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Introduction
  • Defined as spinal cord injury with some preserved motor or sensory function below the injury level including
    • voluntary anal contraction (sacral sparing)
      • sacral sparing critical to separate complete vs. incomplete injury
    • OR palpable or visible muscle contraction below injury level 
    • OR perianal sensation present
  • Epidemiology
    • 11,000 new cases/year in US
      • 34% incomplete tetraplegia
        • central cord syndrome most common
      • 17% incomplete paraplegia
      • remaining 47% are complete
  • Prognosis
    • most important prognostic variable relating to neurologic recovery is completeness of the lesion (severity of neurologic deficit) 
Anatomy
  • Descending Tracts (motor)
    • lateral corticospinal tract (LCT)
    • ventral corticospinal tract
  • Ascending tracts (sensory)
    • dorsal columns
      • deep touch
      • vibration
      • proprioception
    • lateral spinothalamic tract (LST)
      • pain
      • temperature
    • ventral spinothalamic tract (VST)
      • light touch
Classification
  • Clinical classification
    • anterior cord syndrome (see below)
    • Brown-Sequard syndrome 
    • central cord syndrome 
    • posterior cord syndrome 
  • ASIA classification
    • method to scale 
 
ASIA Impairment Scale
A Complete No motor or sensory function is preserved in the sacral segments S4-S5.
B Incomplete  Sensory function preserved but not motor function is preserved below the neurological level and includes the sacral segments S4-S5.
C Incomplete Motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade less than 3.
D Incomplete Motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of 3 or more.
E Normal Motor and sensory function are normal.
 
Central Cord Syndrome
  • Epidemiology
    • incidence
      • most common incomplete cord injury  
    • demographics
      • often in elderly with minor extension injury mechanisms 
        • due to anterior osteophytes and posterior infolded ligamentum flavum
  • Pathophysiology
    • believed to be caused by spinal cord compression and central cord edema with selective destruction of lateral corticospinal tract white matter
    • anatomy of spinal cord explains why upper extremities and hand preferentially affected
      • hands and upper extremities are located "centrally" in corticospinal tract
  • Presentation
    • symptoms
      • weakness with hand dexterity most affected
      • hyperpathia
        • burning in distal upper extremity 
    • physical exam
      • loss
        • motor deficit worse in UE than LE (some preserved motor function) 
        • hands have more pronounced motor deficit than arms
      • preserved
        • sacral sparing
    • late clinical presentation
      • UE have LMN signs (clumsy)
      • LE has UMN signs (spastic)
  • Treatment
    • nonoperative vs. operative 
      • extremely controversial
  • Prognosis
    • final outcome  
      • good prognosis although full functional recovery rare
      • usually ambulatory at final follow up
      • usually regain bladder control
      • upper extremity and hand recovery is unpredictable and patients often have permanent clumsy hands
    • recovery occurs in typical pattern
      • lower extremity recovers first
      • bowel and bladder function next
      • proximal upper extremity next
      • hand function last to recover
Anterior Cord Syndrome
  • A condition characterized by
    • motor dysfunction
    • dissociated sensory deficit below level of SCI
  • Pathophysiology
    • injury to anterior spinal cord caused by
      • direct compression (osseous) of the anterior spinal cord
      • anterior spinal artery injury 
        • anterior 2/3 spinal cord supplied  by anterior spinal artery
  • Mechanism
    • usually result of flexion/ compression injury
  • Exam
    • lower extremity affected more than upper extremity
    • loss
      • LCT (motor)
      • LST (pain, temperature)
    • preserved
      • DC (proprioception, vibratory sense)
  • Prognosis
    • worst prognosis of incomplete SCI
    • most likely to mimic complete cord syndrome
    • 10-20% chance of motor recovery
Brown-Sequard Syndrome
  • Caused by complete cord hemitransection
    • usually seen with penetrating trauma
  • Exam
    • ipsilateral deficit
      • LCS tract
        • motor function
      • dorsal columns
        • proprioception
        • vibratory sense 
    • contralateral deficit
      • LST
        • pain
        • temperature
        • spinothalamic tracts cross at spinal cord level (classically 2-levels below)
  • Prognosis
    • excellent prognosis
    • 99% ambulatory at final follow up
    • best prognosis for function motor activity
Posterior Cord Syndrome
  • Introduction 
    • very rare
  • Exam
    • loss
      • proprioception
    • preserved
      • motor, pain, light touch
 

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