Snapshot 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) Introduction Spinal cord lesions can result in permanent neurologic disability it is important to quickly evaluate and treat spinal cord injury quadriplegia and permanent function loss possible if untreated patients can become wheelchair bound and develop other complications as a result skin ulcers UTIs autonomic dysreflexia severe overactivity of the autonomic nervous system caused by urinary retention, constipation, or other painful conditions Causes of spinal cord lesions can be divided into extrinsic causes such as spinal stenosis abscess focal back pain, fever, and an elevated CSR confirm with MRI tumor herniated disc spinal epidural 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 usually 1 to 2 levels below level of the lesion 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