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Emergency and Acute Medicine: Spinal Cord Syndromes
Spinal cord syndromes represent patterns of neurologic deficits caused by localized disruption of spinal cord pathways, most commonly due to trauma. These injuries produce characteristic combinations of motor and sensory loss depending on the portion of the cord affected. While high-energy trauma is the most frequent cause, patients with underlying spinal disease such as arthritis, osteoporosis, or metastatic lesions are at increased risk of cord injury even after minor trauma.
Several classic syndromes are recognized. Anterior cord syndrome typically results from flexion or axial loading injuries, or from direct compression by fractures, discs, tumors, or abscesses, and occasionally from compromise of the anterior spinal artery. It presents with bilateral motor paralysis and loss of pain and temperature sensation below the lesion, while dorsal column functions (proprioception and vibration) are preserved. Brown-Séquard syndrome results from hemisection of the cord, most often due to penetrating trauma, and produces ipsilateral motor weakness and loss of proprioception, with contralateral loss of pain and temperature, usually beginning a few levels below the injury. Central cord syndrome, commonly seen in elderly patients with cervical spondylosis, follows hyperextension injuries and leads to greater motor weakness in the upper extremities than the lower, with variable sensory deficits. Dorsal cord syndrome involves loss of proprioception, position sense, and coordination, while complete cord syndrome represents total disruption of the cord, resulting in complete motor and sensory loss below the lesion, often accompanied by neurogenic shock characterized by hypotension, bradycardia, warm skin, and sometimes priapism. Deficits that persist beyond 24 hours are usually permanent.
Patients typically present with an acute loss of motor and/or sensory function following trauma. A detailed neurologic examination is essential to determine the level of injury, using known sensory and motor landmarks such as the clavicles (C4), nipples (T4), umbilicus (T10), and perianal region (S5), as well as key motor functions like elbow flexion (C5), finger movement (C8–T1), and ankle motion (L4–S1). Accurate documentation of these findings is critical for diagnosis, monitoring progression, and guiding management.
Evaluation begins with a thorough neurologic assessment and urgent neurosurgical consultation if any deficit is present. Imaging should include plain radiographs of suspected areas, though CT scanning is often preferred, especially in older patients or when radiographs are inconclusive, as it better visualizes bony injury and canal compromise. MRI is the imaging modality of choice for assessing spinal cord injury, particularly when neurologic deficits are unexplained, progressing, or when surgical intervention is being considered. If MRI is unavailable, CT myelography may be used. Additional studies such as lumbar puncture may be considered when alternative diagnoses like demyelinating or inflammatory conditions are suspected.
The differential diagnosis includes peripheral nerve injuries, dorsal root lesions, Guillain–Barré syndrome, multiple sclerosis, transverse myelitis, epidural abscess, and stroke, all of which may mimic spinal cord pathology and must be carefully distinguished.
Management begins in the prehospital setting with strict spinal immobilization and rapid transport to a trauma center. In the emergency department, immobilization must be maintained at all times, including during airway management with in-line stabilization. Intravenous fluids should be administered, particularly in cases of hypotension, though other causes such as hemorrhage must be excluded. Neurogenic shock should be suspected when hypotension is accompanied by bradycardia, and if unresponsive to fluids, vasopressors (preferably alpha-agonists) may be required.
Early involvement of neurosurgery is critical, as timely decompression or stabilization may improve outcomes. Associated injuries should be treated concurrently, and patients with penetrating trauma require antibiotics and tetanus prophylaxis. The routine use of high-dose corticosteroids is no longer recommended, as evidence has not demonstrated clear benefit and may increase complications.
All patients with suspected spinal cord syndromes require hospital admission, typically to an intensive care unit, for close monitoring and management. No patient with signs of spinal cord injury should be discharged from the emergency department. Early recognition, accurate neurologic assessment, and prompt specialist involvement are key factors influencing prognosis and long-term outcomes.
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