Spinal Cord Syndromes

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Spinal Cord Syndromes

• Resident Rounds
• April 12, 2007
• Juliette Sacks

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Anatomy

• Spinal cord ends as
• conus medullaris at
• level of first lumbar
• vertebra
• lumbar and sacral
• nerve roots exit below
• this and form the
• cauda equina

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Neuroanatomy

• Corticospinal tracts
• Spinothalamic tracts
• Dorsal (posterior) columns

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Corticospinal Tract

• Descending motor pathway
• Forms the pyramid of the medulla
• In the lower medulla, 90 of fibers decussate and
  descend as the lateral corticospinal tract
• Synapse on LMN in the spinal cord
• 10 that do not cross descend as the ventral
  corticospinal tract
• Damage to this part cause ipsilateral UMN findings

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Spinothalmic Tract

• Ascending sensory tract from skin and muscle via
  dorsal root ganglia to cerebral cortex
• Temperature and pain sensation
• Damage to this part of the spinal cord causes
• Loss of pain and temperature sensation in the
  contralateral side
• Loss begins 1-2 segments below the level of the
  lesion

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Dorsal (Posterior) Columns

• Ascending neurons that do not synapse until they
  reach the medulla at which point they cross the
  midline to the thalamus
• Transmits vibration and proprioceptive
  information
• Damage will cause ipsilateral loss of vibration
  and position sense at the level of the lesion

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Complete vs Incomplete

• Incomplete
• Sensory, motor or both functions are partially
  present below the neurologic level of injury
• Some degree of recovery
• Complete
• Absence of sensory and motor function below the
  level of injury
• Loss of function to lowest sacral segment
• Minimal chance of functional motor recovery

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Light touch

• Transmitted through both the dorsal columns and
  the spinothalamic tracts
• Lost entirely ONLY if both tracts are damaged

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Case 1

• 33 yo F fell off a 20 cliff snowboarding
• C/o inability to move both legs
• GCS 15 BP 130/68 HR 89 regular
• Normal UE exam
• No power in LE
• Vibration and position sense normal in LE
• Sensation normal in LE
• No rectal tone or perianal sensation

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Anterior Cord Syndrome

• Damage to the corticospinal and spinothalamic
  tracts
• Dorsal column function is intact
• Loss of
• Motor function
• Pain and temperature sensation
• Vibration, position and crude touch are maintained

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ACS contd

• Causes
• Direct injury to anterior spinal cord
• Flexion injury of cervical spine causing a cord
  contusion
• Bony injury causing secondary cord injury
• Thrombosis of anterior spinal artery

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Symptoms

• Complete paralysis below the level of the lesion
  with loss of pain and temperature sensation
• Preservation of proprioception and vibration sense

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What to do?

• Urgent CT/MRI
• Surgical decompression may be an option
• Prognosis POOR

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Case 2

• 24 y.o. M came off motorcycle at high speed
• Wore no helmet and sustained severe head injury
• C-spine films were unremarkable apart from a
  narrow spinal canal
• Once conscious, he was quadriparetic with 2/5
  power in most muscle groups
• No other neurological findings

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Where is the lesion?
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Whats the deal?

• MRI
• Mild swelling of the cord at C3/4
• Prevertebral soft tissue swelling and disruption
  of anterior longitudinal ligament
• Prognosis
• Within 48h, power in UE 3/5 and LE 4/5
• At 2/12, further but not full recovery

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Central Cord Syndrome

• Older patients
• Preexisting central
• spondylosis
• Hyperextension injury
• Injury affects central cordgt
• peripheral cord
• Damage to corticospinal
• and spinothalamic tracts
• Upper extremitiesgtthoracic
• gtlower extremitiesgtsacral

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CCS

• Present with
• Decreased strength
• Decreased pain and temperature sensation
• Uppergtlower extremities
• Spastic paraparesis/quadriparesis
• Maintain bladder and bowel control
• Prognosis GOOD
• Although fine motor recovery of the upper
  extremities is rare

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Case 3

• 24 y.o. M stabbed in the
• neck during stampede
• argument over whose
• doolie tires were bigger
• No LOC
• C/o inability to pick up his hat with his left
  hand
• Unaware of his girl holding his right arm

