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| IMAGE QUIZ ARCHIVE | ||||||
| Image Quiz | ||
| Rapid Onset of Severe Low Back Pain and Lower Extremity Paralysis1 (continued) | ||
| Answer: Aortic dissection presenting as acute cauda equina syndrome. | ||
 Fig. 1 |
 Fig. 2 |
For larger view, click on image |
| Fig. 1 Computerized tomographic scan of the chest. Note (a) the
small true lumen of the descending aorta, (b) extensive retrograde
flow into the inferior vena cava, and (c) a large pericardial effusion,
all secondary to proximal aortic dissection. Fig. 2 Computerized tomographic scan of the abdomen. Note (a) the small true lumen of the aorta and (b) extensive retrograde flow into the hepatic vein. |
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| The results of the vascular examination coupled with the presence of low-back pain led to the performance of an emergent abdominal ultrasound, which revealed an intimal tear in the descending aorta. An immediate vascular consultation was obtained. Computerized tomography showed a type-A aortic dissection (beginning in the ascending aorta and extending down through the external iliac arteries) with aortic root involvement and pericardial tamponade. There was substantial compression of the true lumen of the aorta and marked reflux of contrast medium into the inferior vena cava and hepatic vessels (Figs. 1 and 2). | ||
| Upon exiting the radiology department, the patient became confused, the legs became mottled, and the blood pressure began to drop. Despite aggressive resuscitative efforts, the patient's condition continued to decline and she died. At the family's request, no autopsy was performed. | ||
| Discussion | ||
| Diagnosis of acute aortic dissection is often delayed secondary to its propensity to masquerade as other illnesses. An orthopaedic surgeon may be the first physician to evaluate a patient who has an acute aortic dissection presenting as a spinal cord injury. The increased mortality associated with a delayed diagnosis necessitates familiarity with this condition. The most common presentation of aortic dissection is an abrupt onset of pain that is localized to the chest, neck, or back. However, some authors have described paraplegia without pain in patients with acute aortic dissection. The majority of patients with this condition also show signs of systemic distress, such as severe hypertension or hypotension, tachycardia, or syncope. Loss of pulses occurs in as many as one-half of the patients with type-A dissection and one quarter of all patients. For patients with the classic presentation, the suspicion for aortic dissection should be high. In the absence of pain, however, the suspicion for aortic dissection may be low and other causes, such as spinal cord compression, inflammation, infection, and toxic and ischemic disorders, may be considered. | ||
| The differential diagnosis of nontraumatic lumbar paraplegia includes cord ischemia, epidural or intradural hematoma near the conus medullaris, epidural abscess, tumor (either epidural or intradural), transverse myelitis, herniated discs in the lower thoracic region, and Guillain-Barré syndrome. Acute aortic dissection should be suspected in patients without recent surgery or a bleeding diathesis who have any of the following symptoms: chest pain, migratory pain cephalad and caudad to the diaphragm, pulse deficits, aortic insufficiency murmur, change in mental status, or hypotension of an unknown cause. | ||
| The increased mortality associated with delayed diagnosis of acute aortic dissection necessitates a high clinical suspicion in the evaluation of acute paraplegia. When prompted by clinical symptoms, an emergent workup and vascular consultation should be employed. | ||
| Reference | ||
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