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 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 Prognosis Most important prognostic variable relating to neurologic recovery is completeness of the lesion (severity of neurologic deficit)