Dear Sir,

It was with great interest that I read the case report of an unusual case of tetraparesis.[1] The authors present a case of transverse myelopathy, and I agree that it is most likely that this was caused by a vascular insult rather than inflammatory transverse myelitis, and the presentation would be in keeping with 'Anterior spinal artery syndrome'. This typically presents with a combination of flaccid weakness, sphincter disturbance and dissociated sensory loss. The anterior spinal artery supplies the ventral part of the spinal cord and as such, the classical presentation is with impaired pain and temperature sensation which follows the spino-thalamic tracts, but preserved fine sensation including position and vibration sense which is transmitted through the posterior columns which are spared. The suggestion that sensation was intact, but lack of a response to cold spray would be in keeping with this. It is important to highlight that early MRI imaging may be normal, while later imaging can show changes including swelling, signal change or atrophy.

Anterior spinal artery compromise has been described following cardiovascular operations, in particular on the aorta.[2,3] Other children may present without any significant preceding intervention or insult, but often there is a history of minor trauma or hyper-extension of the neck.[3,4] The pathophysiology in these cases has been speculative and there has been suggestion about fibro-cartilaginous emboli causing compromise of the anterior spinal artery.[5] A small number of children have been identified as having arachnoiditis, compromising the vascular supply of the spinal cord, increasing their risk of developing this clinical problem.[4]

While the Chiari malformation and the crowding around the foramen magnum may have been contributory to the progression of the myelopathy, the primary mechanism of the myelopathy could well be unrelated to this. I note the report of a fall down the stairs prior to presentation, which would be suggestive of a preceeding 'minor trauma' that has been reported in other children who do not have a Chiari malformation.

It is helpful to raise awareness of the specific features of this relatively rare presentation.

Christian de Goede

Correspondence to Dr Christian de Goede, Department of Paediatric Neurology, Royal Preston Hospital, Sharoe Green Lane, Preston PR2 9HT, UK; Christian.degoede@lthtr.nhs.uk

Competing interests: none

REFERENCES 1. Sullivan DJ, Bevan C, Sinha S. An unusual case of acute tetraparesis. Arch Dis Child 2011;96:1047

2. Puntis JWL, Green SH. Ischemic spinal cord injury after cardiac surgery. Arch Dis Child 1985;60:517-520

3. Blennow G, StarckL. Anterior spinal artery syndrome. Report of seven cases in childhood. Pediat Neurosci 1987;13:32-37

4. De Goede CGEL, Jardine PE, Eunson P et al. Severe progressive late onset myelopaty and arachnoiditis following neonatal meningitis. Eur J of Paediatr Neurol 2006;10:31-36

5. 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;85:153-157

Conflict of Interest:

None declared