Cervical Spinal Cord Injury | Spine Specialist

Cervical Spinal Cord Injury Overview

The spinal cord is an extension of the lower part of the brain. It is not just a message delivery system, but has some important complex processes to keep muscle motion coordinated and bowel/bladder function normal. Injury to the spinal cord is many times irreversible but there are some occasions that with time, healing can occur and improvement in function can be noted.

In sports, “stingers” are commonly seen in football and rugby. These are stretch injuries to the brachial plexus-the nerve centers in the shoulder. This is not a spinal cord injury but an injury to the peripheral nerves. Many times, these heal with no residuals.

There are essentially five different types of spinal cord injuries; central cord syndrome, Brown Sequard syndrome, anterior cord syndrome, posterior cord syndrome and global cord injury. A subset of injuries called conus injury and myelopathy will also be discussed.

Anatomy and Biomechanics

The spinal cord sits in a bony tunnel called the spinal canal. This tunnel has outlets at every vertebral level called the foramen where the nerve roots exit to service all the skin, muscle, bone, tendon and joints that go to and from that level. For example, the nerve root at C7 (lower neck) travels to the arm relaying important information from the brain to the arm and visa versa. The nerve at T10 (lower chest) relays information to the chest, belly and skin of the abdomen.

The spinal cord ends in the upper portion of the lower back. An injury below the first lumbar vertebra cannot injure the spinal cord.

The spinal canal is great protective armour plating for the cord and it is made of bone, disc and facet. These structures can fail under great loads. Falling out of a tree, getting hit by a car, being ejected from a car because seatbelts weren’t worn, a simple bike fall or football tackle can cause injury to the spinal vertebra. If the spinal canal becomes crushed because of a displaced bone fragment or the canal distorts when the vertebra become misaligned, the spinal cord becomes injured.

Sometimes, a simple injury such as a slip and fall can cause spinal cord injuries under the right circumstances. In these circumstances, the individual will have a pre-existing condition called spinal stenosis.

It is important to know what happens to the size of the spinal canal as it relates to neck motion. Bending the head forward causes the spinal canal to enlarge by as much as 30% and conversely, bending the head backwards causes reduction (or narrowing) of as much as 30%. With spinal stenosis, as the spinal canal narrows, there is increased pressure placed on the spinal cord. There are occasions where the cord can be acutely pinched with a forceful blow to the front of the head causing a condition called central cord syndrome.

(Click to Enlarge Image) This is a side view MRI of severe cervical stenosis and spinal cord compression (note the brighter signal in the spinal cord at the arrow).

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(Please keep reading below for more information on this condition.)

Central Cord Syndrome

A central cord syndrome is normally associated with a fall and impact to the front of the head causing it to bend backwards. There normally is an immediate loss of motor control to the legs and arms that can return to normal within minutes to hours. The legs normally recover before the arms do. The only residual symptoms may be a burning of the back of the hands (burning hands syndrome) that many ER locations may misdiagnose as wrist sprains. A detailed history and thorough neurological examination will pick up the diagnosis.

This injury is considered a “bruising” of the cord. The reason the legs come back before the arms is the location of the tracts that carry information from the legs and arms. It just so happens that the leg tracts are on the outside of the cord and the arm tracts are on the inside. Since it is a central cord injury, the outside has less injury and returns faster than the inside.

This injury can give permanent residuals of arm or hand weakness and stiffness of gait. A hypersensitivity of the back of the hands can also be permanent.

Brown Sequard Syndrome

This is the rarest of all spinal cord injuries, but it is a good example in understanding how the spinal cord is wired. In this injury, the spinal cord is injured only on one side where the other half is intact (hemi section of the cord). Normally, the damage is caused by a gun shot wound or knife wound.

The nerve tracts that run up the spinal cord jump over to the other side at various points either in the cord itself or in the brain stem. (We all remember from middle school that one side of the brain operates the opposite side of the body). The pain and temperature tracts jump to the other side almost right where they enter the cord. The motor and proprioception tracts wait until the base of the brain in the brain stem to make this jump.

By the way- proprioception is the knowledge of where your arm or leg is in space without looking at it. You can close your eyes and “know” where your right arm is, That is proprioception and it is directly involved with coordination.

Let’s say the injury is at T10 on the right side. The right leg would have good pain and temperature sensation but would be paralyzed with the individual having no knowledge of where it is in space. The left leg would have good strength and coordination but would feel no pain and temperature sensation.

Anterior Cord Syndrome

This syndrome results from injury to the anterior part of the spinal cord. It may be due to an insult to the anterior blood supply. The front of the cord is devoted to delivery of both motor signals and pain/temperature signals. The back of the cord delivers proprioception signals (see above). Therefore, this cord injury causes weakness and loss of pain and thermal sensations below the injury site but preservation of proprioception.

