In any case of SCI.
What are the possible clinical presentation / findings?
💡 Mention the major tracts in spinal cord
- Sensory “Ascending” pathway
- Spinothalamic → Pain and Temperature
- Dorsal Columm → Vibration, Position, Fine Touch, Sensory Ataxia
- Spinocerebellar → Cerebellar Ataxia
- Motor “Descending” pathway Corticospinal
- Tone → Spasticity
- Motor power
- Reflexes → Planter, BCR, Anal Wink & DTR
- Autonomic System
- Bowel, Bladder, Sex
- Skin, Vessels, Heart
Dr. Maitham’s Note: Helpful way for guessing the clinical manifestation of “x” syndrome or couldn’t know the type of injury or lesion in give case.
Draw spinal cord termination 🔑🔑
Dr. Maitham’s Notes
- T11 - T12, Lumbar bulb, Lumbar roots L1 - L5 (UMN features)
- T12 - L1, Conus medullaris, Sacral roots S1 - S5 (UMN features)
- L1 - L2, Cauda Equina (LMN features)
Gray 39’s Anatomy for Students - 4th Edition (2020)
Burst L1 Fracture, Weak legs and hypoactive bowel and bladder. How to tell if your patient developed conus medullaris or cauda equina?
CONUS MEDULLARIS SYNDROME
💡 T12–L1–L2 vertebral level injury,
- High conus (A)
- Saddle distribution sensory loss
- Normal motor function of LEs
- Hyperreflexic LEs
- BCR and micturition reflexes are preserved (UMN)
- Bowel, bladder, and sexual dysfunction may occur
- Low conus (B) → Involvement of Onuf’s nucleus (origin of the pudendal nerve) at S2
- Saddle distribution sensory loss
- Sacral root involvement result in S1-2 motor abnormalities → Gastrocsoleus & Gmax
- Lumbar root involvement result in flaccid weakness (LMN) → Iliopsoas, quads, tib antrior, posterior, hamstring and Gmed.
- Areflexic bladder and bowel, and lower limbs
CAUDA EQUINA SYNDROME
💡 Below L1–L2 to sacrum vertebral level
- High cauda equina lesions (lumbar roots)
- Spare bowel and bladder (spared spinal reflex arc at S2-S4)
- Low cauda equina lesions (S3–S5):
- Abnormalities may predominate on one side (asymmetric)
- Sensory loss in root distribution
- Pain is a more significant feature
- Motor weakness (flaccid paralysis) and atrophy of the LEs (L2–S2)
- Areflexic LEs
- Absence of anal wink/BCR
- Neurogenic bowel and bladder (S2–S4)
- Sexual dysfunction
- Aflexic bowel, bladder
Cuccurollo 4th Edition Chapter 7 SCI pg560 Figure 7-20 & pg561 Table 7-5
What is the condition of bowel, bladder and sex in cauda equina?🔑🔑
💡 Sacral center is located in S2-S4, it will be working as reflexive arc if lesion is above.
- High cauda equina lesions (lumbar roots)
Spare bowel and bladder due to sparing of sacral center
- Low cauda equina lesions (S3–S5)
Areflexic bowel, bladder, and sexual dysfunction due to involvement of sacral center
Cuccurollo 4th Edition Chapter 7 SCI pg561
List 4 causes of Cauda Equina Syndrome 🔑 List 4 causes of Conus Medullaris 🔑
Cuccurollo 4th Edition Chapter 7 SCI pg561 Table 7-5
List 3 causes of central cord syndrome. 🔑 🔑
- Long-standing cervical spondylosis.
- Hyperextension injury
- Syrinx
Cuccurollo 4th Edition Chapter 7 SCI
Pt fell down and developed weakness in the UL more distal.
What is the diagnosis?
List 4 other causes of cervical myelopathy.
Central Cord Syndrome
- Produces greater motor weakness in the upper limbs than the lower limbs, with variable loss of sensation, bowel, and bladder function.
- LEs recover first and to a greater extent, Followed by improvement in bladder function, then proximal UE, and finally intrinsic hand function.
Causes
- Cervical spondylitic myelopathy
- Multiple sclerosis
- Motor neuron disease
- Vasculitis
- Syringomyelia
- Spinal tumors
- Neurosyphilis
- Subacute combined degeneration
Braddom 6th Edition Chapter 32 Neck pg646
Bonus Answer
- Hematoma secondary to AV malformation (case in the ward)
Differential diagnosis of cervical radiculopathy (Bonus). DDx of Neck and arm pain.
- Cardiac pain
- Cervical spondylotic myelopathy
- CRPS
- Brachial neuritis
- Rotator cuff impoengment
- Thoracic outlet syndromes
Syrinx – what is the most common resulting symptom?
