Vascular myelopathy
Vascular myelopathy refers to an abnormality of the spinal cord in regard to its blood supply. The blood supply is complicated and supplied by two major vessel groups: the posterior spinal arteries and the anterior spinal arteries—of which the Artery of Adamkiewicz is the largest. Both the posterior and anterior spinal arteries run the entire length of the spinal cord and receive anastomotic vessels in many places. The anterior spinal artery has a less efficient supply of blood and is therefore more susceptible to vascular disease. Whilst atherosclerosis of spinal arteries is rare, necrosis in the anterior artery can be caused by disease in vessels originating from the segmental arteries such as atheroma or aortic dissection.
Spinal cord infarction
Anterior spinal artery syndrome
Anterior spinal artery syndrome is necrosis of tissue in the anterior spinal artery or its branches. It is characterised by pain which radiates at onset and sudden quadraplegia or paraplegia. Within days, flaccid limbs become spastic and hyporeflexia turns into hyperreflexia and extensor plantar nerve responses. Sensory loss to pain and temperature also occurs up to the level of damage on the spinal cord, as damage to different areas will affect different parts of the body.In diagnosis, other causes of abrupt paralysis should be excluded such as cord compression, transverse myelitis and Guillain–Barré syndrome. A specific cause of the infarction should be looked for, such as diabetes, polyarteritis nodosa or systemic lupus erythematosus. Neurosyphilis is also a known cause. Other causes include:
| Type of disease | Causes |
| Small blood vessel | Diabetes, polyarteritis nodosa, systemic lupus erythematosus, neurosyphilis |
| Arterial compression or occlusion | Extradural tumors, aortic dissection, disk fragmentation, aortic surgery |
| Embolic occlusion | Decompression sickness, aortic arteriography |
| Hypotensive | Myocardial infarction |
Treatment is supportive and aims to relieve symptoms. The prognosis is dependent upon individual circumstances and factors.
Posterior spinal artery syndrome
Posterior spinal artery syndrome is much rarer than its anterior counterpart as the white matter structures that are present are much less vulnerable to ischemia since they have a better blood supply. When posterior spinal artery syndrome does occur, dorsal columns are damaged and ischemia may spread into the posterior horns. Clinically the syndrome presents as a loss of tendon reflexes and loss of joint position senseTransient ischemic attack
Transient ischemic attacks rarely affect the spinal cord and usually affect the brain; however, cases have been documented in these areas. Spinal ateriovenous malformations are the main cause and are represented later in this article. However, TIAs can result from emboli in calcific aortic disease and aortic coarctation.Spinal arteriovenous malformations
Spinal arteriovenous malformations are congenital abnormalities of blood vessels. Arteries that directly communicate with veins bypass the capillary network and thus creates a shunt. AVMs appear as a mass of, dilated vessels. In regards to the spinal cord, they are usually located in the thoracolumbar region, as opposed to the upper thoracic and cervical regions. Cervical malformations arise from the anterior spinal artery and lie within the cord, whereas thoracolumbar malformations can be internal, external or encompass both areas of the cord.Malformations can be recognised as part of an acute illness or gradual onset disease. In diseases such as subarachnoid hemorrhage, signs and symptoms include headache, neck stiffness and back and leg pain. Extradural, subdural and intramedullary hematomas are all signs of acute cord compression. Gradual onset diseases are more common and are usually due to an increased venous pressure. Other factors such as thrombosis or arachnoiditis can be involved. A bruit may be heard overlying the spinal arteriovenous malformation. Very occasionally, nevus or angiolipomas are found.
Myelography is used to confirm the diagnosis of AVMs and it shows 'snake-like' vessels on the cord's surface. If the myelogram is positive, angiography is required to show the extent of malformation and the exact site of the shunt. Magnetic resonance imaging may show the appropriate area. If AVMs are left untreated, 50% of patients with gradual symptoms will be unable to walk within 3 years of onset. Operations can prevent progression and may improve any gait or incontinence.