NeurologyTier 2Disease (DEADMAN)

Anterior cord syndrome

Description

Incomplete spinal cord syndrome from infarction/injury of the anterior two-thirds of the cord (anterior spinal artery territory) - spares the dorsal columns
Loss of: motor function (corticospinal tracts) and pain/temperature (spinothalamic tracts) bilaterally below the lesion
Preserved: vibration and proprioception (dorsal columns) - the defining feature

Epidemiology

Most common cause: anterior spinal artery infarction, classically after aortic surgery (cross-clamping, aneurysm repair) or profound hypotension; also disc herniation, trauma with cord compression

Aetiopathogenesis

The anterior spinal artery supplies the anterior 2/3 of the cord from a single vessel with a sparse collateral supply (particularly the mid-thoracic cord, T4-T8) - explains vulnerability to hypoperfusion
Direct compression (disc, tumour, haematoma) can produce the same clinical pattern without vascular occlusion

Diagnosis

Clinical: bilateral motor weakness + loss of pain/temperature below the lesion, with preserved vibration/proprioception
MRI spine - cord signal change/infarction or a compressive lesion; distinguishes vascular from compressive causes

Management

Compressive cause -> urgent surgical decompression
Vascular cause - supportive: optimise spinal cord perfusion pressure (treat hypotension, consider CSF drainage post-aortic surgery to raise spinal perfusion pressure); no proven reperfusion therapy
Rehabilitation - bowel/bladder, mobility, spasticity management as for any spinal cord injury

Associations

Aortic aneurysm repair/dissection, profound hypotension, disc herniation, epidural haematoma/abscess

Natural history & complications

Prognosis is worse than other incomplete cord syndromes (e.g. Brown-Sequard) - motor recovery is often limited given the extent of tissue loss
Distinguish from posterior cord syndrome (rare, dorsal column loss with preserved motor/pain-temperature) and central cord syndrome (upper limb weaker than lower limb, classically a hyperextension injury in an elderly patient with cervical spondylosis)

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