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Key Features

Essentials of Diagnosis

  • History of trauma

  • Development of an acute neurologic deficit

  • Signs of myelopathy on examination

General Considerations

  • Although spinal cord damage may result from whiplash injury, severe injury usually relates to fracture-dislocation causing compression or deformity of the cord either in the cervical or in the lower thoracic and upper lumbar regions

  • Extreme hypotension following injury may also lead to cord infarction

Clinical Findings

Symptoms and Signs

Total cord transection

  • Immediate flaccid paralysis and loss of sensation below the level of the lesion

  • Reflex activity is lost for a variable period; urinary and fecal retention

  • As reflex function returns, spastic paraplegia or quadriplegia develops, with hyperreflexia and extensor plantar responses

  • A flaccid atrophic (lower motor neuron) paralysis may be found depending on the segments of the cord affected

  • The bladder and bowels regain some reflex function, permitting urine and feces to be expelled at intervals

  • As spasticity increases, flexor or extensor spasms (or both) of the legs become troublesome, especially if bed sores or a urinary tract infection develops

  • Paraplegia with the legs in flexion or extension may eventually result

Lesser degrees of injury

  • Mild limb weakness, distal sensory disturbance, or both

  • Sphincter function may be impaired, urinary urgency and urge incontinence being especially common

  • A unilateral cord lesion leads to an ipsilateral motor disturbance with accompanying impairment of proprioception and contralateral loss of pain and temperature appreciation below the lesion (Brown-Séquard syndrome)

  • A central cord syndrome may lead to a lower motor neuron deficit and loss of pain and temperature appreciation, with sparing of posterior column functions

  • A radicular deficit may occur at the level of the injury—or, if the cauda equina is involved, there may be evidence of disturbed function in several lumbosacral roots

Differential Diagnosis

  • The history of the preceding trauma distinguishes the disorder from other causes of nontraumatic myelopathy

Diagnosis

Diagnostic Procedures

  • Obtain history of trauma

Treatment

Medications

  • Early treatment with high doses of corticosteroids (eg, methylprednisolone, 30 mg/kg by intravenous bolus, followed by 5.4 mg/kg/h for 23 hours)

    • Can improve neurologic recovery if commenced within 8 hours after injury

    • However, evidence is limited and some neurosurgical guidelines do not recommend their use

Surgery

  • If there is cord compression, early decompressive laminectomy and fusion (within 24 hours)

Therapeutic Procedures

  • Immobilization

  • Anatomic realignment of the spinal cord by traction and other orthopedic procedures is important

Outcome

Follow-Up

  • Subsequent care of the residual neurologic deficit—paraplegia or quadriplegia—requires treatment of spasticity ...

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