Basics
Description
- Anterior cord syndrome:
- Results from flexion or axial loading mechanism or direct cord compression from vertebral fractures, dislocations, disc herniation, tumor, or abscess
- Rarely, can be caused by laceration or thrombosis to the anterior spinal artery
- Brown-Sequard syndrome:
- Hemisection of the spinal cord, classically as a result of a penetrating wound
- Rarely unilateral cord compression
- Central cord syndrome:
- Most commonly occurs in elderly patients who have pre-existing cervical spondylosis and stenosis
- Forced hyperextension causes buckling of the ligamentum flavum, creating a shearing injury to the central portion of the spinal cord.
- Dorsal cord syndrome:
- Associated with hyperextension injuries
- Complete cord syndrome:
- Blunt or penetrating trauma that results in complete disruption of spinal cord
- Symptoms that remain >24 hr generally are permanent.
Etiology
- Spinal cord syndromes result from localized disruption of neurotransmission and exhibit mixed motor and sensory deficits. The most common mechanism is trauma.
- Patients with arthritis, osteoporosis, metastatic disease, or other chronic spinal disorders are at risk of developing spinal injuries as the result of minor trauma.
Diagnosis
Signs and Symptoms
History
Acute loss of motor and/or sensory function usually following a traumatic event ‚
Physical Exam
- Anterior cord syndrome:
- Bilateral spastic paralysis and loss of pain and temperature sensation below the level of the lesion
- Preservation of dorsal column function (proprioception and position sense)
- Brown-Sequard syndrome (lateral cord syndrome):
- Ipsilateral spastic paresis and loss of dorsal column function (proprioception and position sense)
- Contralateral loss of pain and temperature sensation
- Deficits usually begin 2 levels below the injury.
- Central cord syndrome:
- Loss of motor function affects upper extremities more severely than lower extremities.
- Most profound deficits occur in the distal upper extremities.
- Sensory loss is more variable.
- Dorsal cord syndrome:
- Loss of proprioception, position sensation, and coordination below the level of the lesion
- Complete cord syndrome:
- Flaccid paresis below the level of the injury
- Low BP and heart rate, flushed skin, priapism may be present (loss of sympathetic tone).
- Sensory deficit levels:
- C2: Occiput
- C4: Clavicular region
- C6: Thumb
- C8: Little finger
- T4: Nipple line
- T10: Umbilicus
- L1: Inguinal region
- L5: Dorsum of the foot
- S5: Perianal area
- Motor deficit levels:
- C5: Elbow flexion
- C7: Elbow extension
- C8: Finger flexion
- T1: Finger abduction
- L2: Hip flexion
- L3: Knee extension
- L4: Ankle dorsiflexion
- S1: Ankle plantar flexion
Essential Workup
- Detailed neurologic exam, focused on determining if any deficit exists and attempting to define the level of injury
- A neurosurgical consultation if deficit exists is recommended in most cases
Diagnosis Tests & Interpretation
Lab
- Basic preoperative lab studies are indicated.
- Consider sedimentation rate and C-reactive protein to risk-stratify other potential diagnoses.
Imaging
All areas of clinical suspicion should be imaged with plain radiographs. ‚
Cases in which plain radiographs may be difficult to interpret due to severe DJD, the use of CT may be more appropriate. ‚
- CT of the spine when plain films are normal or ambiguous:
- CT allows assessment of the spinal canal and any impingement by bone fragments.
- MRI is the imaging modality of choice for detection of spinal cord damage; in the acute setting, the indications for MRI are:
- Neurologic deficits not explained by plain films or CT
- Clinical progression of a spinal cord lesion
- Determination of acute surgical candidacy
- Disadvantages of MRI include:
- The inability to adequately monitor the patient while undergoing the study
- The incompatibility with certain metal devices
- The time to complete the exam
Diagnostic Procedures/Surgery
- Myelography is used with CT when MRI is not available or cannot be performed.
- A lumbar puncture may be required if considering Guillain " “Barre, multiple sclerosis, or transverse myelitis.
Differential Diagnosis
- Dorsal root injury
- Peripheral nerve injury
- Guillain " “Barre syndrome
- Multiple sclerosis
- Transverse myelitis
- Epidural abscess
- Cerebral vascular accident
Treatment
Pre-Hospital
- Full spinal immobilization
- IV access should be established for fluid resuscitation in the setting of neurogenic shock.
