Nucleus Polposus Embolism Causing Anterior Spinal Artery Occlusion: A Rare but Possible Cause of Fibrocartilaginous Embolic Myelopathy.

Abstract

Fibrocartilaginous embolic myelopathy (FCEM) is a rare cause of spinal cord infarction. It has been confirmed by autopsy in postmortem cases. Herein we describe a case of FCEM diagnosed based on clinical grounds. A 58-year-old man presented with acute onset of complete paraplegia with bladder and bowel involvement developing a few hours after a trivial trauma. There were no upper motor neuron signs. His magnetic resonance imaging (MRI) was suggestive of longitudinally extensive transverse myelitis from T5 to the conus. There was left paracentral disc protrusion at the T4-T5 level. However, no features of inflammatory, infectious, or autoimmune etiology were found on history, on examination, or in blood or cerebrospinal fluid analysis, and there was no contrast enhancement on MRI. A diagnosis of anterior spinal artery occlusion was made based on clinical examination with sparing of posterior column sensations in the lower limbs, predominant involvement of anterior half of the spinal cord on MRI, and accompanying new onset of back pain with rapid symptom progression to nadir as opposed to inflammatory etiology. Fibrocartilaginous embolism was suspected after ruling out all other causes of vascular compromise and presence of disc herniation at T4-T5. He was managed with rehabilitation and showed no signs of recovery. FCEM, though rare, should be kept in mind as a differential diagnosis of acute medical myelopathy when no other cause can be identified.