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Images in Neurology
May 6, 2019

Spinal Claudication Secondary to Anterior Disco-Osteo-Arterial Conflict and Mimicking Stiff Person Syndrome

Author Affiliations
  • 1Division of Neuroimmunology, Johns Hopkins Hospital, Baltimore, Maryland
  • 2Division of Interventional Neuroradiology, Johns Hopkins Hospital, Baltimore, Maryland
JAMA Neurol. 2019;76(6):726-727. doi:10.1001/jamaneurol.2019.1007

A 68-year-old man presented with a 2-year history of severe muscle spasms in the lower back and pelvis. His symptoms were always precipitated by a period of walking or sustained erect posture. The muscle spasms were described as a painful viselike grip and were relieved by dropping to the ground and flexing his trunk. The patient was ultimately referred to the clinic for evaluation of treatment-resistant stiff person syndrome, since baclofen and benzodiazepines had no clinical effect. Neurological examination results were remarkable only for depressed reflexes in the lower extremities, moderately reduced vibration in the toes, and slightly broad-based gait. He had no hyperlordosis or truncal rigidity. Nerve conduction studies, electromyography, and extensive laboratory testing results for autoimmune and rheumatological conditions were unremarkable. A magnetic resonance image of his lumbar spine showed mild lumbar spondylosis with multilevel facet arthropathy and notable anterior disc degeneration from the first to third lumbar vertebrae (L1 to L3) (Figure 1). In addition, a high T2 signal was seen in the gray matter of the conus medullaris. A spinal digital subtraction angiographic image suggested that a proximal nonostial stenosis of the left L2 intersegmental artery (ISA) from which the main anterior radiculomedullary artery (artery of Adamkiewicz) and a prominent posterior radiculomedullary artery both arose. A computed tomographic angiographic image visualized the bilateral ISAs at L2 to L3 coursing superiorly over an anterior disc osteophyte complex (Figure 2).