|
https://upload.orthobullets.com/topic/2008/images/mri sagital_moved.jpg
https://upload.orthobullets.com/topic/2008/images/spinal cord pathways 4.jpg
https://upload.orthobullets.com/topic/2008/images/central cord syndrome final.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
    • 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
 

Please rate topic.

Average 4.4 of 70 Ratings

Questions (8)

(OBQ04.250) Which of the following clinical scenarios would be an indication for surgical intervention of the spine? Review Topic

QID: 1355
1

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.

1%

(8/917)

2

25-year-old male with trans-colonic gun shot wound and cord hemi-transection without retained bullet fragment.

3%

(26/917)

3

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.

3%

(27/917)

4

37-year-old male with type III odontoid fracture who is neurologically intact.

3%

(30/917)

5

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.

89%

(818/917)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5
Question locked
Sorry, this question is for
Virtual Curriculum Members Only
Click here to purchase
Question locked
Sorry, this question is for
Virtual Curriculum Members Only
Click here to purchase

(OBQ08.123) 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. Review Topic

QID: 509
FIGURES:
1

The patient will continue to deteriorate in a step-wise manner.

29%

(568/1969)

2

The patient will most likely regain full function in her hands.

8%

(158/1969)

3

More likely than not she will regain her ability to ambulate independently.

51%

(1000/1969)

4

There is a less than a 10% chance the patient will regain her bowel and bladder function.

4%

(79/1969)

5

The patient will continue to deteriorate in a rapid and progressive manner.

8%

(157/1969)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ04.135) In patients with incomplete spinal cord injuries what is the most important prognostic variable relating to neurologic recovery? Review Topic

QID: 1240
1

Severity of neurologic deficit

85%

(2272/2662)

2

Mechanism of injury

5%

(130/2662)

3

Administration of spinal dose steroids within 8 hours

3%

(76/2662)

4

Gender

0%

(2/2662)

5

Early definitive surgery

7%

(181/2662)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(OBQ11.150) 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? Review Topic

QID: 3573
FIGURES:
1

Posterior funiculi

1%

(24/2483)

2

Lateral corticospinal tract

70%

(1747/2483)

3

Central Gray matter

19%

(482/2483)

4

Lateral spinothalamic tract

5%

(115/2483)

5

Ventral spinothalamic tract

4%

(105/2483)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(OBQ09.164) 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? Review Topic

QID: 2977
FIGURES:
1

Bilateral upper extremity loss of motor function and unilateral lower extremity loss of pain and temperature sensation

1%

(27/3198)

2

Bilateral loss of motor function and unilateral loss of pain and temperature sensation

1%

(33/3198)

3

Ipsilateral loss of motor function and contralateral loss of pain and temperature sensation

91%

(2907/3198)

4

Bilateral loss of pain and temperature sensation and unilateral loss of motor function

1%

(25/3198)

5

Ipsilateral loss of pain and temperature sensation and contralateral loss of motor function

6%

(188/3198)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ11.53) 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? Review Topic

QID: 3476
FIGURES:
1

Fasciculus gracilis

1%

(56/4253)

2

Fasciculus cuneatus

3%

(128/4253)

3

Anterior corticospinal

25%

(1051/4253)

4

Lateral corticospinal

69%

(2914/4253)

5

Lateral spinothalamic

2%

(91/4253)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4
EVIDENCE & REFERENCES (30)
GROUPS (1)
Topic COMMENTS (13)
Private Note