Neurology · Traumatic Spinal Cord Injury
The facts most likely to be tested
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Anterior cord syndrome presents with loss of pain and temperature sensation and motor function below the level of injury, while dorsal column function (vibration and proprioception) remains intact.
Central cord syndrome typically occurs in elderly patients following hyperextension injuries, characterized by disproportionate upper extremity motor deficits compared to lower extremities.
Brown-Séquard syndrome (hemicord lesion) manifests as ipsilateral motor loss and loss of vibration/proprioception with contralateral loss of pain and temperature sensation starting two levels below the injury.
Spinal shock is a transient state of areflexia and flaccid paralysis immediately following acute injury, which must resolve before determining the final neurological level of injury.
Neurogenic shock results from injury above T6, causing sympathetic outflow disruption leading to hypotension and bradycardia (or lack of compensatory tachycardia).
Autonomic dysreflexia is a life-threatening emergency in patients with injuries at or above T6, triggered by noxious stimuli (e.g., bladder distension) causing paroxysmal hypertension and bradycardia.
Methylprednisolone is no longer recommended as a standard of care for acute spinal cord injury due to a lack of proven benefit and increased risk of gastrointestinal complications and infection.
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A 72-year-old male is brought to the emergency department after a fall down a flight of stairs. He complains of weakness in his hands and arms, but notes he can still walk with a steady gait. Physical examination reveals bilateral upper extremity weakness and diminished sensation in a shawl-like distribution over the shoulders, while lower extremity strength is 5/5. He has no history of bowel or bladder incontinence. Deep tendon reflexes are hyperactive in the lower extremities.
What is the most likely diagnosis?
Central cord syndrome
The patient's presentation of disproportionate upper extremity weakness following a hyperextension injury in an elderly patient is classic for central cord syndrome, which is tested in Bet #2.
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Etiology / Epidemiology
Most common in young males due to motor vehicle accidents and falls. High-velocity trauma is the primary mechanism.
Clinical Manifestations
Look for spinal shock (areflexia) and priapism. Loss of sensation below the level of injury is pathognomonic.
Diagnosis
MRI of the spine is the gold standard. CT scan is the initial study to rule out fractures.
Treatment
Methylprednisolone is no longer recommended (no proven benefit, increased infection risk); focus on surgical stabilization. Avoid hypotension to maintain perfusion.
Prognosis
Complete injuries have <5% chance of recovery. Autonomic dysreflexia is a life-threatening complication.
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Epidemiology & Etiology
Incidence peaks in young adults (15-30) and the elderly. Motor vehicle accidents account for nearly 50% of cases, followed by falls and violence. High-energy trauma is the most frequent cause of acute cord compression.
Pertinent Anatomy
The spinal cord ends at the L1-L2 vertebral level. Injuries above C4 typically result in respiratory failure due to phrenic nerve involvement. The corticospinal tract mediates motor function, while the spinothalamic tract handles pain and temperature.
Pathophysiology
Primary injury occurs at the moment of impact via mechanical disruption. Secondary injury follows due to ischemia, edema, and excitotoxicity. Hypotension exacerbates secondary injury by reducing spinal cord perfusion pressure.
Clinical Manifestations
Spinal shock presents as transient flaccid paralysis and areflexia below the lesion. Neurogenic shock manifests as hypotension with bradycardia due to loss of sympathetic tone. Red flags include bowel/bladder incontinence and priapism in males.
Diagnosis
CT scan is the initial imaging of choice to identify bony fractures. MRI of the spine is the gold standard for evaluating soft tissue, cord edema, and hematoma. Always assess for cervical spine clearance in trauma patients.
Treatment
Maintain MAP 85-90 mmHg for 7 days to optimize cord perfusion. Surgical decompression is indicated for unstable fractures or progressive deficits. Avoid routine high-dose steroids in acute SCI due to lack of proven benefit and increased infection/hyperglycemia risk.
Prognosis
Patients are at high risk for deep vein thrombosis and pressure ulcers. Autonomic dysreflexia (hypertension, bradycardia, headache) occurs in injuries above T6; treat by removing the noxious stimulus.
Differential Diagnosis
Transverse myelitis: rapid onset of weakness without trauma
Guillain-Barre syndrome: ascending paralysis, areflexia, no sensory level
Epidural abscess: fever, back pain, and neurological deficits
Syringomyelia: cape-like distribution of sensory loss
Cauda equina syndrome: saddle anesthesia and bowel/bladder dysfunction