Synopsis
Localise spinal disease from tract, segmental and autonomic findings, recognise classic incomplete cord patterns and use the neurological level to direct urgent imaging without overclaiming anatomical precision.
- A spinal-cord syndrome combines upper-motor-neurone dysfunction below a lesion, segmental lower-motor-neurone signs at the level, a tract-pattern sensory disturbance and possible autonomic impairment.
- The perceived cutaneous sensory boundary can sit several segments below the structural lesion, especially for pain and temperature, so it guides but must not narrowly limit imaging.
- Corticospinal fibres have crossed in the medulla and descend ipsilaterally, so a hemicord lesion causes ipsilateral pyramidal weakness below the lesion.
- Dorsal-column fibres ascend ipsilaterally, producing ipsilateral loss of vibration and joint position below a hemicord lesion.
- Spinothalamic fibres enter, travel one or two segments and cross through the anterior white commissure, so contralateral pain and temperature loss may begin below the lesion.
- Anterior cord syndrome impairs motor and pain-temperature pathways while relatively sparing dorsal-column vibration and position; spinal-cord infarction is an important cause.
- Central cord syndrome disproportionately affects upper limbs and may add sacral sparing, classically after cervical hyperextension in an older narrowed canal, but MRI defines the actual injury.
- Brown-Sequard syndrome combines ipsilateral weakness and dorsal-column loss with contralateral pain-temperature loss below the hemicord lesion.
- Posterior cord syndrome causes sensory ataxia and impaired proprioception with relatively preserved power and pain-temperature sensation; B12 deficiency and tabes are classic causes.
- Sacral sparing indicates an incomplete lesion and has prognostic significance, but examination must include voluntary anal contraction and deep anal pressure only when clinically appropriate and consented.
Key red flags
Motor and all sensory modalities are absent below the neurological level with no sacral sensory or motor preservation after spinal shock and confounders are considered.
Acute bilateral weakness and loss of pain and temperature occur below the lesion with relative preservation of vibration and position sense, often plus autonomic dysfunction.
Ipsilateral pyramidal weakness and proprioceptive loss occur below a hemicord lesion, with contralateral pain and temperature loss beginning a little lower.
Upper limbs are weaker than lower limbs after cervical injury or central expansion, with variable sensory, bladder and sacral-sparing features and possible burning hand pain.
At the lesion, dermatomal sensory change, focal pain, wasting and reduced reflexes may coexist with long-tract signs below, helping locate a cervical or thoracic process.
Investigation priorities
Define the most caudal normal motor and sensory segments, sacral sparing and an incomplete-syndrome pattern.
Management branches
A new truncal sensory boundary accompanies bilateral weakness or autonomic symptoms.
- Use ABCDE, check respiratory mechanics for cervical disease, document motor, sensory and sacral status and immobilise if trauma or instability is possible.
- Arrange emergency MRI and spinal advice, using pain, fever, cancer, trauma, anticoagulation and onset tempo to prioritise compression, abscess, haematoma and infarction.
- After external compression is excluded, pursue inflammatory, infectious, vascular and metabolic causes with contrast imaging, CSF and targeted blood tests.
- Manage retention, pressure, thrombosis, bowel, pain and rehabilitation needs from presentation rather than after the syndrome is named.