The individual will have paralysis below the level of injury but will still “be able to tell where the legs are” and have vibration sensation.

Posterior Cord Injury

This is an exceeding rare condition and normally associated with the sexually transmitted disease syphilis. The posterior columns of the spinal cord are affected and the individual has no proprioception. He or she will “walk like a drunken sailor” as they can’t feel their feet and have to carefully watch where they walk. Please see the lecture on this web site regarding inflammatory and infectious diseases that cause neurological injury for more information.

Global Cord Injury

Unfortunately, next to central cord syndrome, this is the most common of spinal cord injuries. This is a global injury to the spinal cord and respects no boundaries. It is normally associated with a severe injury to the vertebral column and resultant injury to the spinal cord.

The injury is measured as complete or incomplete. That is, is there some sparing of some tracts when the patient comes into the emergency department? If there is no sensation or motor strength below the level of injury and the normal lower reflexes have returned (no spinal shock), then the injury is said to be “complete” and no recovery is expected.

If there is some intact sensation or motor movement, there is a guarded but better prognosis. Surgery, medications and rehab will determine the eventual outcome and the final results may not be known for over a year.

If the injury is very high in the neck, it may not be survivable as the phrenic nerve exits out of the upper cervical spine. The phrenic nerve supplies the diaphragm and without the diaphragm, breathing cannot take place. These patients, unable to breath will die of asphyxiation unless they are given mouth to mouth resuscitation immediately after injury.

Conus Injury

The conus medularis is at the very end of the spinal cord which itself ends behind the body of L1- the first of the five lumbar vertebra. A fracture to this area can injure just the conus. The conus regulates the bowel and bladder through a series of nerves called nervi erigantes. If the conus is injured, it is an injury to the central nervous system and therefore may not recover. The patient will have full motor and sensory strength but will have no bowel and bladder function.

Myelopathy

Myelopathy is a chronic injury to the spinal cord over time and is caused by chronic compression of the cord. Since the cord has no pain receptors, the condition is essentially painless.

There are symptoms that occur that initially are very subtle. Because the spinal cord is partly responsible for coordinating hand movements, hand incoordination is common. Fine motor skills like zipping a zipper, using a key in a lock and picking a dime up off a counter become more difficult. Handwriting over time may change to a more sloppy appearance. Dropping objects unintentionally is common.

Balance and walking skills may become impaired. Some individuals feel off balance and may feel like they are walking on the deck of a rolling ship. When the lights are off and there are no visual clues for balance, standing up in the dark may be more difficult.

A lightening-like electric shock sensation may occur down the spine with head and neck motion called L’hermitte’s sign.

The bowel and bladder function may change. It should be noted that bowel and bladder function commonly may change with age and not be related to myelopathy.

Weird pins and needles and numbness (called paresthesias) may occur in the arms and legs for no reason or may occur with neck motion.

There are specific signs that occur with myelopathy that are apparent on a careful physical examination and can help confirm the presence of this condition. An MRI of the neck (and occasionally of the thoracic spine) is mandatory if myelopathy is suspected.

For more information on cervical spinal cord injuries, please contact Dr. Donald Corenman, spine specialist and neck doctor offering diagnostic and surgical second opinions to patients in the USA and around the world.

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Eric S

Sep 26, 2021

by Eric S on Donald Corenman, MD, DC

Successful pars repair at 46 years old

Back in November of 2018 (at 46 years old) I came from Vancouver BC to have a pars repair done with Dr. Donald Corenman at the Steadman Clinic in Vail Colorado. I'm finally posting this review nearly three years later in late 2021. The reason I waited so long was I wanted to know the final result before I posted my review. Unfortunately in that time Dr. Corenman has retired. Nevertheless, I want to post this review of Dr. Corenman and his staff at the Steadman Clinic in their excellent treatment of my L5 pars interarticularis.

