Anterior cord syndrome

Background

Sensory dermatome by spinal level.
Spinal cord tracts
Anatomy of anterior cord injury.
  • Injury to the anterior two-thirds of the spinal cord, sparing the posterior columns
  • Etiologies:
    • Anterior spinal artery occlusion/thrombosis (most common non-traumatic cause)
    • Hyperflexion injury of cervical spine
    • Direct anterior cord compression (disc herniation, fracture-dislocation, mass)
    • Aortic pathology: AAA repair, aortic dissection (watershed ischemia)

Clinical Features

  • Motor: Paraplegia or quadriplegia below the level of the lesion (corticospinal tracts)
  • Sensory: Loss of pain and temperature below the lesion (spinothalamic tracts)
  • Preserved: Proprioception, vibration, and light touch (dorsal columns intact — distinguishing feature)
  • Autonomic dysfunction: orthostatic hypotension, bowel/bladder/sexual dysfunction
  • Most devastating of the incomplete cord syndromes

Differential Diagnosis

Spinal Cord Syndromes

Evaluation

  • MRI spine — gold standard; shows anterior cord infarction or compression
  • CT angiography if aortic pathology suspected
  • MRA or conventional angiography for anterior spinal artery occlusion
  • Neurological exam: document motor level, sensory level (pinprick vs light touch), rectal tone

Management

Acute Management of Spinal Cord Injury

  • Neurogenic shock management
  • Consider intubation injuries at C5 or above
    • Manual in-line stabilization reduces cervical movement better than C-collar, but be careful of tracheal pressures inadvertently applied which can worsen laryngeal visualization[1][2]
    • Direct laryngoscopy causes C-spine extension at atlanto-occipital junction, C1-C2, and C4-C7 in order from most to least
    • Consider video laryngoscopy with hyperangulated stylet or bougie assisted DL to intubate higher-grade laryngoscopy views of vocal cords without C-spine overextension[3]
    • Post-intubation sedation takes into consideration hemodynamics and potential intraoperative EMG and evoked potential monitoring by anesthesia
  • Consider surgical intervention for:
  • Steroids are no longer recommended
    • Administration of methylprednisolone (MP) for the treatment of acute spinal cord injury (SCI) is not recommended. Clinicians considering MP therapy should bear in mind that the drug is NOT approved by the FDA for this indication. There is no Class I or Class II medical evidence supporting the clinical benefit of MP in the treatment of acute SCI. Scattered reports of Class III evidence claim inconsistent effects likely related to random chance or selection bias. However, Class I, II, and III evidence exists that high-dose steroids are associated with harmful side effects including death.[6]
    • See EBQ:High Dose Steroids in Cord Injury for further discussion
  • Treat underlying cause:
    • Surgical decompression for compressive etiologies (disc, fracture, mass)
    • Aortic repair if caused by dissection/aneurysm
    • Anticoagulation consideration for thrombotic etiologies (in consultation with neurology/neurosurgery)

Prognosis

  • Worst prognosis of incomplete spinal cord syndromes
  • Only 10-20% regain functional motor recovery
  • Sensory recovery (pain/temperature) may be slightly better than motor

Disposition

  • Admit all patients — neurosurgery or spine surgery consult
  • ICU for high cervical lesions or hemodynamic instability
  • Vascular surgery consult if aortic etiology

See Also

References

  1. ↑ The effect of laryngoscopy of different cervical spine immobilisation techniques. Heath KJ. Anaesthesia. 1994 Oct; 49(10):843-5.
  2. ↑ Manual in-line stabilization increases pressures applied by the laryngoscope blade during direct laryngoscopy and orotracheal intubation. Santoni BG, Hindman BJ, Puttlitz CM, Weeks JB, Johnson N, Maktabi MA, Todd MM. Anesthesiology. 2009 Jan; 110(1):24-31.
  3. ↑ Cervical spinal motion during intubation: efficacy of stabilization maneuvers in the setting of complete segmental instability. Lennarson PJ, Smith DW, Sawin PD, Todd MM, Sato Y, Traynelis VC. J Neurosurg. 2001 Apr; 94(2 Suppl):265-70.
  4. ↑ Improvement of motor-evoked potentials by ketamine and spatial facilitation during spinal surgery in a young child. Erb TO, Ryhult SE, Duitmann E, Hasler C, Luetschg J, Frei FJ. Anesth Analg. 2005 Jun; 100(6):1634-6.
  5. ↑ Effects of dexmedetomidine on intraoperative motor and somatosensory evoked potential monitoring during spinal surgery in adolescents. Tobias JD, Goble TJ, Bates G, Anderson JT, Hoernschemeyer DG. Paediatr Anaesth. 2008 Nov; 18(11):1082-8.
  6. ↑ Hurlbert RJ et al. Pharmacological therapy for acute spinal cord injury. Neurosurgery. 2013 Mar;72 Suppl 2:93-105 http://www.ncbi.nlm.nih.gov/pubmed/23417182
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