This topic keeps coming up in the SAQs. One notable appearance was in Question 5 from the first paper of 2010, where the candidates needed to not only identify the features, but also the causes of the partial spinal cord injury syndrome. This was again repeated in the identical Question 15 from the first paper of 2015, and then again in Question 4 from the first paper of 2021. The college also asked about the anterior spinal artery syndrome in Question 23 from the first paper of 2018, where much detail was expected regarding the management of a poorly perfused spinal cord. In Question 30 from the first paper of 2020, they wanted the difference between a high (C6/C7) and very high (C3/C4) spinal cord injury.
The canonical resource for this would have to be Ch.78 from Oh's Manual, Spinal injuries by Sumesh Arora and Oliver J Flower. Specifically, on page 798, cord syndromes are discussed with enough detail to pass Question 5. If one happens to not own the Manual, one may find a similar amount of detail in the "International standards for neurological and functional classification of spinal cord injury" from 1997, and in a similar article on classifying partial cord syndromes from 2000. And if one were for some reason in need of a massive amount of detail, one might instead wish to purchase a copy of Diseases of the Spine and Spinal Cord By Thomas N. Byrne, which remains a definitive text on this subject.
The information from these abovementioned resources has been mixed, boiled and condensed into the table below.
Syndrome |
Characteristic features |
Causes |
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There are some causes which are generic for all these syndromes, and they will not be repeated in each box. These are:
Any of these can cause any of the spinal syndromes, anywhere. Instead of these, the causes listed below are the characteristic pathological processes which usually give rise to a specific spinal cord syndrome, eg. anterior spinal artery occlusion causing anterior spinal syndrome. |
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Cord transection |
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Cord hemisection |
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Anterior cord injury |
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Interruption of the blood supply to the anterior spinal cord:
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Posterior cord injury |
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Central cord syndrome |
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Conus medullaris syndrome |
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Cauda Equina syndrome |
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*Discriminating conus medullaris from cauda equina lesions can be tricky.
Thomas N. Byrne's textbook offers a table on page 77, which answers this question in some detail. The relevant features are reproduced below:
Conus Medullaris |
Cauda Equina |
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Remember this diagram?
This diagram hopefully makes it easier to understand the stereotypical cord section syndromes.
Though this has exam relevance (Question 23 from the first paper of 2018) it is in fact a very rare syndrome, appearing in 2% of patients undergoing ruptured aortic aneurysm repair, and in only 0.4% of elective AAA repairs (Gialdini, 2017).
Sensory signs of anterior spinal cord syndrome are:
Motor signs of anterior spinal cord syndrome are:
Perioperative risk factors for anterior spinal artery syndrome are
Apart from "perioperative factors", Djurberg & Haddad (1995) list "conditions affecting blood flow in the anterior spinal artery":
Management of an infarcted anterior cord involves maximising the perfusion of the cord via collaterals. The best information about this about this seems to come from Hnath et al (2007), who published a fairly successful protocol. This consisted of:
Hnath et al reported a 60% improvement, but their series had only 5 patients in the treatment arm, which somewhat dampens the enthusiasm of anybody following their footsteps. Chiesa et al (2005) list several other possible strategies:
Oh's Manual: Chapter 78 (pp. 795) Spinal injuries by Sumesh Arora and Oliver J Flower
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Lin, Vernon W., et al. "Spinal Cord and Cauda Equina Syndromes." (2003).
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Hayes, Keith C., et al. "Classifying incomplete spinal cord injury syndromes: algorithms based on the International Standards for Neurological and Functional Classification of Spinal Cord Injury Patients." Archives of physical medicine and rehabilitation 81.5 (2000): 644-652.
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Djurberg, H., and M. Haddad. "Anterior spinal artery syndrome." Anaesthesia 50.4 (1995): 345-348.
Eltorai, Ibrahim M. "Anterior Spinal Artery Syndrome." Rare Diseases and Syndromes of the Spinal Cord. Springer, Cham, 2016. 437-440.
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TRIGGS, WILLIAM J., and ALEKSANDAR BERIĆ. "Sensory abnormalities and dysaesthesias in the anterior spinal artery syndrome." Brain 115.1 (1992): 189-198.
Aydin, A. "Mechanisms and prevention of anterior spinal artery syndrome following abdominal aortic surgery." Angiologiia i sosudistaia khirurgiia= Angiology and vascular surgery 21.1 (2015): 155-164.
Santamato, Andrea, et al. "Paraplegia due to Anterior Spinal Artery Stroke: Rehabilitative Program on Lower Extremity Weakness and Locomotor Function." Int J Phys Med Rehabil1.118 (2013): 2.
Ullery, Brant W., et al. "Risk factors, outcomes, and clinical manifestations of spinal cord ischemia following thoracic endovascular aortic repair." Journal of vascular surgery 54.3 (2011): 677-684.
Cheshire, William P., et al. "Spinal cord infarction Etiology and outcome." Neurology 47.2 (1996): 321-330.
Gialdini, Gino, et al. "Retrospective analysis of Spinal Cord Infarction after Aortic Repair (P6. 300)." Neurology 88.16 Supplement (2017): P6-300.
Hnath, Jeffrey C., et al. "Strategies to improve spinal cord ischemia in endovascular thoracic aortic repair: outcomes of a prospective cerebrospinal fluid drainage protocol." Journal of vascular surgery 48.4 (2008): 836-840.
Chiesa, Roberto, et al. "Spinal cord ischemia after elective stent-graft repair of the thoracic aorta." Journal of vascular surgery 42.1 (2005): 11-17.
Coselli, Joseph S., et al. "Left heart bypass during descending thoracic aortic aneurysm repair does not reduce the incidence of paraplegia." The Annals of thoracic surgery 77.4 (2004): 1298-1303.
Safi, Hazim J., et al. "Thoracic and thoracoabdominal aortic aneurysm repair using cardiopulmonary bypass, profound hypothermia, and circulatory arrest via left side of the chest incision." Journal of vascular surgery 28.4 (1998): 591-598.
Cambria, Richard P., et al. "Clinical experience with epidural cooling for spinal cord protection during thoracic and thoracoabdominal aneurysm repair." Journal of vascular surgery 25.2 (1997): 234-243.
Cinà, Claudio S., et al. "Cerebrospinal fluid drainage to prevent paraplegia during thoracic and thoracoabdominal aortic aneurysm surgery: a systematic review and meta-analysis." Journal of vascular surgery 40.1 (2004): 36-44.
Taira, Yutaka, and Martin Marsala. "Effect of proximal arterial perfusion pressure on function, spinal cord blood flow, and histopathologic changes after increasing intervals of aortic occlusion in the rat." Stroke 27.10 (1996): 1850-1858.
Strohm, Tamara, Seby John, and Muhammad Hussain. "Cerebrospinal Fluid Drainage for Acute Spinal Cord Infarction (P1. 301)." Neurology 88.16 Supplement (2017): P1-301.