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Brown-Séquard Syndrome

• Hemisection of the cord
• Ipsilateral loss of
• Motor function
• Proprioception and vibration sense
• Contralateral loss of
• Pain and temperature sensation

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BSS

• Caused by
• Penetrating injury
• Lateral cord compression from
• Disk protrusion
• Hematomas
• Bone injury
• Tumours
• Prognosis GOOD

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Case 4

• 76 y.o. Grandpa says hes got the rheumatism
  some bad in his legs with the crazy weather
  these days
• His wife tells you hes wetting himself which
  is unlike him
• He seems to be having lots of trouble riding his
  bike because he thinks the bike seat isnt under
  him when it actually is

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Cauda Equina Syndrome

• Peripheral nerve injury to lumbar, sacral and
  coccygeal nerve roots
• Symptoms
• Variable motor and sensory loss in lower
  extremities
• Sciatica
• Bowel and bladder dysfunction
• Saddle anaesthesia
• Prognosis GOOD

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ED Stabilization

• ABCs
• Airway
• Low threshold for definitive airway in patient
  with cervical spine injury especially if higher
  then C5
• Spinal immobilization very important

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Spinal Shock

• Loss of neurological function and autonomic tone
  below level of lesion
• Loss of all reflexes
• Resolves over 24-48h but may last for days
• Bulbocavernosus reflex returns first

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Spinal Shock

• Symptoms
• Flaccid paralysis
• Loss of sensation
• Loss of DTRs
• Bladder incontinence
• Bradycardia
• Hypotension
• Hypothermia
• Intestinal ileus

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Hypotension

• Must determine cause
• Spinal cord injury
• Blood loss
• Cardiac injury
• Combination of above
• Blood loss is the cause of hypotension until
  proven otherwise!
• Vitals are often non specific
• R/O other causes with CXR, FAST, CT

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Neurogenic Shock

• Neurogenic Shock
• Warm
• Peripherally vasodilated
• Bradycardic
• Bradycardia may be caused by something other than
  neurogenic shock
• Cervical spine injury may cause sympathetic
  denervation
• Resuscitate with fluids /- vasopressors

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Corticosteroids

• Controversial
• Based on NASCIS trials
• Methylprednisolone improved both motor and
  sensory functional outcomes in complete and
  incomplete injuries
• Benefit dependent on dose and timing of dose

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Corticosteroids

• NASCIS recommends
• Treatment must begin within 8h of injury
• Methylprednisolone 30mg/kg bolus iv over 15
  minutes
• 45 minute pause post bolus
• Maintenance infusion 5.4mg/kg/h
  methylprednisolone is continued x 23h
• Evaluated in blunt injury only
• Large doses of steroids in penetrating injury may
  be detrimental to recovery of neurological
  function

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Steroid Therapy as per NACSIS

• Attributed to antioxidant effects
• Treat for 24h in patients treated within 3h of
  injury
• Treat for 48h in patients treated within 3-8h of
  injury
• Worse outcome if started 8h post injury
• Conflicting evidence re benefit therefore more
  trials required

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Pros Cons

• Believed to inhibit formation of free
  radical-induced peroxidation
• May increase spinal cord blood flow
• Increase extracellular calcium
• Prevent potassium loss from cord

• Pneumonia
• Sepsis
• Wound infection
• GIB
• Delayed healing

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NASCIS IBracken et al. 1984. Efficacy of
methyprednisolone in acute spinal cord injury,
JAMA, 25145-52

• Prospective, randomized double blind trial with
  330 patients
• 2 treatment arms
• 100 mg bolus MP, then 25 mg q6h x 10 d
• 1000 mg bolus, then 250 mg q6h x 10 d
• No sig difference in primary outcomes
• 4x increase in wound infections in high dose
  group
• Trend towards increased sepsis, PE, death in
  higher dose group

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NASCIS IIBracken NEJM 1990 322 1405-11

• DBRCT of methylprednisone vs naloxone vs placebo
  (total N487)
• Methylprednisone 30 mg/kg bolus then 5.4 mg/kg/hr
  X 23 hours
• Outcome neurological function at 6 weeks and 6
  months assess by a neuro function score
• NO benefit of naloxone
• NO benefit of steroids overall
• NO difference in mortality
• Trend to more infections and GI bleeds with
  steroids