List 6 common symptoms of post-traumatic syringomyelia. 🔑
What percentage of pts with a syrinx are in fact symptomatic?
💡 Syrinx is fluid filled sac compressing spinal cord, brain step and vertebral spine.
CENTRAL CORD SYNDROM
Syrinx = Sensory + Motor + Autonomic + Local Compression
- Sensory
- Impaired pain and temperature (Lateral spinothalamic tract)
- Loss of crude touch and pressure (Anterior spinothalamic tract)
- Sensory ataxia (Dorsal Column)
- Complains: Dysthesia, Radicular pain, Neuropathic pain
- Tone
- Hypotonia at level +/- fasciculation
- Spasticity below level
- Motor
- Upper limb more than lower limb weakness and atrophy
- Claw hand deformity
- Reflexes
- Hoffman & Babinski sign positive
- Autonomic
- Horner Syndrome
- Autonomic Dysreflexia
- Impaired bowel and bladder
- Compression “Syringobulbia”
- Cranial Nerves affections: dysphagia, dysphonia, nystagmus
- Cardiorespiratory: Reduced respiratory drive, Sleep apnea, Diaphragmatic paralysis
- Spine: Worsen scoliosis
DDX
- AIDP
- CIDP
- ALS
- Cervical Spondylosis
Cuccurollo 4th Edition Chapter 7 SCI pg601
Ref: SC medicine principles practice textbook pg 502-503
List 2 causes of central cord syndrome other than syrinx.
- Long-standing cervical spondylosis.
- Hyperextension injury
What is Hydromyelia? How does it present?
Dilatation of the central canal of the spinal cord
- rapidly progressive scoliosis
- change in strength or coordination of the upper or lower limbs (Central cord syndrome)
- spasticity.
Braddom Chapter 48
27yo male came with LL weakness after an armed fight. Diagnosis and Clinical Findings 5 marks 🔑🔑
At the level
- Ipsilateral flaccid paralysis (anterior horn cells) → LMN syndrome
- Ipsilateral loss of all sensory modalities (anterior white commissure)
Below the level
- Ipsilateral spastic paralysis (corticospinal) → UMN syndrome
- Ipsilateral loss of vibration, light touch and proprioception (dorsal columns) → sensory ataxia
- Contralateral loss of pain and temperature, crude touch and pressure (lateral & ventral spinothalamic)
Cuccurollo 4th Edition Chapter 7 SCI pg558
Anterior cord syndrome case.
Name common artery clamped in surgery that can cause this syndrome.
List 3 clinical findings in anterior cord syndrome. 🔑🔑
💡 Clamping of aorta at or above origin of artery of Adamkiewicz (T9-L2). Surgery for abdominal aortic aneurysm repair.
- Bilateral weakness below lesion. (corticospinal)
- Bilateral loss of pain/temperature. (spinothalamic)
- Preserved vibration/proprioception below lesion. (posterior column)
Cuccurollo 4th Edition Chapter 7 SCI pg559
MS Patient now c/o unbalanced gait.
Syphilis patient complain of repeated falls and unsteadyeness
Localize the lesion and what is the prognosis? 2 marks 🔑🔑
Posterior Cord Syndrome
- Proprioceptive loss (dorsal columns)
- Muscle strength, pain, and temperature modalities spared
Prognosis
Poor ambulation secondary to the proprioceptive deficits
Cuccurollo 4th Edition Chapter 7 SCI pg559
36 with central disc protrusion.
- Weak below C7.
- Impaired pain/temp below C7
- Preserved vibration, proprioception, and fine touch of limbs.
Questions:
- Localization? 2. Artery involved?
- Anterior cord syndrome at C7 level.
- Corticospinal tracts bilaterally.
- Spinothalamic tracts bilaterally.
- Sparing of posterior columns.
- Anterior spinal artery.
56 falls down stairs, hyperextension of neck.
- Weak upper limbs, relative preservation of lower.
- Impaired pain/temp in upper limbs.
- Bladder/bowel preserved.
Question:
- Localization?
Central cord syndrome.
- Involvement of cervical segments more than lumbosacral segments
27 with gunshot wound to back.
- Spastic paralysis on left below T10.
- Babinski on left
- Impaired vib/proprioception on left below T10.
- Impaired pain/temp below 10 on right.
Question:
- Localization?
- Syndrome?
- Left hemisection of the spinal cord.
- Brown Sequard syndrome.
25 yr with SCI.
- Impaired proprioception/vibration bilaterally below T6.
- Preserved pain/temp in extremities.
- Incomplete mild weakness in some muscles in legs.
- Bowel/bladder spared.
Question:
- Localization?
- Syndrome?
- Posterior columns.
- Posterior cord syndrome
