THE syndrome of acute anterior-spinal-artery thrombosis has been well described.12 Although earlier reports considered pain a major symptom of this syndrome, more recent publications have not emphasized this manifestation. We have recently observed 2 patients with this syndrome. In both cases not only was pain the initial manifestation, but its severity obscured the immediate neurologic diag nosis. Therefore, this report re-emphasizes pain as an important presenting manifestation of this syn drome and one that might initially becloud the cor rect diagnosis.
CASE REPORTS
CASE 1. A 52-year-old woman had been well until ap proximately 5 hours before entering Walter Reed General Hospital, when a dull, oppressive subxiphoid pain asso ciated with mild shortness of breath had developed while she was housecleaning. She rested for a few minutes and experienced some transient relief, but the pain soon recurred. It became progressively more severe, with radiation from the substernal region into both shoulders and the left axilla and down the inner aspect of the left arm. This was accompanied by further shortness of breath and a mild diaphoresis. Because of the progressive severity of the chest pain, she was hospitalized as having a possible coronary occlusion. Upon admission to the ward, she was anxious and still in enough pain to require morphine for relief. She also complained of paresthesia and muscle spasm in both lower extremities.
Physical examination revealed marked weakness in the left lower extremity and anesthesia to pain and temperature.
There was also minimal hypesthesia in the right lower ex tremity, but position, tactile discrimination and vibratory sensory modalities were intact in both extremities. Reflexes were unimpaired, and plantar responses were normal.
The temperature was normal, and the pulse 70. The blood pressure was 160/90.
During the first 18 hours in the hospital the pain subsided to a residual ache in both axillae that persisted for several days. The physical findings remained stable except for progressive changes in the neurologic findings. A complete flaccid paralysis developed in the left lower extremity with a Babinski sign, and a definite paresis developed in the right lower extremity. Hyporeflexia appeared in both lower extremities, the superficial abdominal reflexes disappeared, and the hypesthesia to pain and temperature, which in volved both lower extremities, extended rostrally to the 3d thoracic segment on the left and to the 5th thoracic seg
ment on the right. It soon became evident that urinary re tention and obstipation had also developed.
Extensive studies were made in an attempt to establish a possible cause. All tests were negative, including a spinal tap and emergency myelography. Although a coronary oc clusion was first suspected, the neurologic progression and the normal studies led to the diagnosis of anterior-spinal- artery thrombosis.
Within 48 hours after admission, a program of progressive physiotherapy, including appropriate bowel and bladder retraining, was instituted. After 1 week the patient regained full control of her bowels, and shortly thereafter she also regained control of her bladder. Pyelonephritis developed and was treated with antibiotics. By the 5th week she was able to walk with the aid of crutches. The neurologic pic tyre changed from an initial flaccid paralysis to one of gradual spasticity. Pyuria, signs of spasticity and a minor degree of hypesthesia persisted; however, 10 weeks after the onset of the illness she was able to walk without the aid of crutches.
CASE 2. On the afternoon before admission to Brooke Army Hospital a 32-year-old woman had what she in interpreted as "gas pains" in the upper part of the abdomen.
Within 2 or 3 hours the pains, which had become sharper and somewhat colicky, became a persistent, dull epigastric ache. Extreme pain in the right arm also occurred on mo tion and radiated into the fingers. Within a few hours she was also complaining of paresthesia and weakness in the right leg and a sensation of numbness in the left leg. Be cause of these developments, she presented herself at a local hospital and shortly after admission was transferred to Brooke Army Hospital. Except for marked tenderness over the right lower quadrant of the abdomen, moderate tender ness over the spinous processes of the 4th through the 10th thoracic segment and abnormal findings on neurological exam amination, the initial physical examination was unremark able. There was a flaccid paraplegia, with a fluctuating hypesthesia to pain and temperature, which involved both lower extremities and extended rostrally to the upper part of the abdomen. The superficial abdominal reflexes as well as the knee and ankle jerks were absent. A neurogenic bladder subsequently developed. In addition to laboratory studies, a spinal tap and myelography failed to reveal any thing unusual. The neurologic examination remained rela tively stable, and the abdominal pain gradually subsided.
The patient continued to complain bitterly of a radicular type of burning pain corresponding to a distribution to the 5th to 6th cervical segments on the right.
A regimen of physical therapy was instituted, and she slowly but progressively improved. She progressed from flaccidity to spasticity within 10 days, regained bladder control in 7 weeks and began walking in parallel bars at 10 weeks. The radicular pain in the right upper extremity responded to mephenesin. After 13 weeks she was able to walk with the aid of braces and crutches, and was discharged from the hospital. Six months after admission she was show ing progressive improvement, but chronic urinary-tract in fection still required treatment.
include infectious transverse myelitis, multiple sclero sis, extradural compression of the spinal cord and spontaneous hematomyelia. A normal spinal tap and a normal myelogram tend to rule out most of these entities. Probably the only condition that cannot be excluded by these measures is a central hemorrhage into the cord.
Occasionally, pain is the heralding feature of acute anterior-spinal-artery thrombosis. If this pain is severe enough, it may overshadow the other manifestations, and a diagnosis of neurologic disease may initially be overlooked. This was the experience in the 2 cases presented above. In each, however, within a few hours of the onset of pain, neurologic features were evident, and a correct diagnosis was made.
In addition to a re-emphasis on pain as an initial manifestation of anterior-spinal-artery occlusion, two features in these cases deserve a brief comment. Pye Nephritis invariably develops as a result of prolonged catheter drainage, and may be one of the most serious long-term residuals of the syndrome. The second point is the favorable prognosis from the standpoint of return of motor function. Most patients, with the aid of proper physiotherapy and muscle re-education, can be returned to a satisfactory functional state.
SUMMARY AND CONCLUSIONS
Two cases of acute thrombosis of the anterior spinal artery are presented. Pain as an initial symp tom of this syndrome is re-emphasized. The proper appreciation of this manifestation may lead to a correct diagnosis.