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A 79-year old man falls sustaining a hyperextension injury to his neck. A lateral radiograph, CT scan and MRI are seen in Figures A through C. On motor examination, he has 3/5 strength in his deltoids, elbow and wrist flexors and extensors. He has 4/5 strength in his hip flexors, knee flexors, extensors, ankle dorsiflexors and plantarflexors. Sensation is preserved in both his upper and lower extremities as well as his sacral segments. Injury to which of the following tracts contributes greatest to his motor function deficits?
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The clinical scenario describes a patient with central cord syndrome, resulting in an injury to his lateral corticospinal tract. Figures A through C show a spondylotic spine with central narrowing and CSF effacement that is worse at the C4-5 level. The lateral corticospinal tract is the main descending motor tract (Illustration A). Its anatomic position places the upper extermity motor tracts at greater risk than the lower extremity tracts. As such, injury to the lateral corticospinal tract is characterized by upper greater than lower extremity involvement and motor deficits being more pronounced than sensory deficits.
Nowak et al reviewed the features of central cord syndrome. Historically, non-surgical treatment has been the mainstay of treatment. Surgical treatment is controversial but a definite indication for surgery is progressive neurological deficit. Long-term studies are needed comparing the two methods of treatment.
Answer 1: Posterior column tract which carries information from the middle thoracic and lower limbs of the body.
Answer 2: Posterior column tract which carries information from the arms.
Answer 3: Descending motor fibers which permit voluntary control but are smaller than the lateral tract.
Answer 5: Ascending tract which transmits pain sensation to the thalamus.
Nowak DD, Lee JK, Gelb DE, Poelstra KA, Ludwig SC
J Am Acad Orthop Surg. 2009 Dec;17(12):756-65. PMID: 19948700 (Link to Abstract)
Nowak, JAAOS 2009
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Average 4.0 of 24 Ratings
A 73-year-old man falls forward from standing height and sustaining a hyperextension injury to his neck. Physical exam of his lower extremities shows he has 4+ of 5 strength to hip flexion, knee extension, and ankle plantar flexion. Physical exam of his upper extremities shows 4 of 5 deltoid and triceps strength, with 3 of 5 wrist flexion and finger flexion strength. A CT scan and MRI are shown in Figures A and B. Which of the following neurologic pathways was most likely affected?
Lateral corticospinal tract
Central Gray matter
Lateral spinothalamic tract
Ventral spinothalamic tract
The clinical presentation is most consistent with a central cord syndrome, which is believe to be caused by involvement of the lateral corticospinal tract.
Central cord syndrome is characterized by motor deficits more pronounced in the upper extremities than lower extremities. In addition, finger and wrist motor function is more affected than shoulder and biceps function. Sensory deficits are usually minimal.
Nowak et al. reviewed central cord syndrome. They report it is the most common incomplete spinal cord injury, typically resulting from an extension injury. They state it presents as a spectrum from hand weakness to quadraparesis with sacral sparring. Early surgical treatment is still controversial.
Dvroak et al. retrospectively reviewed ASIA motor scores (AMS) and health-related quality of life (HRQoL) in patients after traumatic central cord syndrome. They determined that AMS increased in the majority of patients. In addition, initial motor score, formal education, comorbidites, age at injury and development of spasticity were predictive of function.
Figures A shows a relatively kyphotic spine with moderate osteophyte formation from C4 through C6. Figure B is an MRI that shows mild multilevel stenosis with no evidence of focal spinal cord compression. Illustration A shows the region within the spinal cord affected by central cord syndrome, and how it affects the lateral cortical spinal tract upper extremities more than the lower extremities (upper extremities more central in lateral corticospinal tract).
Answer 1: The posterior funiculi are the dorsal afferent sensory pathways responsible for deep touch, proprioception, and vibration. Injury would not lead to the the motor findings consistent with central cord syndrome.
Answer 3: While it use to be thought that central cord syndrome was due to a central hemorhhagic process, new studies confirm it involves the white matter, primarily the lateral corticospianl tracts.
Answer 4: The lateral spinothalamic tract is a afferent sensory pathway responsible for pain and temperature, and injury would not cause the motor findings consistent with central cord syndrome.
Answer 5: The ventral spinothalamic tract is a afferent sensory pathway responsible for light touch, and injury would not cause the motor findings consistent with central cord syndrome.
Dvorak MF, Fisher CG, Hoekema J, Boyd M, Noonan V, Wing PC, Kwon BK, Kwon B
Spine. 2005 Oct;30(20):2303-11. PMID: 16227894 (Link to Abstract)
Dvorak, SPINE 2005
Average 3.0 of 16 Ratings
A 35-year-old male is involved in a motor vehicle accident and sustains the neck injury shown in Figures A and B. The patient's physical exam is consistent with a Brown-Sequard spinal cord injury. Which of the following likely represents the motor and sensory findings?
