**5.1 Central cord syndrome**

Central cord syndrome (CCS) is seen primarily in patients in the fifth decade of life and beyond and is usually a result of hyperextension injury [95, 98]. In younger patients, CCS is usually due to high-velocity trauma. CCS in older patients tends to occur in the setting of pre-existing degenerative narrowing of the spinal canal; this narrowing combined with hyperextension can cause an expanding hematoma that exerts pressure on the spinal cord [99]. Depending on the location and severity, we see a different range of symptoms. Milder injuries can result in burning sensation of the upper extremities. Most presentations consist of weakness in all limbs, with upper extremities more affected than the lower extremities. Majority of central cord injuries are due to a lesion at the levels of C4–C6. Patients with the following history and signs should be evaluated for CCS [100].


Any patient that is being evaluated for incomplete SCI should have a highresolution computed tomography (CT) to identify spinal fractures, dislocations,


**Table 2.**

**117**

*Spinal Shock: Differentiation from Neurogenic Shock and Key Management Approaches*

and potential hematomas [100]. A magnetic resonance imaging (MRI) should be considered when CT is normal, but CCS is still suspected. In roughly 4–6% of individuals with CCS, it is possible that all imaging, with the exception of MRI, can show no abnormalities. Once the severity on the CCS is identified and classified using the American Spinal Injury Association (ASIA) scale (**Table 2**), management pathway can be selected [102]. The Congress of Neurological Surgeons recommends that patients receive immediate surgery in cases of fractures or dislocations [103, 104]. However, decompressive surgery in CCS is controversial as many studies looking at outcomes comparing surgical and nonsurgical management have been inconclusive. The use of steroids is not recommended as it has been shown no benefit when com-

It has been noted that 75–80% of patients can regain full neurological recovery [96, 110, 111]. Depending on the ASIA score that was determined during admission, one can begin determining prognostic considerations [112]. Usually younger patients with CCS from traumatic injuries tend to have the best prognosis [113]. The timeline for recovery can be up to 1 year after injury. Patients will usually regain

Unlike CCS, the Brown-Sequard syndrome (BSS) is a rare type of incomplete SCI [114]. It is usually seen in penetrating trauma, including knife and gunshot wounds. It can also occur with the loss of vascular supply due to a herniation or edema to a hemisection [115–117]. BSS presents with ipsilateral loss of motor function, ipsilateral loss of sensation, and proprioception and contralateral loss of pain and temperature [114]. These symptoms are due to a lesion involving the corticospinal, dorsal column, and spinothalamic tracts, respectively. In some cases, there is loss of bowel and bladder function. BSS has the best prognosis of all the incomplete spinal cord injuries. Roughly 90–99% of patients gain back full function [99]. Diagnosis should be suspected based on a combination of physical examination/presenting signs and confirmed with an MRI. Management is similar to CCS, consisting of conservative approach with a strong focus on early rehabilitation.

Complete recovery following BSS can take up to 2 years. However, most patients regain full motor skills within the first 6 months. Pain and temperature sensations tend to recover before full motor function is regained [122, 123]. It is vital that patients receive immediate physical therapy following the acute treatment phase to maximize recovery. During the treatment and management phase of BSS, providers must be careful in completely addressing the underlying condition that lead to BSS, such as spinal cord herniation or a CSF leak through a dural tear, as these could lead

Anterior cord syndrome (ACS) is a rare incomplete SCI that accounts for approximately 1–3% of spinal injuries [95]. It also has the worst prognosis of all the

*DOI: http://dx.doi.org/10.5772/intechopen.92026*

pared to observation [105–109].

**5.2 Brown-Sequard syndrome**

functions in an ascending manner [99].

Surgery is indicated in the following scenarios [118–121]:

1.Lesion requiring decompression.

3.An abscess compressing the spinal cord.

to permanent loss of neurologic function [124, 125].

2.Presence of a tumor.

**5.3 Anterior cord syndrome**

*American Spinal Injury Association (ASIA) classification for incomplete spinal cord injuries at level of injury.*

*Spinal Shock: Differentiation from Neurogenic Shock and Key Management Approaches DOI: http://dx.doi.org/10.5772/intechopen.92026*

and potential hematomas [100]. A magnetic resonance imaging (MRI) should be considered when CT is normal, but CCS is still suspected. In roughly 4–6% of individuals with CCS, it is possible that all imaging, with the exception of MRI, can show no abnormalities. Once the severity on the CCS is identified and classified using the American Spinal Injury Association (ASIA) scale (**Table 2**), management pathway can be selected [102]. The Congress of Neurological Surgeons recommends that patients receive immediate surgery in cases of fractures or dislocations [103, 104]. However, decompressive surgery in CCS is controversial as many studies looking at outcomes comparing surgical and nonsurgical management have been inconclusive. The use of steroids is not recommended as it has been shown no benefit when compared to observation [105–109].

It has been noted that 75–80% of patients can regain full neurological recovery [96, 110, 111]. Depending on the ASIA score that was determined during admission, one can begin determining prognostic considerations [112]. Usually younger patients with CCS from traumatic injuries tend to have the best prognosis [113]. The timeline for recovery can be up to 1 year after injury. Patients will usually regain functions in an ascending manner [99].

