A 24 year old builder is brought into the Emergency Department following an accident at work in which a tool has fallen on his head causing a flexion injury. He has bilateral loss of motor function and bilateral loss of pain and temperature sensation. Proprioception and vibration sensation are intact bilaterally. Which of the following syndromes is most likely present?
The spinal cord originates at the caudal end of the medulla oblongata at the foramen magnum. In adults, it usually ends near the L1 bony level as the conus medullaris. Below this level is the cauda equina, which is somewhat more resilient to injury.
Of the many tracts in the spinal cord, only three can be readily assessed clinically: the lateral corticospinal tract, spinothalamic tract, and dorsal columns. Each is a paired tract that can be injured on one or both sides of the cord. When a patient has no demonstrable sensory or motor function below a certain level, he or she is said to have a complete spinal cord injury. An incomplete spinal cord injury is one in which some degree of motor or sensory function remains; in this case, the prognosis for recovery is significantly better than that for complete spinal cord injury.
Tract | Location | Function |
---|---|---|
Dorsal columns | Posteromedial aspect of cord | Transmits ipsilateral proprioception, vibration and fine-touch sensation |
Spinothalamic tract | Anterolateral aspect of cord | Transmits contralateral pain, crude-touch and temperature sensation |
Lateral corticospinal tract | Posterolateral aspect of cord | Controls ipsilateral motor power |
Spinal cord injuries can be classified according to level, severity of neurological deficit, spinal cord syndromes, and morphology.
Spinal cord syndrome | Mechanism | Tracts affected | Clinical features |
---|---|---|---|
Complete cord transection | Major trauma | All tracts |
|
Brown-Séquard syndrome | Hemitransection e.g. penetrating trauma or unilateral compression of the cord | All tracts on one side |
|
Central cord syndrome | Hyperextension injury of cervical spine in patient with pre-existing cervical stenosis e.g. forward fall with facial impact in elderly patient (can occur even without cervical spine fracture/dislocation) | Corticospinal tract and spinothalamic tract |
|
Anterior cord syndrome | Occlusion of anterior spinal artery with infarction of anterior cord by direct anterior cord compression, flexion injuries of the cervical spine, or thrombosis of anterior spinal artery | Corticospinal, spinothalamic and spinocerebellar tracts |
|
Posterior cord syndrome | Penetrating trauma to the back or hyperextension injury associated with vertebral arch fractures (very rarely occurs in isolation) | Dorsal column |
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Biochemistry | Normal Value |
---|---|
Sodium | 135 – 145 mmol/l |
Potassium | 3.0 – 4.5 mmol/l |
Urea | 2.5 – 7.5 mmol/l |
Glucose | 3.5 – 5.0 mmol/l |
Creatinine | 35 – 135 μmol/l |
Alanine Aminotransferase (ALT) | 5 – 35 U/l |
Gamma-glutamyl Transferase (GGT) | < 65 U/l |
Alkaline Phosphatase (ALP) | 30 – 135 U/l |
Aspartate Aminotransferase (AST) | < 40 U/l |
Total Protein | 60 – 80 g/l |
Albumin | 35 – 50 g/l |
Globulin | 2.4 – 3.5 g/dl |
Amylase | < 70 U/l |
Total Bilirubin | 3 – 17 μmol/l |
Calcium | 2.1 – 2.5 mmol/l |
Chloride | 95 – 105 mmol/l |
Phosphate | 0.8 – 1.4 mmol/l |
Haematology | Normal Value |
---|---|
Haemoglobin | 11.5 – 16.6 g/dl |
White Blood Cells | 4.0 – 11.0 x 109/l |
Platelets | 150 – 450 x 109/l |
MCV | 80 – 96 fl |
MCHC | 32 – 36 g/dl |
Neutrophils | 2.0 – 7.5 x 109/l |
Lymphocytes | 1.5 – 4.0 x 109/l |
Monocytes | 0.3 – 1.0 x 109/l |
Eosinophils | 0.1 – 0.5 x 109/l |
Basophils | < 0.2 x 109/l |
Reticulocytes | < 2% |
Haematocrit | 0.35 – 0.49 |
Red Cell Distribution Width | 11 – 15% |
Blood Gases | Normal Value |
---|---|
pH | 7.35 – 7.45 |
pO2 | 11 – 14 kPa |
pCO2 | 4.5 – 6.0 kPa |
Base Excess | -2 – +2 mmol/l |
Bicarbonate | 24 – 30 mmol/l |
Lactate | < 2 mmol/l |