About 300,000 Americans are living with a spinal cord injury, and experts expect about 12,000 new cases per year.
Of these injuries about 53% are partial transactions or injury of the cord that lead to partial tetra or paraplegia. This has proven especially true when patients develop anterior cord syndrome. Those injuries also can lead to a condition known as triplegia — the loss of sensation and or motor function in one upper limb and both lower limbs, according to SpinalCord.com. More than half (55%) of all spinal cord injuries are cervical.
The nature of the injury can be traumatic. For example, stab wounds often cause partial cord syndromes.
Two-thirds of spinal cord injuries are traumatic in nature owing largely to lifestyle, inattention to safety equipment, extreme sports, alcohol and drugs, according to the Journal of Spinal Cord Medicine. The remainder of injuries (about 30%) are non-traumatic spinal cord injuries.
While this seems to contradict the above statement, the nature of data collection and regional differences account for the apparent discrepancy. In the developing world, non-traumatic spinal cord injury may account for a higher percentage of cord syndromes because of degenerative pathology or disease (tumor, HIV or TB) instead of trauma.
Iatrogenic reasons are also causative, secondary to medical procedures. Ischemia and cord compression are common mechanisms, such as spinal infarct and pathological disc herniation.
Spinal cord injury syndromes
Anterior cord syndrome
Six distinct spinal cord injury syndromes exist. Of those types, anterior cord syndrome, represents less than 1% of total injuries but 89% of that small percentage are non-traumatic, according to the Journal of Spinal Cord Medicine.
When talking total traumatic spinal cord injuries, only about 2.7% are traumatic anterior cord syndrome. This represents a considerable number of patients considering 300,000 people have spinal cord injuries with predictions of 12,000 new cases per year moving forward.
The anatomy of the spinal cord determines the clinical presentation of the various cord syndromes. In a simplified version, the cord is composed of five tracts bilaterally, both motor and sensory.
Other spinal cord injuries
The dorsal tract — functionally being a single tract — is sensory and primarily responsible for the sensation vibration and proprioception ipsilaterally. The corticospinal tracts lie in the lateral aspect of the cord, yet are included in the anterior two-thirds. Functionally this tract controls ipsilateral motor process.
The final tracts are the spinothalamic tracts, which are sensory but also contralateral. This tract relays pain and temperature information. The level of the injury determines the extent of functional and sensory loss, such as cervical versus lumbar.
In general, there is a complete loss of motor function. This is because of involvement of the corticospinal tracts below the level of the lesion.
Since the syndrome actually involves the anterior two-thirds of the spinal cord, it affects the lateral tracts. Patients lose pain and temperature sensation below the spinal cord injury because of damage to the spinothalamic tracts. The body preserves vibratory senses and proprioception, however, as the dorsal tracts remain intact.
Other autonomic dysfunction can result depending on the level of the lesion, such as orthostatic hypotension and bladder, bowel and sexual dysfunction, according to an article on Radiopaedia.
With traumatic etiology, spinal shock can result as can actual neurogenic shock. Again, the severity depends on the level of the lesion. Spinal shock will eventually resolve, but it may result in hyperflexion and spasticity as spinal reflexes gradually return.
Spinal symptoms providers should keep top of mind
During this period, the risk of autonomic dysreflexia has been reported in about 27% of cases that result from partial transection, according to the article “Autonomic Dysreflexia in Spinal Cord Injury” published on Medscape.
As stated earlier, a greater percentage of cases are non-traumatic in nature and present for a variety of reasons. Pathologies, such as tumors, infection or degenerative disease play a significant role, according to the 2007 article, “Incident and Outcomes of Spinal Cord Injury Clinical Syndromes,” published in the Journal of Spinal Cord Medicine.
Ischemia is a major precipitating factor in anterior cord syndrome, often as a direct result of cord or vascular compression. However, conditions effecting the anterior spinal artery, stenosis or infarct are most common.
The anterior spinal artery supplies the anterior two-thirds of the cord, thus motor function and partial sensory function (spinothalamic tract), below the cord lesion is lost — depending on the level of the insult vital function can be compromised.
Hypotension and respiratory failure may ensue, according to an article on UpToDate.com. Referred to as Beck’s Syndrome, or anterior artery syndrome, the vascular syndrome represents a significant portion of the non-traumatic anterior cord syndrome.
Both Beck’s and traumatic anterior cord syndromes present acutely. Signs of neurogenic shock, as well as respiratory compromise or outright failure, may be present depending on the level of the lesion.
Treatment focuses on eliminating the causal factor, such as:
- Decompression or improving blood flow to the affected area
- Fibrinolysis in the case of Beck’s Syndrome
- Surgical intervention to relieve compression
Often surgical intervention is employed post-event, following the physiological encapsulation of the traumatic spinal lesion, according to the article “Spinal Cord Contusion,” published in Neural Regenerative Research. But successful recovery is more dependent on long-term rehabilitation.
How to handle patients with anterior cord syndrome and other spinal cord injuries
In the case of a traumatic presentation, initial focus is on supporting vital function and attending to concomitant injuries, stabilization and transport to a trauma facility. The same approach is appropriate in an acute ischemic event, but transport to a neuro-surgical facility would be in order. This is the primary responsibility of EMS.
Long-term rehabilitation, however, is the definititive solution to the syndrome. How successful that is depends upon the level and extent of the lesion.