Sudden disruption of spinal cord function from trauma, compression, ischemia, or inflammation; outcome depends on completeness of injury and time to decompression.
Also known as: spinal cord injury, SCI, acute spinal cord compression, traumatic spinal cord injury, cord syndrome
Overview
Acute disruption of spinal cord function due to mechanical injury (fracture/dislocation, penetrating trauma), extrinsic compression (epidural abscess, hematoma, metastasis, large disc), vascular insult (anterior spinal artery syndrome, dural AV fistula), or inflammatory/demyelinating disease (transverse myelitis). Severity is classified by the ASIA Impairment Scale (AIS A-E).
Epidemiology
Traumatic SCI incidence ~50-60 per million per year in the US; male predominance ~4:1; bimodal peaks in young adults (motor vehicle, sports, violence) and older adults (falls with cervical stenosis). Non-traumatic compression most often from malignancy (lung, breast, prostate, multiple myeloma, lymphoma).
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Question 1NeurologyMedium
A 60-year-old man reports 8 months of slowly progressive hand clumsiness, difficulty buttoning his shirt, and a stiff, unsteady gait. On examination there is bilateral intrinsic hand muscle weakness, spasticity and hyperreflexia in both legs, an extensor plantar response, and a positive Hoffman sign; vibration sense is diminished in the feet. There are no fasciculations, bulbar symptoms, or cranial nerve deficits. MRI of the cervical spine shows multilevel degenerative disc-osteophyte complexes narrowing the spinal canal with increased T2 cord signal at C3-C5, without an intramedullary syrinx or demyelinating plaques. Which of the following is the most likely diagnosis?
ACervical spondylotic myelopathy
BMultiple sclerosis
CAmyotrophic lateral sclerosis
DCervical syringomyelia
Reveal answer & full explanation
Correct answer: A — Cervical spondylotic myelopathy
ACervical spondylotic myelopathy✓
BMultiple sclerosis
CAmyotrophic lateral sclerosis
DCervical syringomyelia
Why Cervical spondylotic myelopathy is correct
Cervical spondylotic myelopathy is the most common cause of non-traumatic spinal cord dysfunction in adults over 55 and presents exactly as here: insidious hand clumsiness, intrinsic hand weakness, and a spastic gait.
Upper-motor-neuron signs in the legs (spasticity, hyperreflexia, extensor plantar response, Hoffman sign) WITH sensory involvement (diminished vibration) localize a compressive cervical cord lesion.
MRI shows multilevel degenerative canal stenosis with T2 cord signal change at C3-C5, and the absence of a syrinx or demyelinating plaques rules out the mimics.
Management is timely surgical decompression (anterior cervical discectomy and fusion or laminoplasty) to halt progression.
Why the others are wrong
Multiple sclerosis — typically affects younger patients with relapsing optic, brainstem, or spinal demyelination; the MRI shows compressive stenosis and no demyelinating plaques (buzzword-matching on 'cord signal change').
Amyotrophic lateral sclerosis — produces mixed upper- and lower-motor-neuron signs but spares sensation and shows fasciculations, not a sensory deficit or cord compression; the diminished vibration sense and compressive MRI exclude it (premature closure on a progressive-weakness picture).
Cervical syringomyelia — causes a cape-like dissociated sensory loss and shows a fluid-filled intramedullary cavity on MRI, which is explicitly absent here (confused-with another structural cord lesion).
Question 2NeurologyMedium
A 72-year-old man undergoing evaluation for severe aortic stenosis develops sudden bilateral leg weakness, urinary retention, and loss of pain and temperature sensation below the level of the umbilicus. Proprioception and vibration sense are preserved in both legs. MRI of the spine shows an anterior cord T2 signal change at the T9 level. In addition to treating the underlying cause, which of the following is the most appropriate management?
AMean arterial pressure augmentation
BTherapeutic anticoagulation
CHigh-dose intravenous corticosteroids
DEmergent surgical decompression
Reveal answer & full explanation
Correct answer: A — Mean arterial pressure augmentation
AMean arterial pressure augmentation✓
BTherapeutic anticoagulation
CHigh-dose intravenous corticosteroids
DEmergent surgical decompression
Why mean arterial pressure augmentation is correct
The presentation is anterior spinal cord syndrome caused by anterior spinal artery ischemia: motor paralysis, loss of pain and temperature sensation, and bladder dysfunction below the lesion, with preserved proprioception and vibration.
