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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Risk factors
- Motor vehicle collision, falls (especially older adults with cervical spondylosis), sports (diving), violence
- Cervical spondylosis or congenital spinal canal narrowing (predisposes to central cord syndrome)
- Ankylosing spondylitis (rigid spine fractures with minor trauma)
- Known malignancy with spine-tropic biology
- Anticoagulation or coagulopathy (epidural hematoma)
- IV drug use, immunosuppression (epidural abscess)
- Vascular risk factors (aortic surgery, atherosclerosis) for anterior spinal artery infarct
Pathophysiology
Primary injury (mechanical disruption, transection, contusion) produces immediate neurologic deficit. Secondary injury — edema, ischemia, glutamate excitotoxicity, oxidative stress, inflammation, apoptosis — extends damage over hours to days. Decompression and stabilization aim to prevent secondary injury and preserve residual function.
Clinical presentation
Symptoms
- Acute weakness or paralysis below the level of injury
- Sensory loss with a discrete dermatomal level on the trunk
- Bowel and bladder dysfunction (retention initially)
- Neck or back pain at the level of injury
- Priapism (complete cord injury), respiratory distress (high cervical injury)
- Specific cord syndromes (see by_subtype)
Signs / physical exam
- Motor: flaccid weakness in spinal shock phase; later spasticity, hyperreflexia, upgoing toes
- Sensory: defined level to pinprick and light touch; dissociated loss in central/Brown-Séquard/anterior cord patterns
- Reflexes: areflexic acutely, hyperreflexic with time (UMN pattern)
- Autonomic: hypotension and bradycardia (neurogenic shock) with injuries above T6; loss of sphincter tone
- Priapism (sympathetic disruption)
Classic findings
Discrete sensory level + motor deficit below + bladder retention + back pain after trauma or in a cancer patient.
Differential diagnosis
- Cauda equina syndrome — Lumbosacral root compression below conus — saddle anesthesia, bladder dysfunction, lower-extremity LMN signs only (see separate entry)
- Guillain-Barré syndrome — Ascending flaccid weakness, areflexia, no sensory level, albuminocytologic CSF
- Transverse myelitis — Subacute (hours-days), sensory level, often inflammatory; consider MS, NMO, autoimmune
- Stroke (anterior cerebral or pontine) — Cortical/brainstem signs, asymmetric, intact spinal exam below lesion
- 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
- CT angiography if vertebral artery injury suspected (penetrating, foramen transversarium fracture)
Treatment
First-line
- 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
- Upper extremity weakness > lower extremity, variable sensory loss, bladder dysfunction
- Surgical decompression for instability or progressive deficit; otherwise conservative with reasonable prognosis for ambulation
Anterior cord syndrome
- Loss of motor function + pain/temperature below lesion; preserved proprioception/vibration (posterior columns spared)
- Often anterior spinal artery infarct (aortic surgery, dissection, atherosclerosis)
- Poorest prognosis of incomplete syndromes
Brown-Séquard syndrome
- Hemisection of cord — ipsilateral motor and dorsal column loss + contralateral pain/temp loss starting 1-2 levels below
- Penetrating trauma, hemorrhage, tumor
- Best prognosis among incomplete syndromes; most regain ambulation
Posterior cord syndrome
- Loss of vibration/proprioception, sensory ataxia
- Rare; consider B12 deficiency, tabes dorsalis, MS
Malignant epidural compression
- Dexamethasone 10 mg IV bolus then 4 mg q6h
- Urgent radiation oncology consultation
- Surgical decompression for single-level disease, radioresistant tumor, instability, or need for tissue diagnosis (per Patchell trial)
Second-line / adjunct
- Early multidisciplinary rehabilitation (PT, OT, SLP, rehabilitation medicine)
- Bladder and bowel program
- Pressure-injury prevention
- Psychological support and peer support programs
- Spasticity management: baclofen (oral or intrathecal), tizanidine, botulinum toxin
Complications
- Neurogenic shock (hypotension + bradycardia) — distinguish from hemorrhagic shock
- Spinal shock — transient flaccid areflexic state lasting hours-weeks
- Autonomic dysreflexia — paroxysmal hypertension from noxious stimuli below T6 lesion; medical emergency: sit patient up, identify trigger (full bladder, fecal impaction), short-acting antihypertensive
- Respiratory failure (high cervical injury), aspiration, pneumonia
- Deep vein thrombosis and pulmonary embolism
- Pressure injuries
- Urinary tract infections, urolithiasis
- Heterotopic ossification, contractures, spasticity
- Chronic neuropathic pain
- Depression and PTSD
PANCE pearls
- 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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