What is Ventral Cord Syndrome?
Ventral cord syndrome (VCS), also known as anterior cord syndrome or anterior spinal artery syndrome, happens when a medical condition causes damage to the front two-thirds of the spinal cord. This damage is called infarction. Although estimates vary, VCS is known to be the most common type of spinal cord infarction.
People with ventral cord syndrome may find that their sense of pain and temperature is not as good as it used to be, but they can still feel vibrations and be aware of their body’s position (proprioception). They may also have difficulties with movement at the place of the injury and below it. A magnetic resonance imaging (MRI) scan can be done to get a better picture of the injury to the spinal cord.
The current treatment for VCS is mainly supportive and follows guidelines similar to those for cerebral ischemia (which is a lack of blood flow to the brain), atherosclerotic vascular disease (which is hardening of the arteries), and acute traumatic spinal cord injury.
What Causes Ventral Cord Syndrome?
Ventral cord syndrome is a condition that results from damage to the front side of the spinal cord. This damage could be direct, where the spinal cord is physically crushed or compressed. This might happen, for example, if there’s a swelling blood clot.
However, most of the time, ventral cord syndrome is caused by indirect damage. This happens when the spinal cord doesn’t get enough blood supply. This lack of blood leads to cell damage, otherwise known as ischemia.
Sometimes ventral cord syndrome occurs due to damage to the aorta (the major blood vessel coming out of the heart) caused by a condition called “aortic dissection”. This can also happen when there’s damage caused by medical procedures such as attempted vascular repair surgeries or when there’s a long-term blockage of the aorta.
Different parts of the spinal cord get their blood from different arteries. A key artery is the Anterior Spinal Artery (ASA), which supplies blood to the front two-thirds of the spinal cord. Any disruption in the ASA – from a clot, crumbling cholesterol deposits, or an aneurysm, for example – can lead to ventral cord syndrome.
Another reason the spinal cord might not get enough blood is if there’s disruption in the blood flow of the Artery of Adamkiewicz, which provides blood to the lower two-thirds of the ASA in the lower part of the chest and upper part of the lower back (between T5 and L2). Syphilitic arteries, injuries, and aneurysms are also known to cause disorders in the ASA’s blood flow.
Finally, less common causes include drops in blood pressure, vein blockages, multiple sclerosis, and damage caused by broken bone fragments.
Risk Factors and Frequency for Ventral Cord Syndrome
There’s limited research on non-traumatic spinal cord injuries, so we don’t have a precise number on how often they happen. The main reason they do occur is due to a type of injury called a non-traumatic ischemic injury. In other words, damage is caused by a lack of blood supply. A specific, rare condition called acute spinal cord infarction is responsible for about 8% of these sorts of spinal problems and represents no more than 1% of all stroke types. In terms of non-traumatic spinal cord injuries, a condition known as ventral cord syndrome is the most common.
- Research on non-traumatic spinal cord injuries is limited.
- The injuries usually happen because of a lack of blood supply to the spine.
- Acute spinal cord infarction, a specific type of these injuries, accounts for 8% of all spinal problems like this and less than 1% of all stroke types.
- Ventral cord syndrome is the most frequent type of non-traumatic spinal cord injury.
- Based on the limited cases studied, these injuries can affect a wide range of ages, from young to old, with most people diagnosed being in their 60s or 70s.
Signs and Symptoms of Ventral Cord Syndrome
Ventral cord syndrome is a complex condition that affects the nervous system. To understand the cause, the patient’s full medical history is crucial. Diagnosing this syndrome includes observing several symptoms and deficits in the patient’s physical abilities and sensations. Neurological exams often show a total loss of motor function, which is the ability to control muscle movement, along with the inability to feel pain, temperature, and less refined touch sensations.
Here are some specific observations:
- Motor function deficits are usually noticed on both sides of the body directly below the injury site.
- Sensory deficits are also bilateral, but they start two to three segments below the injury site. This is because the sensory pathway (spinothalamic tract) in the spine ascends two to three segments before crossing to the other side at the front central area (anterior commissure).
- Initial motor deficits due to “spinal shock” include floppy muscles (flaccidity) with absent reflexes. Over time, the reflexes gradually return and the muscle tone increases, which can lead to muscle stiffness or spasticity.
- Patients with ventral cord syndrome can still feel light touch, know their body position (proprioception), and perceive vibration.
- If the injury impacts the parts of the spine that control body functions (autonomic centers), the patients can have issues with blood pressure regulation (orthostatic hypotension), bladder and bowel control, and sexual function.
- Pain is another common symptom, which could be a distinct radiating (radicular) pain or scattered (diffuse) pain.
Testing for Ventral Cord Syndrome
Magnetic resonance (MR) imaging, also known as an MRI, is the preferred method for doctors to visually examine an issue called spinal cord ischemia. This procedure typically involves taking detailed scans from different directions. This procedure can reveal distinct signs like a pencil-like signal or lack of blood flow in certain areas – which can suggest spinal cord ischemia. Sometimes, the MRI might show what’s known as a “snake eyes” appearance in the central spinal cord, which is deemed characteristic of spinal cord infarction, but this can also be seen with spinal pressure symptoms and different infections or inflammation in the spine. To further examine the condition of the blood vessels, MR angiography or CT angiography might be conducted. For cases needing an intervention, digital subtraction angiography will be needed to clearly visualize the vascular anatomy.
