# Clinical Cases: Spinal Cord ## Case 1: Cauda Equina Syndrome ### Patient Presentation **Demographics:** 52-year-old male **Chief Complaint:** Severe low back pain, leg weakness, and urinary retention for 24 hours **History of Present Illness:** A 52-year-old man with a history of chronic low back pain and lumbar disc disease presents with sudden worsening of back pain radiating to both legs that began 24 hours ago while lifting heavy furniture. Over the past 12 hours, he has developed progressive weakness in both legs and has been unable to urinate despite feeling the urge. He also reports numbness in his buttocks and inner thighs and decreased sensation around his anus. He denies fever, recent infection, or trauma besides the lifting event. **Physical Examination:** - Vital signs: BP 148/92, HR 88, T 37.0C - General: In significant pain; cannot sit comfortably - Neurological: - Mental status: Normal - Motor: Bilateral ankle dorsiflexion 3/5; knee extension 4/5; hip flexion 4/5 - Sensory: Saddle anesthesia (perineal and perianal numbness); decreased sensation posterior thighs bilaterally - Reflexes: Absent ankle jerks bilaterally; knee jerks 1+ - Rectal examination: Markedly decreased rectal tone; absent anal wink reflex - Bladder: Palpable distended bladder; post-void residual 650 mL on catheterization **Workup:** - **MRI lumbar spine (emergent):** Large central disc herniation at L4-L5 severely compressing the cauda equina; complete effacement of the thecal sac - **Urinalysis:** Normal (no UTI) **Diagnosis:** Cauda equina syndrome secondary to massive L4-L5 disc herniation **Treatment:** - EMERGENT neurosurgical consultation - Foley catheter placement for urinary retention - Emergency L4-L5 laminectomy and discectomy performed within 12 hours of presentation - Post-operative gradual improvement in leg strength - Bladder function slowly recovering but requiring intermittent catheterization at discharge - Intensive physical therapy - At 6-month follow-up: walking independently, partial recovery of bladder control, persistent mild sensory deficits in saddle area **Clinical Pearl:** Cauda equina syndrome is a surgical emergency caused by compression of the nerve roots below the conus medullaris (typically below L1-L2). Unlike spinal cord compression, cauda equina is a lower motor neuron injury causing flaccid paralysis, areflexia, and LMN bladder dysfunction (urinary retention with overflow incontinence). The pathognomonic features are saddle anesthesia, bilateral leg weakness/sciatica, and bowel/bladder dysfunction. Surgical decompression within 24-48 hours correlates with better outcomes, though some advocate for even earlier intervention. Delayed surgery leads to permanent deficits, particularly bladder dysfunction. --- ## Case 2: Cervical Spinal Cord Injury - Central Cord Syndrome ### Patient Presentation **Demographics:** 68-year-old male **Chief Complaint:** Weakness in arms greater than legs after a fall **History of Present Illness:** A 68-year-old man with a history of cervical spondylosis fell forward onto his face after tripping on a curb, hyperextending his neck. He immediately noticed weakness, more severe in his arms than his legs. He can move his legs somewhat but has very limited arm and hand function. He reports burning pain in both arms and numbness in his hands. He was able to briefly walk with assistance at the scene but his arm weakness has made this difficult. **Physical Examination:** - Vital signs: BP 95/62 (possible spinal shock), HR 58, RR 18, T 36.5C - Cervical spine: Immobilized; tender to palpation - Neurological: - Mental status: Alert, oriented - Cranial nerves: Intact - Motor: - Upper extremities: 2/5 bilateral deltoid, 1/5 wrist extension, 0/5 hand grip - Lower extremities: 4/5 bilateral hip flexors, 4/5 knee extension, 4/5 ankle dorsiflexion - Sensory: Decreased pain and temperature sensation in cape-like distribution (C4-T1); sacral sensation preserved - Reflexes: Absent biceps and brachioradialis; knee jerks 2+; ankle jerks 2+; Babinski upgoing bilaterally - Rectal tone: Present **Workup:** - **CT cervical spine:** Severe multilevel cervical spondylosis with narrowed spinal canal; no fracture - **MRI cervical spine:** Central cord contusion at C4-C5 with intramedullary T2 hyperintensity; cord compression from degenerative disc disease and ligamentum flavum hypertrophy - **Vital capacity:** 75% predicted (monitor closely) **Diagnosis:** Central cord syndrome secondary to