SCI Clinical Syndromes

Complete vs Incomplete

Incomplete Syndromes

• Central-Cord Syndrome (CCS)
• Brown-Sequard Syndrome (BSS)
• Anterior Cord Syndrome (ACS)
• Posterior Cord Syndrome (PCS)

Central Cord Syndrome

• Characterized by a disproportionately motor impairment more in the upper extremities than lower extremities.
• Most common traumatic spinal cord injuries
• Etiologies: falls and motor vehicle accidents
• Symptoms: Bladder dysfunction, Spasticity, Respiratory compromise, Cardiovascular (orthostatic hypotension), Autonomic Dysreflexia, Temperature dysregulation
• Complications: Pressure injuries, Venous thromboembolism, Contractures
• Predictor of prognosis: hand function, early motor recovery, age, decreased spasticity, and higher Modified Barthel Index scores upon admission.
• Direction of recovery: inferior to superior (cent-penny mnemonic)
• Precautions: watch for lines and peripherals, cervical precautions with hard collars (e.g., Philadelphia collar) for 6 weeks, log rolling for bed mobility, fall prevention
• OT Interventions: hand function (strength, dexterity), overall function with ADLs (feeding, dressing, bathing, hygiene), pain, falls (lack of UE protective reaction) and symptom management, psychosocial
• Splints may be used to prevent contractures outside of therapy.

Brown-Sequard Syndrome

• Characterized by a lesion that results in ipsilateral motor and proprioceptive loss as well as contralateral loss of sensitivity to pain and temperature below the level of the lesion.
• “Hemisection” – one side of spinal cord is damaged
• Rarer form – 1-4% of traumatic SCIs
• Known to be caused by knife injuries, but also trauma and falls; disc herniation, tumors, MS, and infections.
• Horner’s Syndrome – lesion at or above T1 characterized by ptosis and impaired pupil dilation.
• Bowel and bladder, respiratory dysfunction
• Good prognosis for ambulation (75-90% recovery)
• Prognosis Predictor: upper extremity is weaker than lower extremity
• Recovery is often faster on the contralateral side.
• Cervical collars may be used.
• Complications: hypotension, spinal shock, pulmonary embolism, infections, autonomic dysreflexia, temperature dysregulation.
• Precautions: vital signs, respiration.
• OT evaluation: MMT, pain, temperature, proprioception, discriminatory touch.
• Outcome measures: Barthel Index, FIM, CARE
• Interventions: bed mobility, transfers, ADLS.
• Prevent muscle atrophy, provide strengthening, normalize tone, maintain range of motion.
• Recommend adaptive equipment.
• Early mobilization is beneficial.
• Provide psychosocial support.
• Address fall prevention and future injuries.

Anterior Cord Syndrome

• Affects the anterior 2/3 of the spinal cord, often T1-L2.
• Often due to flexion injuries.
• Characterized by motor loss, as well as pain and temperature loss below the level of the lesion, but proprioception and light touch are spared.
• Normal vibratory sense, two-point discrimination, and fine touch.
• Caused by ischemia within the artery that supplies blood to the 2/3rd of the spinal cord, e.g., surgical repairs such as aortic surgery, hypotension from cardiac arrest, vasculitis, sickle cell, AV malformation, disc herniation, cocaine use.
• Similar symptoms as other syndromes: pain, spasticity, autonomic dysfunction, hypotension, neurogenic bowel and bladder, and also sexual dysfunction.
• Precautions: lines and drains when mobilizing patients; vitals.
• Interventions: prevent immobility, pressure injuries, DVTs, pulmonary embolism, and loss of function.
• Promote participation in occupations.
• Encourage lifestyle changes including managing blood pressure, dyslipidemia, diabetes, and smoking cessation.
• Discharge planning should address barriers to function such as getting in and out of the house, showering, toileting, and so on.

Posterior Cord Syndrome

• Rare – 1% of incomplete SCIs – cervical to lumbar.
• Characterized by impaired proprioception, vibration, two-point discrimination, and deep touch below the level of injury.
• Lower body is often more affected.
• Causes: traumatic injuries (more specifically a hyperextension injury such as from a car accident), tumors, degenerative disc disease, B12 deficiency, multiple sclerosis, and untreated syphilis.
• Other symptoms: pain (burning, tingling)
• The loss of proprioception can severely compromise mobility, self-care, and other occupations.
• Patients may have poor balance and unsteady gait putting them at a risk for falls (especially in darker environments).

Conus Medullaris & Cauda Equina Syndromes

• Main difference between these syndromes are location.
• Conus medularis is anatomically higher as a sacral injury compared to cauda equina, which is lower, below L1.
• Both syndromes are characterized by lower extremity motor and sensory loss.

Summary of Team Goals and Outcomes

• Prevent pressure injuries
• Increase independence with bowel and bladder
• Decrease and manage pain
• Increase knowledge about the disease
• Manage spasticity
• Improve function
• Improve endurance
• Improve flexibility
• Improve strength
• Improve mobility
• Improve balance
• Promote lifestyle changes
• Prevent complications (e.g., DVT, UTI, autonomic dysreflexia)
• Address psychosocial
• Referral to support groups

Sources

Ameer, M. A., Gallagher, S., & Gillis, C. C. (2017). Central cord syndrome.

Nowak, D. D., Lee, J. K., Gelb, D. E., Poelstra, K. A., & Ludwig, S. C. (2009). Central cord syndrome. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 17(12), 756-765.

Shams, S., & Arain, A. (2020). Brown Sequard Syndrome. In StatPearls [Internet]. StatPearls Publishing.

Wirz, M., Zörner, B., Rupp, R., & Dietz, V. (2010). Outcome after incomplete spinal cord injury: central cord versus Brown-Sequard syndrome. Spinal Cord, 48(5), 407-414.