Fibrocartilaginous embolism of the spinal cord: a clinical and pathogenetic reconsideration.
A 16 year old girl did a handstand for fun, returned to her feet, experienced a sudden pain in her back, and became progressively paraplegic within 30 hours. MRI showed lumbar cord swelling, multiple Schmorl's nodes, a collapsed T11-T12 disc space, and intraspongious disc prolapse into the T12 vertebral body. These findings, related to the initial manoeuvre, suggested that an acute vertical disc herniation could have occurred as the first step in a process leading to spinal cord infarction due to fibrocartilaginous emboli from the nucleus pulposus of the intervertebral disc. The medical literature so far reports 32 cases of fibrocartilaginous embolism (FCE) of the spinal cord, all at necropsy, with the exception of one histologically demonstrated in a living patient. A clinical diagnosis of FCE would be desirable for many important reasons, but was never made. This causes severe limitations in the knowledge of the disease and precludes any therapeutic possibility. On the basis of the clinical features and findings in the present case, compared with data from the reported cases, a first attempt is made to identify the clinical context within which new information obtainable through MRI examination can lead to a reliable clinical diagnosis of FCE. The vexed question of the pathogenesis has been reviewed. An increased intraosseous pressure within the vertebral body, due to acute vertical disc herniation, seems to offer a consistent pathogenetic explanation and some therapeutic prospects.