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 login to view 4 more bullets Causes of spinal cord lesions can be divided into extrinsic causes such as spinal stenosis abscess login to view 2 more bullets 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 login to view 1 more bullet cauda equina login to view 4 more bullets the spinal cord contains both white and gray matter the H-shaped gray matter contain cell bodies and nonmyelinated neuronal fibers login to view 3 more bullets the white matter contain ascending and descending myelinated fibers login to view 9 more bullets 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 login to view 1 more bullet tendon reflex loss login to view 1 more bullet 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 login to view 1 more bullet bilateral loss of pain and temperature sensation login to view 1 more bullet urinary incontinence login to view 1 more bullet 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 login to view 2 more bullets 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