762 Correspondence

References

1. Houry R, Kemball K, Rhodes V, Kaslow J. intimate partner violence and mental health symptoms in African American female ED patients. Am J Emerg Med 2006;24:444 – 50.
2. Zeitler MS, Paine AD, Breitbart V, Rickert VI, Olson C, Stevens L, et al. Attitudes about intimate partner violence screening among an ethnically diverse sample of young women. J Adolesc Health 2006; 39:119.e1-e8.

Spinal cord infarction after weight lifting (Am J Emerg Med. 2006 May;24(3):352-5)

To the Editor,

We read the interesting report of Cooper et al [1] on the case of a 15-year-old previously healthy boy who suffered spinal cord infarction after weight lifting. To our knowledge, it is the typical history of fibrocartilaginous embolism (FCE), an uncommon cause of spinal cord infarction, first reported by Naiman et al [2]; since then, approximately 40 cases of FCE have been reported to date. The main clinical features include sudden severe pain of back or neck (depending on localization), a symptom-free interval (few hours to days), and then progressive neurologic symptoms indicating a bspinal stroke in evolution,Q which often leads to severe para- or tetraparesis with urinary and bowel incontinence [3]. In approximately one half of the cases possible precipitating factors have been postulated, for example, minor trauma-like fall, physical exertion, or Valsalva-like maneuvers. Cooper et al claim their patient to be the first reported case of anterior spinal artery syndrome occurring in association with weight lifting. We know at least 2 articles [4,5] on FCE reporting 3 cases of acute ischemic myelopathies associated with heavy lifting; one of them was about a 16-year-old boy with spinal cord infarction in the territory of the anterior spinal artery, similar to the patient of Cooper et al. Several theoretical mechanisms of FCE have been proposed. The most likely hypothesis is that nucleus pulposus material may be exposed to the vertebral body vasculature by forceful herniation into

the vertebral body (eg, during increased intervertebral disc pressure) and then enters the arterial system by arteriovenous communications during simultaneous excessive Valsalva (eg, with heavy weight lifting), causing arterial embolization of spinal cord. From the radiologic point of view, a magnetic resonance imaging finding of cord swelling with a collapsed disc space strongly suggests vertical disc herniation as the first step of a process leading to spinal ischemia, sometimes associated with vertebral body infarction [6]. At present, there are no noninvasive tests to confirm the diagnosis. The occurrence of a sudden painful myelopathy, however, after minor trauma and/or Valsalva maneuver has to include FCE in the differential diagnosis when other common causes of myelopathy are excluded.

Hakan Sarikaya MD Barbara Tettenborn MD Department of Neurology Kantonsspital St Gallen

CH-9007 St Gallen, Switzerland E-mail address: [email protected]

doi:10.1016/j.ajem.2006.07.005

References

1. Cooper D, Magilner D, Call J. Spinal cord infarction after weight lifting. Am J Emerg Med 2006;24(3):352 – 5.
2. Naiman JL, Donohue WL, Prichard JS. Fatal nucleus pulposus embolism of spinal cord after trauma. Neurology 1961;11:83 – 7.
3. Tosi L, Rigoli G, Beltramello A. Fibrocartilaginous embolism of the spinal cord: a clinical and pathogenetic reconsideration. J Neurol Neuro- surg Psychiatry 1996;60:55 – 60.
4. Han JJ, Massagli TL, Jaffe KM. Fibrocartilaginous embolism–an uncommon cause of spinal cord infarction: a case report and review of the literature. Arch Phys Med Rehabil 2004;85:153 – 7.
5. McLean JM, Palagallo GL, Henderson JP, et al. Myelopathy associated with fibrocartilaginous emboli: review and two suspected cases. Surg Neurol 1995;44:228 – 35.
6. Haddad MC, Aabed al-Thagafi MY, Djurberg H. MRI of spinal cord and vertebral body infarction in the anterior spinal artery syndrome. Neuroradiology 1996;38:161 – 2.