#### **5.2 Brown-Sequard syndrome**

*Clinical Management of Shock - The Science and Art of Physiological Restoration*

motor vehicle accidents (MVA), falls, and swimming injuries [96, 97].

history and signs should be evaluated for CCS [100].

degenerative changes in the spinal canal.

Sequard syndrome.

**5.1 Central cord syndrome**

sacrum spared).

lower extremities.

**Grade Description**

E No loss of function noted

may also be seen [101].

on functions that are preserved. **Table 2** describes the preserved functions in all grades. Incomplete spinal cord injuries can be categorized into four types: central cord syndrome, anterior cord syndrome, posterior cord syndrome, and Brown-

The incidence of incomplete SCI has reported range from 40 to 50% of all spinal injuries [93–95]. Central cord syndrome tends to be the most common injury with posterior cord being the rarest of the incomplete spinal injuries. We will start by exploring the central cord syndrome. Most cases of incomplete SCI are caused by

Central cord syndrome (CCS) is seen primarily in patients in the fifth decade of life and beyond and is usually a result of hyperextension injury [95, 98]. In younger patients, CCS is usually due to high-velocity trauma. CCS in older patients tends to occur in the setting of pre-existing degenerative narrowing of the spinal canal; this narrowing combined with hyperextension can cause an expanding hematoma that exerts pressure on the spinal cord [99]. Depending on the location and severity, we see a different range of symptoms. Milder injuries can result in burning sensation of the upper extremities. Most presentations consist of weakness in all limbs, with upper extremities more affected than the lower extremities. Majority of central cord injuries are due to a lesion at the levels of C4–C6. Patients with the following

1.Patients over 50 years of age: Hyperextension with a previous history of

2.Patients under 40 years of age: High velocity trauma (MVA, skiing, etc.).

3.Sensory Loss: Cape-like distribution (upper extremities and thorax with

4.Motor loss: Weakness that is more prominent in the upper extremities than

5.Autonomic regulation: Loss of bowel and bladder. Orthostatic hypotension

Any patient that is being evaluated for incomplete SCI should have a highresolution computed tomography (CT) to identify spinal fractures, dislocations,

D Sensory functions intact, and all motor functions are at least grade 3/5 (able to move against

*American Spinal Injury Association (ASIA) classification for incomplete spinal cord injuries at level of injury.*

A Complete spinal cord injury. No motor or sensory function B Motor function is lost, while sensory function is preserved

gravity, but not against active resistance)

C Sensory function is lost, with motor function spared at the sacral level

**116**

**Table 2.**

Unlike CCS, the Brown-Sequard syndrome (BSS) is a rare type of incomplete SCI [114]. It is usually seen in penetrating trauma, including knife and gunshot wounds. It can also occur with the loss of vascular supply due to a herniation or edema to a hemisection [115–117]. BSS presents with ipsilateral loss of motor function, ipsilateral loss of sensation, and proprioception and contralateral loss of pain and temperature [114]. These symptoms are due to a lesion involving the corticospinal, dorsal column, and spinothalamic tracts, respectively. In some cases, there is loss of bowel and bladder function. BSS has the best prognosis of all the incomplete spinal cord injuries. Roughly 90–99% of patients gain back full function [99]. Diagnosis should be suspected based on a combination of physical examination/presenting signs and confirmed with an MRI. Management is similar to CCS, consisting of conservative approach with a strong focus on early rehabilitation. Surgery is indicated in the following scenarios [118–121]:


Complete recovery following BSS can take up to 2 years. However, most patients regain full motor skills within the first 6 months. Pain and temperature sensations tend to recover before full motor function is regained [122, 123]. It is vital that patients receive immediate physical therapy following the acute treatment phase to maximize recovery. During the treatment and management phase of BSS, providers must be careful in completely addressing the underlying condition that lead to BSS, such as spinal cord herniation or a CSF leak through a dural tear, as these could lead to permanent loss of neurologic function [124, 125].

#### **5.3 Anterior cord syndrome**

Anterior cord syndrome (ACS) is a rare incomplete SCI that accounts for approximately 1–3% of spinal injuries [95]. It also has the worst prognosis of all the incomplete SCI, with only 10–20% of patients achieving some level of functional recovery [126]. ACS has two primary pathogenetic mechanisms. In about 90% of cases, it is caused by decreased vascular perfusion to the anterior spinal artery which supplies the anterior 2/3 of the spinal cord [95, 126]. Another possible cause is from increased direct pressure on the spinal cord caused by compression trauma or "over-flexion" [127]. The first signs of ACS include bilateral loss of motor function, pain, and temperature sensation. These findings are more dominant in the lower extremities. Patients also tend to present with loss of bladder and bowel function [126]. Presentation of ACS is usually acute with severe back pain and loss of neurologic function mentioned. The best confirmatory test is a spinal MRI; however, computed tomography angiography (CTA) may be used for faster diagnosis. Emergent surgical management may be required depending on the underlying pathology responsible for the ACS (e.g., aortic aneurysm). Once the underlying condition is treated, management of ACS is similar to other SCIs and consists of physical and occupational therapy. While the patient may never regain the lost motor and sensory function, it is vital that physical therapy is provided on a regular basis to prevent contractions and spastic paralysis [128].