Proprioception and vibration are preserved because the dorsal columns are supplied by the separate posterior spinal arteries.
The anterior two-thirds of the cord is supplied by the anterior spinal artery and is injured by hypoperfusion.
Because the injury is ischemic, the cornerstone of management is augmenting spinal cord perfusion by targeting a mean arterial pressure above roughly 85–90 mm Hg and avoiding hypotension, alongside treatment of the underlying cause.
Anterior cord syndrome is classically associated with aortic disease, hypotension, and embolic events.
Why the others are wrong
B) Therapeutic anticoagulation — Not first-line; the mechanism is typically arterial hypoperfusion or embolism rather than a thrombus requiring systemic anticoagulation, and it carries bleeding risk without proven benefit.
C) High-dose intravenous corticosteroids — Tempting because students associate steroids with acute spinal cord injury, but they are not evidence-based for ischemic anterior cord syndrome and are not standard of care here.
D) Emergent surgical decompression — Indicated for compressive cord lesions such as epidural hematoma, abscess, or tumor; imaging here shows ischemic signal change without a compressive mass, so there is nothing to decompress.
Additional high-yield points
Anterior cord syndrome carries the worst prognosis of the incomplete cord syndromes, underscoring the importance of optimizing perfusion early.
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Conversion / functional weakness — Inconsistent exam, give-way weakness, preserved bowel/bladder; diagnosis of exclusion after imaging
Diagnostic workup
Diagnostic criteria
ASIA International Standards for Neurological Classification of SCI: motor (key muscles graded 0-5) and sensory (pin-prick and light touch in 28 dermatomes) examination defines the neurological level and AIS grade A (complete) through E (normal).
Labs
CBC, CMP, coagulation studies
Type and screen
Toxicology if trauma context
ESR/CRP, blood cultures if infection suspected
Imaging
CT cervical/thoracic/lumbar spine — first-line trauma imaging for bony injury
MRI whole spine with and without contrast — modality of choice for cord and soft tissue evaluation, especially in compression, abscess, hematoma, malignancy, or transverse myelitis
ABCs — high cervical injury (above C5) compromises diaphragm; intubation often required
Spinal immobilization (rigid collar, log-roll precautions) until injury cleared
Maintain MAP 85-90 mm Hg for 7 days post traumatic SCI to support cord perfusion (vasopressors as needed)
Foley catheter for bladder management
Emergent neurosurgical or orthopedic spine consultation for decompression and stabilization
DVT prophylaxis (mechanical immediately; pharmacologic once hemorrhage excluded, typically within 72 h)
Corticosteroids (methylprednisolone) — NOT routinely recommended for traumatic SCI per current AANS/CNS guidance; risk of complications exceeds benefit
Central cord syndrome
Most common incomplete cervical SCI, often in older adults with cervical spondylosis after hyperextension
Maintain MAP 85-90 mm Hg for 7 days after traumatic SCI to optimize cord perfusion and neurologic recovery.
Autonomic dysreflexia: think 'full bladder, full bowel, or pressure injury' — sit the patient up FIRST, then treat the trigger.
Methylprednisolone is no longer routinely recommended for acute traumatic SCI; check current AANS/CNS guidance and shared decision-making.
Beware the older adult who falls and complains of arm weakness with neck pain — central cord syndrome from cervical hyperextension.
Cancer patient with new back pain = MRI whole spine until proven otherwise; do not wait for neurologic deficit.
References
AANS/CNS 2013 — Walters BC et al. Guidelines for the management of acute cervical spine and spinal cord injuries: 2013 update. Neurosurgery 2013;72(Suppl 2):1-259.
ASIA 2019 — ASIA International Standards for Neurological Classification of Spinal Cord Injury (revised).
Patchell Trial — Patchell RA et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer. Lancet 2005;366:643-648.
STASCIS — Fehlings MG et al. Early versus delayed decompression for traumatic cervical SCI. PLoS One 2012;7:e32037.
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