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Updated: Nov 22 2022

Incomplete Spinal Cord Injuries

Images sagital_moved.jpg
  • 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
    • Incidence
      • 11,000 new cases/year in US
        • 34% incomplete tetraplegia
          • central cord syndrome most common
        • 17% incomplete paraplegia
        • remaining 47% are complete
  • Anatomy
    • Descending Tracts (motor)
      • lateral corticospinal tract (LCT)
      • ventral corticospinal tract
    • Ascending tracts (sensory)
      • dorsal columns
        • fine touch
        • vibration
        • proprioception
      • lateral spinothalamic tract (LST)
        • pain
        • temperature
        • gross sensation
      • 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
      • No motor or sensory function is preserved in the sacral segments S4-S5.
      • Complete
      • B
      • Sensory function preserved but not motor function is preserved below the neurological level and includes the sacral segments S4-S5.
      • Incomplete
      • C
      • 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.
      • Incomplete
      • D
      • 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.
      • Incomplete
      • E
      • Motor and sensory functions are normal.
      • 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
          • <50 years of age associated with greatest neurologic recovery
        • 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
      • 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
      • 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
  • Prognosis
    • Most important prognostic variable relating to neurologic recovery is completeness of the lesion (severity of neurologic deficit)
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