Acute paraplegia with or without coronavirus disease 2019 infection: Decision-making algorithm

Abstract

We thank our colleagues for their letter. Acute paraplegia should always suggest two urgent diagnoses that require immediate specific treatment: acute aorta occlusion (AAO), favored by coagulation disorders in those with coronavirus disease 2019 (COVID-19) infection, and spinal cord compression, with COVID-19 as a coexisting condition. AAO can be easy to diagnose in the presence of acute pain, pallor and coldness of the lower limbs, mottling, and the absence of femoral pulses. However, in most cases, the diagnosis will remain difficult, and the patients will often be referred to a neurologist or neurosurgeon. The specificity of pulse palpation is very low,1Currie I.C. Jones A.J. Wakeley C.J. Tennant W.G. Wilson Y.G. Baird R.N. et al.Non-invasive aortoiliac assessment.Eur J Vasc Endovasc Surg. 1995; 9: 24-28Abstract Full Text PDF PubMed Scopus (37) Google Scholar and the use of the ankle brachial index must be systematic. The use of pulsed wave Doppler ultrasound by well-trained emergency physicians could identify AAO; however, urgent computed tomography remains the reference standard. AAO is a life-threatening event with mortality of near 30%. The main determinants of mortality are the interval until revascularization and the neurologic status of the extremities.2Babu S.C. Shah P.M. Nitahara J. Acute aortic occlusion—factors that influence outcome.J Vasc Surg. 1995; 21: 567-572Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar In the case of AAO, the neurologic symptoms can be caused by ischemia of the peripheral nerves or spinal cord ischemia. Almost all the blood supply to the sacral roots and plexus derives from the internal iliac arteries.3Gloviczki P. Cross S.A. Stanson A.W. Carmichael S.W. Bower T.C. Pairolero P.C. et al.Ischemic injury to the spinal cord or lumbosacral plexus after aorto-iliac reconstruction.Am J Surg. 1991; 162: 131-136Abstract Full Text PDF PubMed Scopus (135) Google Scholar The physiopathology of spinal cord ischemia in those with AAO is not totally understood. The blood supply of the terminal cord can depend on the lower lumbar or sacral radicular arteries, when the Adamkiewicz artery originates abnormally high or is chronically occluded.3Gloviczki P. Cross S.A. Stanson A.W. Carmichael S.W. Bower T.C. Pairolero P.C. et al.Ischemic injury to the spinal cord or lumbosacral plexus after aorto-iliac reconstruction.Am J Surg. 1991; 162: 131-136Abstract Full Text PDF PubMed Scopus (135) Google Scholar The variable intensity of sensorimotor deficits might be explained by the variable collateralization of the spinal arterial supply.4Zalewski N.L. Rabinstein A.A. Krecke K.N. Brown Jr., R.D. Wijdicks E.F.M. Weinshenker B.G. et al.Characteristics of spontaneous spinal cord infarction and proposed diagnostic criteria.JAMA Neurol. 2019; 76: 56-63Crossref PubMed Scopus (84) Google Scholar However, urgent revascularization is always required for both causes. The neurologic recovery will be better in the case of peripheral ischemia. However, patients can also have spinal cord compression with no relationship to COVID-19 infection. The presence of COVID-19 infection can lead us astray, and we can miss the urgent diagnosis requiring medullar magnetic resonance imaging studies and surgical decompression.5Laur O. Nandu H. Titelbaum D.S. Nunez D.B. Khurana B. Nontraumatic spinal cord compression: MRI primer for emergency department radiologists.Radiographics. 2019; 39: 1862-1880Crossref Scopus (14) Google Scholar Finally, the diagnosis might be acute myelopathy associated with COVID-19 infection6Canavero I. Valentino F. Colombo E. Franciotta D. Ferrandi D. Mussa M. et al.Acute myelopathies associated to SARS-CoV-2 infection: viral or immune-mediated damage?.Travel Med Infect Dis. 2021; 40: 102000Crossref Scopus (6) Google Scholar; however, this must remain a diagnosis of elimination, in particular, because no specific treatment is available. Thus, with or without COVID-19 infection, patient with acute paraplegia must very quickly undergo computed tomography and, if the findings are negative, medullar magnetic resonance imaging. Paraparesis due to aortic thromboembolism as a rare complication of COVID-19 infectionJournal of Vascular SurgeryVol. 74Issue 3PreviewIn the context of the coronavirus disease 2019 (COVID-19) pandemic, a recent report by Naudin et al1 sought to explain arterial thrombosis as a presentation of COVID-19 infection. Their patient was admitted with acute monoparesis and sensory loss of the left lower limb as a consequence of aortoiliac thrombosis and limb ischemia during COVID-19 infection.1 However, we want to emphasize that, in addition to limb ischemia, spinal cord ischemia should be considered in patients with acute limb paresis and COVID-19 infection. Full-Text PDF