Spine Trauma, Fractures & Cord Syndromes

Spine Trauma, Fractures, and Localization

Examine the Cord and the Column Separately

A patient can have an unstable fracture without an initial neurologic deficit, or a substantial cord injury without an obvious fracture on CT. Maintain appropriate spinal precautions while assessing airway, circulation, associated injuries, and alignment. Obtain a baseline motor and sensory examination before and after transfers or interventions when feasible. Document confounders such as sedation, painful limb fractures, peripheral nerve injury, or inability to cooperate. Do not call an untestable muscle definitively paralyzed.

Use the International Standards for Neurological Classification of Spinal Cord Injury to record key muscles, sensory levels, sacral sensation, deep anal pressure, and voluntary anal contraction. Sacral sparing is central to distinguishing complete from incomplete injury. A syndrome description is a useful localization tool, but it cannot substitute for the formal examination or predict an individual's final recovery. Early spinal shock can obscure the expected upper motor neuron signs, so repeat assessment is necessary.

Incomplete Syndromes

Central cord syndrome describes greater upper than lower limb motor impairment, often especially affecting hand function, with variable sensory and bladder abnormalities. Cervical hyperextension in a stenotic degenerative canal is a common setting; younger patients can have other traumatic mechanisms. MRI evaluates cord injury, ongoing compression, disc injury, and ligament disruption. The older explanation that arm corticospinal fibers are concentrated centrally and sacral fibers laterally is not a reliable description of human tract organization. Recognize the clinical pattern without treating that proposed anatomy as proven.

Anterior cord syndrome classically combines weakness and impaired pain/temperature below a lesion with relative preservation of dorsal-column modalities. Trauma and anterior spinal arterial ischemia can produce this pattern. Actual lesions are often mixed, and complete preservation of every light-touch or proprioceptive response is not required. A negative early MRI does not exclude every vascular cord injury. Assess aortic disease and other causes when the onset and context suggest ischemia rather than mechanical trauma.

Brown-Séquard syndrome classically causes ipsilateral motor and dorsal-column impairment with contralateral pain/temperature loss beginning below the lesion. Spinothalamic fibers cross over several nearby segments, so sensory boundaries do not always match a single textbook level. Pure hemisection is uncommon; partial or mixed patterns are frequent. These distinctions guide localization, but outcome depends on injury completeness, level, mechanism, complications, and rehabilitation rather than a fixed syndrome-specific walking percentage.

Conus and Cauda Equina Emergencies

The conus usually terminates near the L1–L2 vertebral level, with normal variation. Its injury may combine cord and root findings, early sphincter dysfunction, and saddle sensory change. Cauda equina injury affects descending lumbosacral roots and can cause radicular pain, flaccid weakness, reduced reflexes, saddle sensory impairment, and urinary dysfunction. Neither symmetry nor timing of incontinence reliably separates every case. Bladder retention is concerning; preserved voiding or a modest residual does not by itself exclude evolving compression.

New saddle symptoms, progressive bilateral deficits, or urinary dysfunction require emergency evaluation, usually urgent MRI and spine surgical consultation. Identify compressive disc disease, fracture, hematoma, tumor, or infection. Decompression should occur as soon as clinically appropriate after diagnosis and coordination, rather than waiting for a supposed protected 48-hour window. Record symptom progression, examination, imaging, consultation, and any reasons for delay. A patient already beyond a quoted research interval still needs urgent assessment and may benefit from treatment.

Stability and Fracture Patterns

Denis's anterior, middle, and posterior columns are a historical framework for thoracolumbar injury. They help describe structural involvement, but middle-column injury alone does not make every fracture an operative emergency. Contemporary assessment incorporates morphology, posterior ligamentous complex integrity, neurologic status, alignment, and validated classification systems. Some neurologically intact burst fractures can be treated without surgery; translation, distraction, progressive deformity, or significant neural compression changes the decision.

For a C1 burst fracture, assess the transverse atlantal ligament and associated injuries. Lateral mass overhang can raise concern for ligament disruption but does not reliably prove or exclude it; CT and selected MRI findings inform management. Odontoid fractures are classified as tip, base, or extension into the C2 body. Type II base fractures have important nonunion risk. Treatment depends on displacement, stability, age, frailty, bone quality, symptoms, and surgical risk. A collar can be appropriate in selected patients, and a halo is not an automatic preferred treatment in older adults because complications can be substantial.

C2 pars injuries and subaxial facet dislocations require specialist assessment of the disc and ligaments as well as bone. Facet dislocation can coexist with major cord injury, radiculopathy, or a preserved examination. Reduction is an urgent specialist procedure with a planned airway, monitoring, imaging strategy, and rescue pathway. Awake closed reduction and operative reduction have different prerequisites. MRI use depends on examination reliability, suspected disc material, local expertise, and urgency; do not attempt unsupervised traction based on a simplified rule. Repeat the neurologic examination after alignment, immobilization, and surgery.

Source: ACS spine injury best practices and 2024 spinal cord injury guidance.

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