For suspected spinal cord ischemia, a series of blood tests are usually performed. These tests could include a complete blood cell count, checks for inflammation, and monitoring of your electrolyte, glucose, creatinine, and cholesterol levels and how your liver is functioning. These tests are aimed at screening for conditions like diabetes, atherosclerosis and high cholesterol that might lead to damage in the blood vessels. If infections are considered a cause, relevant tests will be done for borreliosis, Lyme disease, syphilis, HIV, HTLV and herpes virus. If vasculitis is suspected as the cause, your doctor may also screen for specific antibodies. Doctors may further need to analyze the condition of your cerebrospinal fluid (this is the fluid found in your brain and spine). This fluid check can reveal an increase in protein concentration without any rise in cell count, or detection of immunoglobulins (proteins that function as antibodies), which may suggest certain pathologies.
Treatment Options for Ventral Cord Syndrome
Typically, the treatment for a spinal cord stroke involves support and follows guidelines for brain stroke, blood vessel disease due to fatty buildups (atherosclerosis), and sudden spinal cord injury. The most important steps are treating the main cause, which can include things like controlling fever and blood sugar, managing blood thinners, and prevention of blood clot formation. In an emergency situation, it’s crucial to ensure the patient can breathe properly, and their blood pressure is stable. If their blood pressure is too low, it needs to be raised with certain medications like phenylephrine, norepinephrine, and high-dose dopamine. If blood pressure needs to be lowered, drugs such as labetalol, esmolol, and nicardipine can be used.
People who have high blood pressure, diabetes, and high blood sugar at the time of admission have a greater risk of severe spinal cord stroke. Since these factors are also known to contribute to brain strokes, treating and preventing them should be a key part of spinal cord stroke management.
In most cases, the main aim of treatment is to improve symptoms and prevent future complications. It’s important to educate the patient on how to adjust to their new condition and physical abilities. Issues that might come up during the hospital stay and after discharge need to be managed, including limited movement, difficulty performing daily tasks, and problems with bladder, bowel, and sexual function. Common complications like pressure sores, pain, and muscle stiffness also need proper attention. After leaving the hospital, patients should obtain and learn to use necessary adaptive equipment to maximize their independence. It’s also important to address the patient’s mental and emotional well-being to improve their independence, quality of life, and overall health outcome.
Some studies have suggested that draining fluid from the lower part of the spine (lumbar CSF drainage) and raising the average blood pressure can help prevent injury due to lack of blood supply during surgery to repair blood vessels. Certain surgical actions can cause quick increases in spinal fluid pressure, which can block the outflow of blood and lead to a lack of oxygen (ischemia). In some cases, this lack of oxygen can be reversed by draining the spinal fluid while maintaining blood pressure. Steroids may also be used to further reduce damage to cells and swelling. For open procedures, maintaining blood flow to the arteries below the heart can help.
What else can Ventral Cord Syndrome be?
Spinal cord injury due to lack of blood supply – or ischemic spinal cord injury – is not common and is often not diagnosed correctly. It’s so much so, certain diseases like multiple sclerosis can display similar results when using MRI scans, making them easy to confuse. The following conditions should also be considered when diagnosing this type of spinal cord injury:
- Spinal cord tumors, but these usually develop slower than a spinal cord injury due to lack of blood supply
- Transverse myelitis, which has a similar appearance to spinal cord injury due to lack of blood supply, although it starts slightly less suddenly
- Venous congestive myelopathy, a condition that’s also similar, but usually presents with noticeable enlarged veins with the involvement of the core and the surrounding white matter of the spinal cord
What to expect with Ventral Cord Syndrome
Patients who have experienced a spinal cord infarct (a type of stroke that occurs in the spinal cord) often have a more favorable outlook compared to those who have had a stroke in the brain. This conclusion comes from a study that followed 30 patients with spinal cord injury for an average of 7.1 years. The study found that, even after taking into account the patient’s age and the severity of their symptoms during the acute (immediate) phase of the condition, those with a spinal cord infarct tended to have a lower risk of death in the long term.
The likely explanation for this is that patients who experience a spinal cord infarct are less likely to also have other health conditions that can affect the heart and blood vessels, such as irregular heartbeat (atrial fibrillation), high blood pressure (hypertension), and heart disease.
The same study found that many patients with a spinal cord infarct were able to make substantial improvements in their symptoms, which contributed to their favorable prognosis. In fact, most of the patients in the study who survived the acute phase of their injury and were above the age of 60 at the time of their injury were able to return to their jobs.
In contrast, the rate of return to work was lower among stroke patients under 60 years of age, even when these patients had less severe symptoms than the spinal cord infarct patients. Patients who have had a stroke in the brain are more likely to have difficulties with cognitive functions like memory and thinking, which is less common among spinal cord infarct patients. Cognitive deficits in this group are no different than in hospitalized patients who have other equally serious conditions.