hyperextension injury in the setting of cervical spondylosis **Treatment:** - Spinal immobilization - Blood pressure support (vasopressors initially to maintain MAP >85 mmHg) - Neurosurgical consultation - Decompressive cervical laminectomy performed on day 3 once stable - DVT prophylaxis - Aggressive physical and occupational therapy - Significant recovery over 6 months; independent ambulation achieved; persistent fine motor deficits in hands **Clinical Pearl:** Central cord syndrome is the most common incomplete spinal cord injury pattern, typically occurring in elderly patients with pre-existing cervical stenosis who experience hyperextension injuries. The characteristic pattern is "arms worse than legs" because the motor fibers for the upper extremities are located centrally in the corticospinal tracts while lower extremity fibers are lateral. The central cord hemorrhage or contusion affects the central fibers preferentially. Prognosis is generally favorable - lower extremity function recovers first, followed by bladder, then proximal arms, with fine hand function recovering last (and often incompletely). --- ## Case 3: Transverse Myelitis ### Patient Presentation **Demographics:** 28-year-old female **Chief Complaint:** Progressive leg weakness and numbness for 3 days **History of Present Illness:** A 28-year-old previously healthy woman presents with ascending numbness that began in her feet 3 days ago and has progressed to her mid-abdomen. She noticed leg weakness yesterday and today cannot walk. She also reports a "band-like" tightness around her mid-torso and difficulty emptying her bladder. She had a mild upper respiratory infection 2 weeks ago. She denies back pain, trauma, or recent travel. She has no history of neurological symptoms. **Physical Examination:** - Vital signs: Normal - General: Anxious young woman in no acute distress - Neurological: - Mental status: Normal - Cranial nerves: Intact - Motor: Upper extremities 5/5 throughout; bilateral hip flexors 3/5, knee extension 3/5, ankle dorsiflexion 2/5 - Tone: Increased in lower extremities - Sensory: Dense sensory level at T8; all modalities reduced below this level - Reflexes: 3+ at knees and ankles; bilateral upgoing Babinski responses - Coordination: Normal in upper extremities - Gait: Unable to walk - Bladder: Post-void residual 400 mL **Workup:** - **MRI spine (complete):** T2 hyperintense signal within the spinal cord from T6-T9; cord swelling; partial gadolinium enhancement - **MRI brain:** Normal (no demyelinating lesions) - **Lumbar puncture:** Elevated protein (85 mg/dL); 45 WBC (lymphocyte predominant); normal glucose; oligoclonal bands negative - **CSF viral studies:** Negative - **NMO-IgG (AQP4 antibody):** Negative - **MOG antibody:** Negative - **Infectious workup:** Negative **Diagnosis:** Idiopathic acute transverse myelitis **Treatment:** - IV methylprednisolone 1 g daily for 5 days - Plasma exchange initiated after incomplete response to steroids - Foley catheter for urinary retention - DVT prophylaxis - Physical therapy - Monitoring for development of MS or NMOSD (30-40% of transverse myelitis cases evolve to MS) - Gradual improvement over 6 weeks; ambulatory with a cane at 3 months **Clinical Pearl:** Transverse myelitis is an inflammatory myelopathy causing motor, sensory, and autonomic dysfunction below the level of the lesion. The "transverse" descriptor indicates that the entire cord width is affected at the involved levels. Key features include bilateral symptoms, a sensory level, and sphincter dysfunction. MRI shows cord signal abnormality, often with swelling and enhancement. Approximately 30-40% of cases represent the first manifestation of multiple sclerosis (MS), particularly when brain lesions are present. Longitudinally extensive lesions (3+ segments) raise concern for neuromyelitis optica spectrum disorder (NMOSD), which has different treatment implications. --- ## Clinical Image ![Spinal cord cross-section with tract organization](case_01_image.jpg) **Image Description:** Cross-sectional diagram of the spinal cord showing the organization of major ascending and descending tracts, including the lateral corticospinal tract, posterior columns (fasciculus gracilis and cuneatus), and anterolateral spinothalamic tract, demonstrating the somatotopic organization relevant to central cord syndrome. **Attribution:** Image from Wikimedia Commons (https://commons.wikimedia.org/), Creative Commons Attribution-ShareAlike license.