rehabilitation efforts.
Inpatient & Outpatient Medications
Persisting spasticity can be alleviated with conventional measures beginning with oral baclofen, tizanidine, and occasionally diazepam. If these measures are ineffectual, intramuscular botulinum toxin or intrathecal baclofen by subarachnoid pump can be recommended.
Transfer
The acute stage involves an urgency for diagnosis and the necessity for excluding emergency spinal decompressive surgery that mandates admission to a major center or hospital facility with the requisite imaging, neurosurgical, and related capabilities.
Neurologic and other disability is usually either permanent or slowly resolving. Hence, long-term care in a rehabilitation hospital or equivalent facility is the best setting once the acute phase is complete and the patient is medically stable. Transfer to this service should be a goal established early in the planning. The optimum setting for maximal and efficient recovery is the clinical unit devoted to spinal cord disorder or injury.
Deterrence/Prevention
Spinal cord ischemia and infarction are determined by vascular risk. Diabetes mellitus is common in this disorder, affecting approximately 50% of patients. As is generally the case for the tertiary complications of diabetes, strict control of blood glucose to minimize the resultant arteriolosclerosis reduces the risk of spinal cord infarction. Giant cell arteritis should be considered particularly in elderly persons and if headache, elevated ESR, or concurrent visual symptoms is present.
Other vascular risk factors including hyperlipidemia, hypertension, and arteritis of numerous types, including dysimmune, syphilis, and "vascular fungi" such as mucormycosis, may predispose patients to spinal cord infarction. Appropriate management of these risk factors is recommended for prophylaxis for future vascular complications.
Complications
Immobility stemming from the paresis and paralysis has a host of medical consequences of which the more common and serious are venous stasis, thrombosis and pulmonary embolus, pneumonia, and decubitus ulcer.
Prognosis
Spinal cord ischemia (and its irreversible tissue injury of infarction) is a myelopathy, generally associated with substantial motor, sensory, and bladder and/or bowel dysfunction. The short-term mortality rate is 20-25% over the first month following onset of symptoms. The overall life expectancy is diminished because of the vascular, infectious, and other medical complications. The striking improvement in medical care and rehabilitation has led to an improvement in quality of life for patients with spinal cord strokes since World War II. A 2012 study of 115 patients with spinal cord infarct found that patients experienced gradual improvement after the event. At 3-year follow-up, 41% of patients using a wheelchair at hospital dismissal were walking and 33% of patients catheterized at dismissal were catheter-free. [21]
Because the extent of damage is less than that sustained in most traumatic cord injuries, and the potential for recovery is greater because ischemia is reversible in part, these patients may have better function than patients with traumatic cord injuries though the prognosis for substantial motor recovery should be guarded.
Patient Education
Those at risk of spinal ischemia cannot be differentiated readily from those at risk of more common disorders of the circulation such as cerebrovascular stroke, myocardial infarction, and renal failure. The measures recommended to reduce these vascular disorders also reduce the incidence and occurrence of myelomalacia. Hence, education of those bearing a treatable vascular risk in regard to diabetic treatment, aspirin prophylaxis, antihypertensive agents, and immunomodulatory therapy logically can be expected to be of benefit and reduce the incidence of spinal thrombosis.
For excellent patient education resources, visit eMedicineHealth's Brain and Nervous System Center. Also, see eMedicineHealth's patient education article Stroke.
-
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.