Chronic pain is a common issue for patients who have had a spinal cord infarct, with almost 80% of these patients reporting persistent pain during follow-up visits. However, these patients are less likely to suffer from depression, likely because their cognitive functions are typically preserved. Factors that were associated with higher mortality in spinal cord infarct patients include older age, severe symptoms during the acute phase, and the presence of peripheral vascular disease (a condition that narrows the arteries and reduces blood flow to the limbs).
The prognosis for patients with ventral cord syndrome, a specific type of spinal cord injury, largely depends on the severity of the impairment at the time of injury.Overall, less serious injuries often have better outcomes. The severity of the initial injury, especially when it involves motor function, is the best predictor of how well a patient will recover functionally.
Possible Complications When Diagnosed with Ventral Cord Syndrome
Ventral cord syndrome can have the same complications as other spinal cord injuries and diseases. After a spinal cord injury, the risk of other medical problems becomes much higher, due mostly to the paralysis and lack of physical activity. Lack of movement can cause insulin resistance, difficulty regulating blood sugar, and abnormal levels of fats in the blood.
In addition, patients with spinal cord injuries are more likely to have calcium build-up in the arteries of their heart than those without spinal cord injuries. Immobility can also increase the risk for broken bones and osteoporosis. These patients may notice decrease in the amount of growth hormone and testosterone in their body.
About 50% of people with spinal cord injuries are at risk of getting bedsores. They may also undergo changes in their body’s soft tissues, such as increase in fat and reduction in muscle. Diffuse gastrointestinal tract dysmotility can lead to issues, including acid reflux and difficulties in bowel movements.
Respiratory trouble could also develop, depending on how severe and where the injury is located. If a patient’s spinal cord injury is above the sixth bone of the spine, they may struggle to maintain their blood pressure. As a result, they may frequently have low blood pressure, which might eventually contribute to memory and thinking problems.
Common Complications:
- Insulin resistance
- Carbohydrate metabolism disorders
- Dyslipidemia (abnormal amount of fats in the blood)
- Calcifications in the coronary arteries
- Fractures and Osteoporosis
- Reduction in growth hormone and testosterone
- Pressure ulcers or bedsores
- Increase in body fat and decrease in muscle mass
- Diffuse gastrointestinal tract dysmotility leading to reflux and bowel movement problems
- Respiratory dysfunction
- Frequent low blood pressure
- Cognitive impairments
Recovery from Ventral Cord Syndrome
Post-surgery treatments for a condition known as ventral cord syndrome are often not very effective. Because of this, strategies to stop damage to the spinal cord during surgery should be undertaken. These strategies may include avoiding low red blood cell counts (anemia), low blood pressure (systemic hypotension), and extreme bending or straightening (hyperextension/hyperflexion) when placing the patient for the operation. Collaborative efforts should be made to limit any surgical mishaps resulting in vascular dissection, which means accidentally cutting blood vessels.
During surgeries that involve the part of the body where the chest and abdomen come together (thoracoabdominal aorta), doctors can spot early signs of spinal cord damage by using methods to test nervous system activity (neuromonitoring with evoked potentials) in patients under anesthesia and through neurological tests in patients who are awake.
Loss of the ability to move the arms and legs (tetraplegia and paraplegia) are serious outcomes of ventral cord syndrome. These movement difficulties can take a physical, social, and financial toll on the affected person and the community. Because currently there is no cure for ventral cord syndrome, patients should take part in rehabilitation programs designed to enhance their independence and standard of living while avoiding further complications from spinal cord injuries. There are multiple types of rehabilitation available, which can include physical, occupational, job-related (vocational), and brain function (neuropsychological) therapies.
Preventing Ventral Cord Syndrome
While in the hospital, patients will need to learn how to adapt to their new way of life after being diagnosed with ventral cord syndrome. Regular follow-ups are not just for health checks, but also for continued support and education about the condition. Adjustment is a dynamic, ever-changing process, and patients need the help of health care professionals to guide them through it.
It’s important for patients to learn effective coping strategies. Studies have shown that patients who’ve undergone coping training tend to experience less depression and anxiety. So, it’s beneficial to learn these strategies during the transition phase.
Psychological resources, internal tools and abilities used to deal with challenging situations, can also make a huge difference. These can be talents, skills, knowledge, and the like. Health care professionals will aid patients in strengthening these resources for a more successful adjustment.
Patients should also be advised about the impact of sports and exercise on their health. Regular exercise can improve both physical performance and psychological well-being, and facilitate better social integration. It’s crucial, though, to undergo adequate health checks before starting any exercise regimen to ensure their safety and effectivity.
Discussing the social aspects of a patient’s life is also essential. Health care professionals can guide individuals towards fruitful employment. They can also provide alternatives and modifications for transportation, which is vital in fostering a sense of independence and social involvement.
Hospital discharge is an excellent opportunity to educate not just the patient, but also the family, friends, and caretakers. The health care team will assess the available options and equipment that can help make the patient’s life easier and more fulfilled. They will also plan for potential emergencies and complications, set up follow-up appointments, determine the need for medical equipment at home, and evaluate the patient’s home environment.