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NASCIS II

• Post hoc SUBGROUP ANALYSIS showed a benefit at
  6 months in the subgroup treated within 8 hrs
• Improved motor score 4 points (p lt 0.03)
• Improved Touch score 5 points (p lt 0.03)
• Improved pin-prick score 5 points (p lt 0.02)
• Concluded that steroids were indicated if started
  within 8hrs
• One year data showed similar improvement in motor
  score but no difference in sensory scores
  (Bracken. J Neurosurg 1992 76 23-31)

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NASCIS IIIBracken JAMA 1997 277(20) 1597-1604

• DBRCT of methylprednisone 24hrs vs 48 hrs vs
  Tirilazad (total N499)
• NO placebo arm
• Overall, NO difference between the three groups
• Post-hoc subgroup analysis 48 hour steroid group
  showed improved motor scores at 6 weeks and 6
  months if started between 3-8hrs
• 6 weeks 5 points motor score (p lt0.04)
• 6 months 4.4 points (p lt0.01)

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NASCIS III

• Adverse outcomes
• Severe pneumonia higher in 48hr group
• 2.6 vs 5.8 (plt0.02)
• Severe sepsis higher in 48hr group
• 0.6 vs 2.6 (plt 0.07)
• They concluded
• Steroids indicated for SCI
• If started within 3hrs, treat for 24hrs
• If started within 3-8hrs, treat for 48hrs

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Cochrane Review

• the randomized trials of MPSS in the treatment
  of acute SCI provide evidence for a significant
  improvement in motor function recovery after
  treatment with the high dose regimen within 8
  hours of injury
• Bracken November 2000
• Update in Spine 2001 by Bracken
• 4 trials and 797 patients randomized to get high
  dose methylpred vs placebo for 24 hours

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Cochrane Review Results

• Primary outcome neurological improvement at 6
  weeks, 6 months, 1 year
• Complicated motor and sensory exam
• High dose methylpred associated with 4/70 point
  increase in motor function at 6 weeks, 6 months
  but not one year

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SCI and Steroids

• Clinical relevance?
• 4 points spread over 14 muscle segments
  unilaterally
• Not validated score
• No inter-rater reliability
• Conclusions based on post-hoc analysis of small
  subgroup from 1 trial
• 65 patients per arm
• Data drudging
• High risk of alpha error
• Serious complications (not statistically
  significant)
• GI bleed and wound infection (RR 4.00, 95 CI
  0.45-35.58)
• Severe pneumonia (RR 2.25, 95 CI 0.71-7.15)
• Range of values in CI huge ? do the risks
  outweigh the benefits??

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SCI and Steroids

• Author consultant for Pharmacia (they make
  methylprednisolone)
• Weak support for use of high dose methylpred in
  acute SCI may be increased risk of severe
  adverse outcomes.

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Bottom Line

• CAEP position statement steroids are NOT
  STANDARD OF CARE
• There is insufficient evidence to support the use
  of high dose methyprednisolone within 8 h of
  acute SCI
• Significant harm to using steroids
• NASCIS subgroup data needs to be validated in
  prospective, randomized, blinded trials
• No new literature to argue for or against this

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Neurological Examination

• LOC
• Deteriorating course
• Neck, back pain and/or bladder, bowel
  incontinence should increase suspicion of sc
  injury
• Define level of lesion
• Motor function
• Sensory level
• Proprioception testing
• DTRs
• Anogenital reflexes

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DI

• C-spine films as per c-spine rules/nexus
• CT
• MRI better for visualizing neurological,
  muscular and soft tissue
• If CT negative and patient has positive
  neurological findings, this is next step
• Important to image entire spine as 10 have 2nd
  injury

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Treatment

• Prevent secondary injury
• Alleviate cord compression
• Establish spinal stability
• Assess the neurological deficit and spinal
  stability
• Imaging
• Consult spine/neurosurgery

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Other cord lesions

• Malignancy
• Epidural hematoma
• Abscesses

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At the end of my rope

• Urgent care necessary
• MRI is better than CT for imaging spinal cord
• Comprehensive serial neurological exams important
  re management options
• Steroids are not the standard of care in Canada
• Consider spinal shock, neurogenic shock and other
  causes of shock in someone with a spinal cord
  injury