I fractured my pars at age 42 back in 2014 when rolling on the gym floor, and was denied treatment by the Canadian healthcare system, probably due to my age. First my GP told me there was no surgical option for a pars defect, which was quite incorrect! I tried to live with it, but the symptoms worsened (periodic random spine slippage and weeks of resultant pain after just bending over to tie my shoe, so I eventually learned to mostly squat and hardly bend). When I finally consulted with Canadian spine surgeons, I was told they believed my pars defect had been congenital (since birth). This was absurd, considering I had done extreme martial arts (including jiu jitsu) for years prior, as well as 5 years of reinforcing steel full time in my 20s, probably the hardest job on the back you can find. No pars defect like mine would possibly have allowed this--ergo it was impossible that I had had the defect since birth. I did however have an asymptomatic congenital spina bifida occulta that made me more susceptible to a pars fracture. In 2014 in one instant, I went from having the strongest back people I knew said they'd ever seen, to being unable to safely bend over and tie my shoe without a non-negligible risk of my spine slipping randomly (which would lead to weeks of pain after each occurrence). This was due to the unilateral L5 pars defect, otherwise known as spondylolysis. It was when lying in pain on the floor 4 years later after maybe the 6th spine slippage event post injury, that I had had enough, and resolved to have surgery. If Canada's "universal health care" said no, I would make lemonade from lemons, and find the very best surgeon in the world at pars repairs. That was Dr. Donald Corenman. Dr. Corenman back in 2018 ran a website https://neckandback.com/ that dedicated many pages to the science of every aspect of pars repairs, from eligibility (good discs on MRI), to best surgical techniques (minimal open compared to minimally invasive), best imaging to use (i.e., O-Arm with Stealth imaging vs. older fluoroscopy), the ideal amount of BMP to use and why not use too much or too little, and much more, all to do with pars repairs, pages upon pages of his site just on the pars, with scientific references and his own extensive expert opinion. As a health research statistician, I was very impressed with this. It was in stark contrast to the websites of other spine surgeons which barely gave the pars a word or two, focusing almost exclusively on fusions. I had found the best surgeon in the world for pars repairs, and so after Dr. Corenman personally screened my MRI to ensure my discs were healthy, I booked the surgery.

Being 46 years old at the time of surgery in 2018, with a 4-year-old pars fracture from 2014 combined with a congenital SBO meant my pars fragment was somewhat atrophied, but it was "very solid", said Dr. Corenman in the operative report. Nevertheless, it was challenging with two things to fix, the pars and SBO, and OR time was around 4 hours. Recovery over the following months was guided by a very clear "Spine binder" from the Steadman Clinic with strict rules of "no BLT" (no bending, lifting or twisting), and illustrated physiotherapy guidelines. They even warned patients to avoid fish oil supplements, which could excessively dampen inflammation and hence slow bone healing. They answered many questions I had during months of recovery, with responses coming from the very supportive Lori Fugate (then director of Dr. Corenman's practice), and Ehrich Bean (then physician's assistant at the practice), as well as a couple calls with Dr. Corenman himself after two of the CT scans. Ehrich Bean offered great advice for taking the spine binder conservatively due to the nature of pars repairs vs. fusions. The final post-op CT scan I had was a couple weeks ago at 34 months post-op, and Dr. Corenman had retired, but I got a very positive and informative call from Eric Strauch (current PA at the Steadman Clinic under Dr. Corenman's replacement there, and who had also worked with Dr. Corenman previously). The staff at the Steadman Clinic were extremely supportive all the way through the process. I should mention, the local Canadian spine surgeon did offer me very good post-operative support including antibiotics as needed to deal with a mild surface incision-site infection early on, booking numerous x-rays when I felt something was amiss, as well as booking all four of my post-op CT scans. I am very grateful for that support also.

My final result shows plenty of solid bone across the pars and a healed SBO, with my vertebral body now a solid bone ring instead of being broken at two places as it was pre-op. Does my spine hold up in the real world? You bet! I have recently dug and moved several yards of dirt and sand and gravel by myself (shovel and wheelbarrow!) to fix our water main, pulled roots from the yard, moved several "portable" (these are HUGE) air conditioners up several flights of stairs my myself, and lifted weights. I now run 2 miles (3.2 KM) several times weekly with a hard 100 meter dash in the middle. I bend deeply before each run I go on, with no spine slippage. My spine feels amazing. I can bend over to do exercise, or real word tasks, with no risk of spine slippage.

My sincere thanks to God, Dr. Donald Corenman, Lori Fugate, Ehrich Bean, Eric Strauch, and the Steadman Clinic, as well as the Canadian spine surgeon who offered me excellent post-operative care back in Canada. You have all given me a new lease on life.

Sincerely,
Eric S

Robert S

May 11, 2021

by Robert S on Donald Corenman, MD, DC

Back Fusion Surgery

I had my entire lumbar spine fused in November of 2018. I had scoliosis , with pinched nerves that were so painful I could hardly walk - and standing for more than a few minutes was impossible. Even sitting was painful.
The fusion surgery produced immediate relief! And the recovery was much easier than I expected.
To this day I can do all the activities I love from hiking, to standing in a stream fly fishing to riding my bike long distances - or just walking down the street with my wife.
Kudos to Dr. Corenman and his staff, (including the two Erics) for taking such good care of me!

Leslie R

Jul 9, 2020

by Leslie R on Donald Corenman, MD, DC

TLIF

I had my TLIF surgery on 6/24/2020 by Dr. Corenman, I can not say enough good things about the Dr or his staff. I was always treated with respect and explained everything throughly, that made it easy for everyone to understand. I highly recommend Dr. Corenman and the Steadman Clinic.

Spinal Cord Injuries