Bilateral upper extremity loss of motor function and unilateral lower extremity loss of pain and temperature sensation
Bilateral loss of motor function and unilateral loss of pain and temperature sensation
Ipsilateral loss of motor function and contralateral loss of pain and temperature sensation
Bilateral loss of pain and temperature sensation and unilateral loss of motor function
Ipsilateral loss of pain and temperature sensation and contralateral loss of motor function
Figure A and B show a traumatic C5-C6 fracture dislocation, which can result in Brown-Sequard syndrome. Brown-Sequard syndrome is defined as a unilateral cord injury with ipsilateral motor deficit and loss of contralateral pain and temperature recognition. Half of the spinal cord is typically damaged, and the loss of pain and temperature sensation usually occurs two levels below the insult. This injury, which is usually result of penetrating trauma, has the best prognosis of all the spinal cord injury syndromes. Illustration A outlines the anatomy of Brown-Sequard syndrome.
Average 4.0 of 20 Ratings
A 78-year-old female slips and falls in the bathroom. In the emergency room she is found to have a laceration on her forehead. On physical exam she has new onset Grade 3 weakness in her upper extremities, more pronounced in her hands, making it difficult for her to hold objects. In her lower extremities she has Grade 4 weakness, but is able to walk with assistance. She has new onset urinary dysfunction. A radiograph and MRI are shown in Figure A and B respectively. History reveals that prior to the fall she was living independently, was able to go on daily walks, and had normal function of her hands. Which of the following most accurately describes her prognosis with nonoperative treatment.
The patient will continue to deteriorate in a step-wise manner.
The patient will most likely regain full function in her hands.
More likely than not she will regain her ability to ambulate independently.
There is a less than a 10% chance the patient will regain her bowel and bladder function.
The patient will continue to deteriorate in a rapid and progressive manner.
The clinical presentation is consistent with central cord syndrome. Patients with central cord syndrome usually regain bowel and bladder function and their ability to ambulate. Return of upper extremity function is less reliable, and patients are often left with deficits in their upper extremity, worse distally, characterized by "clumsy" hands.
Harrop et al. describe "classic" central cord syndrome in the elderly, which presents after a hyperextension mechanism and cord compression as the result of a stenotic spondylotic cervical canal where no fracture is evident. They report that the majority of patients have some degree of recovery with nonoperative treatment. They recommend surgical decompression only when there is persistent cord compression or spinal instability.
Epstein at al. looked at the effect of degenerative stenosis superimposed on acute trauma. They found patients with the lowest anteroposterior diameters of the spinal canal had the most severe myelopathy after trauma. Patients with absolute stenosis were more susceptible to traumatic myelopathy than were those with relative stenosis.
Answer 1: "Step-wise" deterioration is consistent with chronic cervical myelopathy, and not central cord syndrome.
Answer 2: Patient with central cord syndrome typically do not gain normal function of their hands, and are left with "clumsy" hands.
Answer 4: Patient with central cord syndrome usually regain bowel and bladder function.
Answer 5: Rapid progression of neurologic deficits is typical for acute and progressive spinal cord compression, as seen with an epidural abscess or tumor.
Harrop JS, Sharan A, Ratliff J
Spine J. 6(6 Suppl):198S-206S. PMID: 17097539 (Link to Abstract)
Harrop, SPINEJ 2006
Epstein N, Epstein JA, Benjamin V, Ransohoff J.
Spine (Phila Pa 1976). 1980 Nov-Dec;5(6):489-96. PMID: 7466456 (Link to Abstract)
Epstein, SPINE 1980
Average 3.0 of 46 Ratings
In patients with incomplete spinal cord injuries what is the most important prognostic variable relating to neurologic recovery?
Severity of neurologic deficit
Mechanism of injury
Administration of spinal dose steroids within 8 hours
Early definitive surgery
In patients with incomplete spinal cord injuries, the severity of the neurologic deficit is the most important prognostic variable.
This is supported by the first reference by Pollard et al, which is a retrospective review of 412 patients with traumatic, incomplete, cervical spinal cord injuries, and an average follow-up period of 2 years. This study found the most important prognostic variable relating to neurologic recovery in a patient with a spinal cord injury is the completeness of the lesion. When an incomplete cervical spinal cord lesion exists, younger patients and those with either a central cord or Brown-Sequard syndrome have a more favorable prognosis for recovery.
