80-year-old male PMHx Osteoarthritis, HTN, DM, COPD presenting to the ED after a mechanical fall. Patient was walking when he tripped over a step and fell forward, hitting his face on the doorframe prior to falling to the ground. He experienced loss of consciousness for approximately five minutes. He is currently awake and alert. He is oriented to person and place. He reports numbness and weakness of some of his extremities. Given the mechanism, what do you expect is the neurologic deficits in this case? 

A.    Unilateral arm and leg numbness with contralateral loss of motor function 

B.    Paralysis of the lower extremities

C.     Loss of pain and temperature in all four extremities with hyperreflexia 

D.    Quadriparesis of all four extremities with upper extremities being worse than lower 

Answer: D. Quadriparesis of all four extremities with upper extremities being worse than lower

Elderly patients with hyperextension injuries are at risk for central cord syndrome. It is often seen in patient with prior osteoarthritis, rheumatoid arthritis, or cervical spondylosis. The central fibers of the spinal cord are most affected, which innervate the upper extremities. The most extensive the injury the increased risk that the lower extremities will be involved as well. Patients may experience loss of pain and sensation along the similar distribution. These fibers run more laterally than motor innervation and thus are affected to a smaller degree. Bladder dysfunction often occurs as well and presents with urinary retention. CT is the best initial imaging modality to rule out any boney injuries. MRI is then required to further assess injury to the spinal cord. These patients must be admitted to the ICU because they are at risk for further compromise including neurogenic shock, bradycardic, respiratory depression, DVT. High dose steroids are controversial and not routinely used. Prognosis and recovery depends on the extent of the injury as classified by the ASIS impairment scale. 

The American Spinal Injury Association (ASIA) Impairment Scale:

A-    Complete- no sensory or motor function is preserved

B-    Sensory Incomplete- no motor function is preserved three levels below the injury, sensation in preserved

C-    Motor Incomplete- at least half of the muscle groups have a grade less than 3

D-    Motor Incomplete- at least half of the muscle groups have a grade greater than 3

E-    Normal- sensation and motor function intact 

For more information on cord injuries read this article:

 https://emdaily.cooperhealth.org/content/board-review-spinal-cord-syndromes

References:

Go, S. (2016). Section 21: Trauma, Chapter 258: Spine Trauma. In 1150286066 864930835 J. E. Tintinalli & 1150286067 864930835 O. J. Ma (Authors), Tintinalli's emergency medicine: A comprehensive study guide (8th ed., pp. 1718-1720). New York, NY: McGraw-Hill

Kirshblum, S. C., Burns, S. P., Biering-Sorensen, F., Donovan, W., Graves, D. E., Jha, A., Johansen, M., Jones, L., Krassioukov, A., Mulcahey, M. J., Schmidt-Read, M., & Waring, W. (2011). International standards for neurological classification of spinal cord injury (revised 2011). The journal of spinal cord medicine, 34(6), 535–546. https://doi.org/10.1179/204577211X13207446293695