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ESSENTIALS OF DIAGNOSIS

ESSENTIALS OF DIAGNOSIS

  • Spinal cord disorders can be organized into categories based on chronicity and etiology, keeping in mind that the categories are not rigid (eg, some entities can present either acutely or subacutely):

    • Nontraumatic

      • Chronic

      • Subacute

      • Acute

    • Traumatic

      • Acute

  • Pathophysiology and epidemiology vary significantly by etiology.

  • Certain anatomic variants (eg, spinal canal stenosis, disk herniation, osteophytes, abnormal ligamentous structures), chromosomal anomalies (eg, trisomy 21), connective tissue disorders (eg, Ehlers-Danlos), and bleeding diatheses (eg, hemophilia) can predispose to or worsen the impact of spinal cord injury.

  • Some of the following sections are treated separately for nontraumatic and traumatic etiologies.

GENERAL CONSIDERATIONS, EPIDEMIOLOGY, AND PREVENTION

Nontraumatic

Epidemiology varies by etiology.

Traumatic

Spinal cord injuries affect many young people under age 30 years, with a male predominance.1 Spinal cord injuries often result in significant medical, psychological, and economic sequelae, with lifetime expenses among patients with high cervical cord injury, for example, topping several million dollars.1 Preventative strategies include the consistent use of safety devices such as seat belts and helmets.

PATHOGENESIS

Nontraumatic

Pathophysiology varies by etiology.

Traumatic

Pathophysiology includes primary injury (transient or persistent compression, cord laceration, or cord transection) as well as secondary injury (early hypoxia and hypoperfusion, followed by reperfusion, inflammation, and blood–spinal cord barrier disruption). Cord swelling peaks at 3 to 6 days and then subsides over weeks.2

CLINICAL FINDINGS

History

Nontraumatic

Chronicity and progression of symptoms are key historical details. Motor, sensory (including pain), and higher-order (cortical) symptoms should be queried, and their precise anatomic patterns discerned, keeping in mind that sensory symptoms can be more reliable than sensory signs. Sensory complaints can be elicited by asking, “Does water temperature feel the same everywhere when you shower or bathe?” When symptom onset is acute, the patient should be asked about urine and stool output over the past 24 hours. Vague abdominal discomfort and delay or loss of lower extremity motor function may suggest a thoracic lesion in a child. Clumsy gait may suggest a slowly progressive disorder. Another helpful clinical pearl is that transverse myelitis can evolve quite dramatically over a time course of hours.

Traumatic

Relevant medical history questions include the presence of genetic disorders or bleeding disorders since these diagnoses make a patient more vulnerable to spinal cord injury. Spinal shock may complicate the initial evaluation, manifesting as flaccid paralysis, areflexia, sensory loss, loss of bladder tone, and autonomic dysregulation. Traumatic brain injury co-occurs in 25% to 50% of spinal cord injury cases, and its evaluation should be considered.2

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