- Patients should be transported to the nearest trauma center:
- Prompt evaluation and neurosurgical intervention may lead to a better outcome.
Cervical collars must be the appropriate size for the child; splinting the head and body with towels and tape is a reasonable alternative. ‚
Initial Stabilization/Therapy
- Spinal immobilization must be maintained at all times.
- Intubation must proceed with in-line spinal immobilization.
- IV fluids should be administered at maintenance levels unless shock is present:
- Spinal trauma may cause hypotension due to loss of sympathetic tone; fluid administration is 1st-line treatment.
- Other causes of hypotension (e.g., hemorrhage) should be sought before being attributed to spinal cord injury (SCI).
- Generally, hypovolemic shock causes tachycardia, whereas neurogenic shock results in bradycardia.
- If BP does not improve after a fluid challenge and no other cause for hypotension can be found, vasopressor use may be necessary;α-agonist is preferred.
Ed Treatment/Procedures
- Other injuries must be treated as indicated.
- Level of SCI should be determined as a baseline to follow for improvement or deterioration.
- A neurosurgeon must be consulted once an SCI is suspected, even when plain films are normal; early surgical decompression or immobilization may reduce morbidity.
- The patient with an SCI should be managed at an appropriate regional trauma or spinal center:
- If necessary, transfer should occur as soon as management of other injuries allow.
- IV antibiotics and tetanus prophylaxis are given to patients with a penetrating injury.
- IV vasopressor support may be required to treat neurogenic shock.
Medication
- Phenylephrine: 0.5 " “2 Ž ¼g/kg bolus then 50 " “100 Ž ¼g/min drip
- Ancef: 1,000 mg q8h
In the early 1990s, the use of high-dose methylprednisolone infusion was widely adopted as standard ofcare following the reports of the 2nd and 3rd National Acute Spinal Cord Injury Study (NASCIS II, NASCIS III); however, extensive systematic review of this therapy and the evidence to supportit has demonstrated that this therapy is not recommended for routine use in SCI. ‚
Follow-Up
Disposition
Admission Criteria
All patients with spinal cord syndrome must be admitted to an ICU setting. ‚
Discharge Criteria
No patient with symptoms suggestive of SCI should be discharged. ‚
Pearls and Pitfalls
- A detailed neurologic exam and attempt to document the spinal level of neurologic symptoms is critical.
- Involve neurosurgical consultants early, as outcome is time-dependent in many cases.
- EM physicians should not start methylprednisolone treatment for acute SCI.
Additional Reading
- Bracken ‚ MB, Shepard ‚ MJ, Collins ‚ WF, et al. A randomized controlled trial of methylprednisolone or naloxone in the treatment of acute spinal cord injury. Results of the Second National Acute Spinal Cord Injury Study. N Engl J Med. 1990;322(20):1405 " “1411.
- Schouten ‚ R, Albert ‚ T, Kwon ‚ BK. The spine-injured patient: Initial assessment and emergency treatment. J Am Acad Orthop Surg. 2012;20(6):336 " “346.
- Theodore ‚ N, Aarabi ‚ B, Dhall ‚ SS, et al. Transportation of patients with acute traumatic cervical spine injuries.Neurosurgery. 2013;72(suppl2):35 " “39.
Codes
ICD9
- 344.89 Other specified paralytic syndrome
- 952.02 C1-C4 level with anterior cord syndrome
- 952.03 C1-C4 level with central cord syndrome
- 952.04 C1-C4 level with other specified spinal cord injury
- 952.00 C1-C4 level with unspecified spinal cord injury
- 952.01 C1-C4 level with complete lesion of spinal cord
- 952.05 C5-C7 level with unspecified spinal cord injury
- 952.06 C5-C7 level with complete lesion of spinal cord
- 952.07 C5-C7 level with anterior cord syndrome
- 952.08 C5-C7 level with central cord syndrome
- 952.09 C5-C7 level with other specified spinal cord injury
- 952.0 Cervical spinal cord injury without evidence of spinal bone injury
ICD10
- G83.81 Brown-Sequard syndrome
- G83.82 Anterior cord syndrome
- S14.129A Central cord synd at unsp level of cerv spinal cord, init
- G83.83 Posterior cord syndrome
SNOMED
- 282785008 anterior cord syndrome (disorder)
- 27982003 Brown-Sequard syndrome (disorder)
- 282787000 central cord syndrome (disorder)
- 282786009 Posterior cord syndrome (disorder)