History and exam

Key diagnostic factors

common

motor weakness

Motor weakness is the most common, classic sign of spinal cord injury.

loss of fine motor coordination

Involvement of the inner corticospinal tracts can lead to a deficit in the muscles concerned with fine motor functions in the hand. This may result in difficulty in prehensile activities and in eating, and result in dropping small objects, and difficulty in writing (if there is involvement of the dominant extremity). These deficits can be very disabling.

spasticity

Can be graded using the modified Ashworth Scale.[41] Severe spasticity can be very disabling.

paresthesia, numbness, dysesthesia

Spontaneous abnormal sensations may be noted early in the pathology and increase in severity to a sharper, burning character (dysesthesia) with chronic spinal cord changes. There may be associated hyperesthesia, hyperalgesia, or numbness.

hyperreflexia and ankle clonus

Hyperexcitable state of the stretch reflex leads to brisk deep tendon jerks that can lead to clonus.

Negotiating stairs, especially when descending, can elicit ankle clonus and lead to unsteadiness and frequent falls.

pathologic reflexes

These include Babinski sign (extensor plantar), inverted radial reflex, Hoffman sign (finger flexor), Lhermitte sign, scapulohumeral reflex (lesion above C4), finger escape sign, and the Oppenheim sign.

uncommon

contractures

Spasticity and increased muscle tone can lead to joint contractures, which classically produce elbow flexion and knee extension.

Keeping joints supple and free of contractures is an important treatment goal to prevent secondary disability.

loss of perianal sensation, voluntary anal contraction and anal tone

A sign of a complete lesion. If perianal sensation, anal tone, or anal contraction are preserved, the patient has sacral sparing and the lesion is partial.

autonomic dysreflexia

Patients develop a sudden, uncontrolled rise in blood pressure, pounding headache, sweating or shivering, anxiety, chest tightness, blurred vision, nasal congestion, blotchy skin rash or blushing above the lesion level, and cold with piloerection below the level of the lesion.

A relative increase in systolic blood pressure >20 mmHg above baseline is diagnostic.

The most likely causes are bladder distension due to catheter blockage (if catheter is in place), urinary retention (if catheter is not in place), or fecal impaction, but can be triggered by any noxious stimulus below the level of injury.

syrinx

A syrinx may develop in some patients. This refers to the development of a cavity (hydromyelia) in the substance of the cord.

While the true percentage of clinically silent lesions is not known, a small proportion of patients develop debilitating symptoms. These include the onset of pain and loss of sensorimotor levels. In patients this can result in loss of respiratory stability or arm function, in the case of upper cord injuries. These symptomatic lesions typically progress over time. Symptomatic lesions may need to be addressed with surgical decompression.

Other diagnostic factors

common

central (midline) pain

Midline pain may arise from a variety of pain generators ranging from dura to osseous nociceptive nerve endings.

The pain is typically axial, constant, and relieved with rest.[32]

Spinal cord tumors produce a different pattern in which the pain is present at rest, even when recumbent, and is nocturnal.

girdle pain

Radiation from a thoracic lesion can present as a girdle pain if it involves a nerve root and is noted in the dermatome or myotome supplied by the root or the intercostal nerve.[32] It is aggravated by coughing and sneezing. Bilateral involvement can present as a "tight-belt" constriction.

musculoskeletal or visceral pain

The pain is usually positional and clearly distinguishable in character and distribution from neurogenic pain.

unsteady gait

Unsteady gait can be due to a combination of weakness of the antigravity lower limb muscles, loss of proprioceptive sensations, and spasticity of the muscles. This can lead to heaviness of the legs, frequent trips and falls around the home, and difficulty in negotiating stairs.

urinary incontinence or retention

Both upper and lower urinary tract complications are common regardless of the mechanism of SCI. Urinary retention with the inability to void is the most common presentation (reflex neurogenic lower urinary tract dysfunction); alternatively, incontinence may be present.[30][31] Spinal imaging and neurologic status are not accurate estimates of the sphincteric status; urodynamic studies are required for proper assessment.[45]

constipation

Constipation is common following SCI and can lead to fecal impaction with overflow incontinence.

sexual dysfunction

Controlled by complex autonomic pathways with cortical input. Parasympathetics control erection whereas sympathetics control erection and ejaculation. Potency affects males. Reduced sensation can lead to a reduced pleasure in both sexes. Lesions of the cord can lead to priapism.

uncommon

nonspecific malaise

SCI substantially alters the symptomatology of many conditions. In particular, symptoms and signs of pain and focal tenderness do not occur below the level of the lesion. Patients presenting with an intercurrent illness may only report a nonspecific feeling of malaise.

radicular pain

The pain may radiate in the dermatome or myotome of any root and cause pain in the extremities. If involving the dorsal root it may cause pain in relation to the posterior musculature. It is increased by coughing or sneezing.

Risk factors

strong

spinal cord trauma or ischemia

The initial spinal cord injury (SCI) is usually due to compression (from a space-occupying lesion) or physical trauma in the form of distraction, shearing, or laceration. Common causes of traumatic SCI include motor vehicle accidents, falls, sports injuries, and violence. NSCISC: spinal cord injury facts & figures at a glance Opens in new window

Depending on the direction and magnitude of the forces causing the injury, some neurons and tracts can be preferentially involved. The amount and location of the intact neural tissue determines the residual function. Mechanical compression of the cord, which occurs over a period, allows for gradual compensatory adjustments that preserve function; compressive lesions are tolerated better than sudden mechanical distortion of the cord such as stretch, laceration, or shear. Vascular injuries (which can be primary or secondary to a mechanical injury) are poorly tolerated and have a poorer prognosis for recovery.

higher-level spinal cord lesion

Injury to higher levels of the spinal cord causes interruption of the conduction of large-diameter fibers. Subaxial cervical lesions cause tetraplegia and thoracic lesions cause paresis of the lower extremities. Injuries of the lumbar spine cause an injury to the nerve roots or the cauda equina. High cervical lesions result in a profound neurologic injury that can require ventilatory support.

weak

extremes of age

In children, the spinal cord is particularly vulnerable because it does not tolerate any stretch. Injury can occur or be exacerbated even in the absence of radiologic abnormalities (a phenomenon known as SCI without radiologic abnormality [SCIWORA]).

In older patients, recovery from SCI is diminished, due to compromise of the vascular supply by degenerative changes in the cervical spine and atherosclerotic changes in the arteries supplying the cord. Falls are the most common cause of SCI for this population. Older patients also have a higher incidence of metastasis of tumors to the spinal column, and of some primary tumors such as myeloma.

narrow spinal canal

This is a developmental abnormality that increases the risk and severity of injury following trauma or a compressive lesion.

male sex

Around three-quarters of patients with SCI are male; this is likely due to the stronger preponderance of risk-taking behavior in males.[1]

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