• A 26-year-old man presents to the emergency department after a bullet injury to the spine. On physical examination, there is right-sided lower extremity weakness and loss of proprioception and vibration sense on the same side. There is also loss of pain and temperature sensation in the left leg. (Brown-Sequard syndrome)
  • Spinal cord lesions can result in permanent neurologic disability 
    • it is important to quickly evaluate and treat spinal cord injury
  • Causes of spinal cord lesions can be divided into
    • extrinsic causes such as
      • spinal stenosis
      • abscess
      • tumor
      • herniated disc
      • hematoma
      • stab wound and other forms of trauma
    • intrinsic causes such as
      • infarction
      • infection (e.g., poliovirus, syphilis, and HIV)
      • vitamin B12 deficiency
      • syrinx
      • tumor of the spinal cord
      • autoimmune
  • The clinical presentation of spinal cord lesions depend on which ascending or descending fibers are involved, for example
    • if the dorsal columns are solely involved the patient will have a deficit in vibration and proprioception sense
  • Spinal cord anatomy
    • the spinal cord descends from the medulla and terminate at L1-2
      • conus medullaris
        • the lower end of the spinal cord
      • cauda equina
        • comprised of dorsal and ventral nerve roots of the
          • lumbar nerves (L2-L5)
          • sacral nerves (S1-S5)
          • coccygeal nerves
    • the spinal cord contains both white and gray matter
      • the H-shaped gray matter contain cell bodies and nonmyelinated neuronal fibers
        • the ventral horn contains lower motor neurons
        • the dorsal horn contains sensory fibers originating from cell bodies in the dorsal root ganglia (DRG)
        • there are also a number of other neurons involved in motor, sensory, and reflexes
      • the white matter contain ascending and descending myelinated fibers
        • ascending fibers carry sensory information
          • lateral spinothalamic tract carries
            • pain and temperature information of the contralateral body
          • anterior spinothalamic tract carries
            • crude touch and pressure information
          • dosal column carries
            • pressure, vibration, fine touch, and proprioception information of the ipsilateral body
        • descending fibers carry motor input
          • lateral corticospinal tract results in voluntary movement of the contralateral body
Central Cord Syndrome
  • Clinical presentation
    • loss of pain and temperature in the distribution of the level of spinal cord injury
      • the spinothalamic fibers crossing the ventral commissure are disrupted
    • if the spinal cord lesion expands it may result in
      • weakness at the level of sensory loss
        • the corticospinal tract and/or the anterior horn gray matter is involved
      • tendon reflex loss
        • neuronal fibers involved in deep tendon reflexes are involved
  • Etiology
    • syringomyelia
    • intramedullary tumor
    • hyperextension injury in patients with a long history of cervical spondylosis
Anterior (Ventral) Cord Syndrome
  • Clinical presentation
    • typically involves tracts in the anterior two-thirds of the spinal cord which result in
      • muscle weakness
        • the corticospinal tracts are involved
      • bilateral loss of pain and temperature sensation
        • the spinothalamic tracts are involved
      • urinary incontinence
        • the descending autonomic tracts are involved
    • the posterior columns are spared
  • Etiology
    • anterior spinal artery infarction which can be caused by
      • compression injury
      • vertebral burst fracture
    • intervertebral disk herniation
    • radiation myelopathy
Brown-Sequard Syndrome
  • Clinical presentation
    • ipsilateral findings
      • weakness
        • lower motor neuron symptoms at the level of the lesion
        • upper motor neuron symptoms below the level of the lesion
      • loss of proprioception, vibration, light touch, and tactile sense
    • contralateral findings
      • loss of pain and temperature sensation
  • Etiology
    • knife or bullet injury
    • multiple sclerosis
Posterior Cord Syndrome
  • Clinical presentation
    • loss of proprioception and vibration sense
    • variable weakness
    • bladder dysfunction
  • Etiology
    • tabes dorsalis
    • Friedreich ataxia
    • subacute combined degeneration
    • multiple sclerosis
Conus Medullaris
  • Clinical presentation
    • sphincter dysfunction
    • flaccid paralysis of the bladder and rectum
    • impotence
    • saddle anesthesia (more commonly bilateral)
      • S3-S5 involvement
  • Etiology
    • disc herniation
    • trauma
    • malignancy
Cauda Equina Syndrome
  • Clinical presentation
    • asymmetric multiradicular pain
    • leg weakness
    • bladder and rectal sphincter paralysis
    • sensory loss
    • saddle anesthesia (more commonly unilateral)
  • Etiology
    • disc herniation
    • lumbar spinal stenosis
    • malignancy

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