Recovery after spinal cord infarcts: long-term outcome in 115 patients

Abstract

Objective: To investigate the long-term outcome of patients with spinal cord infarct (SCI) and identify prognostic predictors.

Methods: We reviewed 115 patients with SCI treated between 1990 and 2007. Severity of impairment was defined using the American Spinal Injury Association (ASIA) scoring. Functional outcome endpoints were ambulatory status, need for bladder catheterization, and pain.

Results: Mean age was 64 years; 72 (62.6%) patients were men. A total of 45% of infarcts were perioperative (69% aortic surgeries). A total of 68% reached maximal deficit within 1 hour (mean = 5 hours). Impairment at nadir was ASIA A 23%, B 26%, C 14%, and D 37%. A total of 75/93 (81%) patients studied with MRI had cord signal abnormality. At nadir, 81% required wheelchair, 86% required catheterization, and 32% had pain. At last follow-up (mean = 3 years), 23% had died. Among survivors, 42% required a wheelchair, 54% required catheterization, and 29% had pain upon last follow-up. Of 74 patients using a wheelchair at hospital dismissal, 41% were walking by final follow-up. Of 83 patients catheterized at dismissal, 33% were catheter-free at last follow-up. Older age (p < 0.0001), increased severity of impairment at nadir (p = 0.02), and peripheral vascular disease (p = 0.003) were independent risk factors for mortality. Severe impairment (ASIA A/B) at nadir predicted wheelchair use (p < 0.0001) and bladder catheterization (p < 0.0001) at last follow-up.

Conclusions: Gradual improvement in not uncommon after spinal cord infarction and it may continue long after hospital dismissal. While severe impairment at nadir is the strongest predictor of poor functional outcome, meaningful recovery is also possible in a substantial minority of these patients.

Figure 1. Sensory level available for 80 patients (1 listed as “upper thoracic” not shown)

Twenty-five patients had no sensory level found; 10 were not examined for level.

Figure 2. MRI

The sagittal MRI (A) shows abnormal increased T2 signal within the central gray matter of the thoracic cord, extending from mid-T10 through the conus. There is associated cord expansion. The axial MRI (B) shows an axial view of the same infarct, demonstrating the classic “owl's eye” pattern of increased T2 signal within the gray matter.

Figure 3. Kaplan-Meier survival curve