The second study by Bravo et al is a randomized sample of 100 patients (50 without neurological recovery, and 50 with several degrees of recovery). This study found the intensity of the lesion (incomplete) and vertebral displacement (under 30%) were statistically associated with neurological recovery. Both of these studies support answer 1, the completeness of the lesion (severity of neurologic deficit).
Pollard ME, Apple DF
Spine. 2003 Jan;28(1):33-9. PMID: 12544952 (Link to Abstract)
Pollard, SPINE 2003
Bravo P, Labarta C, Alcaraz MA, Mendoza J, Verdú A.
Paraplegia. 1996 Mar;34(3):164-6. PMID: 8668357 (Link to Abstract)
Average 3.0 of 22 Ratings
Which of the following clinical scenarios would be an indication for surgical intervention of the spine?
18-year-old male with T12 burst fracture, 25% loss of vertebral body height, 30% encrouchment of the spinal canal due to retropulsion, no evidence of injury to the posterior ligamentous complex, and no neurologic deficits.
25-year-old male with trans-colonic gun shot wound and cord hemi-transection without retained bullet fragment.
80-year-old female with global upper extremity weakness but preserved lower extremity function following a fall with an extension mechanism to the cervical spine and imaging showing diffuse spondylitic changes but no current focal spinal cord compression.
37-year-old male with type III odontoid fracture who is neurologically intact.
18-year-old male with incomplete sensory and progressive motor deficits after gun shot wound with retained bullet fragment and radiographic evidence of neural compression of the cauda equina region.
The only clinical scenario in which surgery is indicated is Answer 5, where the patient has an incomplete spinal cord injury, progressive motor deficits and a retained bullet leading to neurologic compression.
Very rarely is surgery indicated in the setting of a GSW to the spine. Infection is more common with a GSW that penetrates the colon and should be covered with broad spectrum Abx, but does not require surgery. Instability is rarely a problem due to the penetrating nature of a bullet. Surgery is indicated for retained spinal canal missile fragments in the setting of an incomplete SCI with progressive deficits or if there is a persistent CSF leak, which is a very rare scenario.
Waters et al describe their experience with 90 patients with bullet fragments retained in the spinal canal. In 20% of the patients, the bullets perforated the alimentary canal, but no cases of infection were noted whith nonoperative management. Therefore, they report bowel penetration is not an indication for surgical treatment. Bullet removal did improve motor recovery when the fragment was located between T12-L4 but not from T1-T11.
Heary et al, describes 239 patients with thoracolumbar spine penetrating wounds and neurologic deficits. They found that steroid use in patients with gun shot wounds to the spine increased incidence of infection without improvement in neurologic outcome. They therefore recommend against steroids in the setting of spinal cord injury secondary to GSW.
Answer 1: The clinical presentation is consistent with a stable burst fracture without neurological deficits. Wood et al performed the first randomized control trial comparing operative versus nonoperative treatment of thoracolumbar burst fractures in patients with no neurological deficits. They found no major long-term advantages with operative treatment, and increased disability and complications with operative treatment.
Answer 2: In the setting of perforation of the alimentary canal and a retained missile in the spinal canal, IV antibiotics are indicated, but surgery is not. This was supported by Walters et al that showed in 20% of the patients, the bullets perforated the alimentary canal, but no cases of infection were noted with nonoperative management.
Answer 3: The clinical presentation is consistent with a Central Cord Syndrome. Harrop et al. report that the majority of patients have some degree of recovery with nonoperative treatment. They recommend surgical decompression only when there is persistent cord compression or spinal instability.
Answer 4: Julien et al performed a Medline meta-analysis (1966-1999) of 96 Level 3 articles. For Type I and III fractures, they found "sufficient evidence to establish a practice guideline, suggesting that cervical immobilization for 6 to 8 weeks is appropriate management".
Waters RL, Adkins RH.
Spine (Phila Pa 1976). 1991 Aug;16(8):934-9. PMID: 1948380 (Link to Abstract)
Waters, SPINE 1991
Heary RF, Vaccaro AR, Mesa JJ, Balderston RA.
Orthop Clin North Am. 1996 Jan;27(1):69-81. PMID: 8539054 (Link to Abstract)
Heary, OCNA 1996
Wood K, Buttermann G, Butterman G, Mehbod A, Garvey T, Jhanjee R, Sechriest V
J Bone Joint Surg Am. 2003 May;85-A(5):773-81. PMID: 12728024 (Link to Abstract)
Wood, JBJS 2003
Julien TD, Frankel B, Traynelis VC, Ryken TC.
Neurosurg Focus. 2000;8(6):e1. Epub 2000 Jun 15. PMID: 16859271 (Link to Abstract)
Average 3.0 of 38 Ratings