spinal cord syndromes

Question 1

what is central cord syndrome?

Answer 1

an incomplete spinal cord injury affecting the corticospinal tracts

Question 2

what is the pathophysiology of central cord syndrome

Answer 2

• pre-existing anterior osteophytes and ligamentum flavum hypertrophy
• commonly mild hyperextension injury - spinal cord oedema
• corticospinal tracts
• haemorrhage results in worse prognosis

Question 3

what are the clinical features of central cord syndrome?

Answer 3

• motor deficit
• upper limb more affected than lower limb
• hands worse affected

Question 4

Central cord syndrome - how will you manage the patient?

Answer 4

Immediate assessment:
* ATLS guidelines - identify and treat life threating injuries
* focused hx, neurological examination and assign an ASIA score
* careful fluid resuscitation to maintain BP to ensure cord perfused, urinary catheter
* spinal immobilisation
* serial neurological examinations

Question 5

what is the prognosis for central cord syndrome?

Answer 5

• good recovery
• early neurological improvement
• no full functional recovery
• recovery starts with: lower limbs > bladder> bowel> proximal upper limb > hands last
• normally ambulatory at final follow up

Question 6

when would you operate on a patient with central cord syndrome?

Answer 6

**Indications: **
* Instability = fracture and neuro deficit
* Plateau in recovery with MRI proven cord compression
* large central disc protrusion

Timing:
* within 24hr if neuro deficit - improved sensorimotor compared to >24hrs
* Lancet neurology multi-trial analysis - 4x Badhiwala 2021
* ASIA improvement scale - improvement of 2 grades

Procedure
* surgical decompression and stabilisation
* 1-2 levels - anterior approach
* >2 levels - posterior or combined

Question 7

tell me about spinal cord injury?

Answer 7

Complete
- asia score A - no motor, sensory or autonomic function below level of injury

Incomplete
* some motor, sensory function or sacral sparing below level of injury
* sacral sparing - anal tone preserved - difference between complete and incomplete
* prognosis - determined by how complete injury is

ASIA level
Can’t be determined until patient out of spinal shock - bulbocavernous reflex is present

Question 8

what is the anatomy of the spinal cord?

Answer 8

Ascending tracts
* dorsal column - proprioception, vibration and deep touch
* lateral spinothalamic - pain and temperature
* anterior spinothalamic - light touch

Descending tracts
* anterior corticospinal tract
* lateral corticospinal tract

ATLS
* Arms - closest to cord - affect first in central cord syndrome
* trunk
* legs
* spine

Question 9

what is neurogenic shock?

Answer 9

what is it?
* acute circulatory failure due to loss of sympathetic tone
* decreased heart rate
* decreased blood pressure

Treatment:
* vasopressors
* careful fluid management

Question 10

What is spinal shock?

Answer 10

what is it?
transient loss of reflexes and function below injury level
* areflexia
* flaccid paralysis
* loss of bulbocavernous reflex - tug on catheter to get an anal contraction

prognosis
normally recovers within 48hrs

stages of spinal shock include:
- hyporeflexia
- initial return of reflexes
- initial hyperreflexia
- spasticity

autonomic dysfunction
- stimulation below the level of injury causes: hypertension, sweating, loss of bladder and bowel control

Question 11

what are the stages of spinal shock?

Answer 11

• hypoflexia - 0- 48hrs
• return of reflexes
  polysynaptic reflexes (bulbocavernous reflex) return in 1-2 days
  monosynaptic reflexes (patella reflex) remain absent.
• hyperreflexia - lasts 1-4 weeks
• spasticity - lasts 1-12 months

Question 12

what is the ASIA score

Answer 12

• A - awful! - no motor or sensory in lowest sacral segment
• B - incomplete - sensory below neuro level but no motor
• C - incomplete - motor below level is <3 muscle grade (mrc)
• D - incomplete - motor below level > 3
• E - excellent - motor and sensory normal

Question 13

what is the management of spinal cord injury?

Answer 13

• ATLS and C-spine immobilisation before detecting
• check not in spinal shock - bulbocavernous reflex
• asia score for level and prognosis

Question 14

what are the incomplete spinal cord syndromes?

Answer 14

• central
• anterior
• brown-sequard
• dorsal column
• cauda equina

Question 15

what is anterior cord syndrome?

Answer 15

• flexion compression injury to the spinal cord
• ischaemic damage to the anterior spinal artery supplying anterior 2/3rd of the cord
• damages anterior corticospinal and anterior spinothalamic tracts
• affects lower limbs more than upper limbs
• sparing of - dorsal columns, lateral corticospinal and lateral spinothalamic tracts
• poor prognosis - 10% recovery

Question 16

what is brown-sequard syndrome?

Answer 16

a complete hemitransection of the cord due to a penetrating injury
* ipsilateral posterior colum and lateral corticospinal tract
* contralateral - lateral spinothalamic
* best prognosis - 99% are ambulant

Question 17

what is dorsal column injury?

Answer 17

injury to the dorsal columns typically due to a medical cause e.g. diabetes
* loss of vibration, proprioception and deep touch