17 year old female presents with sharp, severe, and sudden onset of spontaneous neck pain followed by hypophonic voice, and hand and feet numbness within 15 minutes. Within one hour she was quadriplegic, hypotensive, and developed severe respiratory failure requiring intubation. She undergoes repetitive self induced cervical adjustment, but otherwise without any medical history. 

Imaging showed restricted diffusion in the anterior medulla with extensive T2 hyperintensities from C2 to C6 isolated to the anterior segment.

Inflammatory myelopathy was suspected and was treated with IVIG, methypredisolone, rituximab, plasmapheresis, and cyclophosphamide without improvement. She was weaker on her right and was initially areflexic followed by hyperreflexic months later when evaluated at another institution. Negative studies include basic CSF studies, oligoclonal bands, autoimmune, vasculitis workup, and infectious evaluation. 

This patient represents a severe presentation of spinal cord infarction. Restricted diffusion of the spinal cord represents a high probability for spinal cord infarction and may be used to help differentiate vascular myelopathies from inflammatory causes. Unfortunately, this imaging modality is not widely available and there are often technical limitations to this testing due to significant artifact. 

Beyond imaging modalities, symptoms presenting in a hyperacute fashion is the most important clinical tool to differentiate spinal cord infarction from other myelopathies. Sudden onset of back or neck pain is another clue to increase likelihood of vascular myelopathy.

Minor movements including neck manipulation such as in this case is a clue that vascular myelopathy is likely. The causes for spinal cord infarction are vast, and is particularly uncommon in children, thus pose a particular challenge. Spontaneous spinal cord infarction occur, as extensive evaluation may be normal.