Examination of the Patient With a Suspected Spinal Cord Problem

Ovid: Field Guide to the Neurologic Examination

Authors: Lewis,
Steven L.

Title: Field
Guide to the Neurologic Examination, 1st Edition

> Table of Contents > Section 3 –
Neurologic Examination in Common Clinical Scenarios >Chapter 51 –
Examination of the Patient With a Suspected Spinal Cord Problem

Chapter 51

Examination of the Patient With a Suspected Spinal Cord


The goal is to recognize, on the basis of the history and
examination, when a patient’s symptoms are likely to be due to spinal cord
dysfunction so that the appropriate investigations can be performed.


Spinal cord dysfunction can occur due to a compressive lesion
extrinsic to the spinal cord (e.g., tumor, abscess, or disc) or due to an
intrinsic lesion within the spinal cord (e.g., demyelination, inflammation, or
infarction). Dysfunction of the spinal cord due to any cause is referred to by
the generic term myelopathy. Acute dysfunction of the
spinal cord causing severe motor and sensory loss below the level of the lesion
is often called a transverse myelopathy. When spinal
cord dysfunction is thought to be due to an intrinsic demyelinative or
inflammatory process, it is called myelitis.

Spinal cord dysfunction generally causes motor, sensory, or
autonomic dysfunction below the level of the spinal cord lesion; however, the
symptoms of spinal cord disease vary, not only depending on the level of the
lesion (e.g., cervical or thoracic), but also the severity of the process and
the part of the cord that is being affected at that level (Table


  • When taking the history, use the combination of motor, sensory,
    and any autonomic (bowel, bladder, sexual) symptoms to clue you in on the
    possibility that your patient’s symptoms might be due to spinal cord
    dysfunction. Be aware that cord lesions can present in several different ways
    (Table 51-1).

  • Ask about bowel, bladder, and sexual function (patients may not
    always volunteer this information); these can be affected by lesions at any
    level of the spinal cord.

  • Patients with a lesion at the level of the cervical spinal cord
    will most likely have symptoms of weakness and sensory loss in the arms and
    legs; however, mild or moderate cervical spinal cord dysfunction might cause
    primarily lower extremity symptoms. Patients with lesions at the level of the
    thoracic cord can have weakness and sensory loss in the legs, trunk, or
    abdomen below the dermatomal level of the lesion, but they would not have
    symptoms in the arms.

  • Patients who have hemi-spinal cord dysfunction (i.e., dysfunction
    affecting only the left or right side of the spinal cord at a particular
    level) may specifically complain of weakness on one side of the body with
    sensory loss to temperature sensation (such as when taking a shower or bath)


    the opposite side of the body, symptoms
    characteristic of the Brown-Séquard syndrome (Table

  • Some patients with a myelopathy have Lhermitte’s sign, an
    uncomfortable feeling of electricity, vibration, or tingling radiating down
    the neck, back, or extremities occurring on neck flexion. Lhermitte’s sign is


    a symptom, and not a sign tested for
    during the examination. Although often primarily thought of as a symptom of
    spinal cord dysfunction due to multiple sclerosis, Lhermitte’s sign can occur
    due to any process affecting the cervical cord (whether intrinsic or
    compressive), causing dysfunction of the posterior columns. Lhermitte’s sign
    can be a helpful clue to a cervical spinal cord localization of pathology;
    therefore, patients with a suspicion of spinal cord dysfunction should
    specifically be asked about the presence or absence of this

  • Most patients with spinal cord dysfunction do not have pain in
    the neck or back. Neck or back pain may occur in some patients with spinal
    cord disorders, however, particularly those with epidural spinal cord
    compression from neoplasms or abscesses that are also affecting bone.
    Radicular pain may occur in patients who have pathology causing simultaneous
    root and cord dysfunction.

  • Like any neurologic process, the temporal course of symptom
    development can provide clues to the most likely mechanism of the cord
    dysfunction. Sudden dysfunction suggests acute compression or infarction,
    whereas more gradually progressive symptoms suggest processes such as chronic
    compression, inflammation, or demyelination.

TABLE 51-1 Signs and Symptoms of
Common Spinal Cord Syndromes and the Cauda Equina Syndrome

Spinal Cord


Signs and Symptoms

Transverse myelopathy

Acute severe bilateral spinal cord dysfunction at a level; may
occur due to compression, ischemia, or inflammation/demyelination
(transverse myelitis)

Severe weakness, sensory loss, bowel and bladder dysfunction, and
upper motor neuron signs below level of lesion.

Brown-Séquard syndrome

Hemi-spinal cord dysfunction; can occur due to intrinsic or
extrinsic lesions affecting one side of cord more than the

Weakness, diminished vibration and proprioception, and upper
motor neuron signs on the same side of the lesion below the level of
lesion; diminished pin and temperature sensation on the side
opposite the lesion below the level of the lesion.

Anterior spinal artery syndrome

Due to infarct in distribution of anterior spinal artery; affects
the corticospinal and spinothalamic tracts, sparing the posterior

Weakness and diminished pinprick sensation (and upper motor
neuron signs) below the level of the lesion; vibration and position
sense spared.

Cervical syrinx

Due to cavitary lesion within the center of the cervical cord
primarily initially affecting the crossing fibers of spinothalamic
tract; may also affect anterior horn cells, causing lower motor
neuron dysfunction in hands

Diminished pin and temperature sensation in the hands and arms,
possibly also the shoulders and chest (cape distribution); may have
atrophy and weakness in hands.

Central (cervical) cord syndrome

Dysfunction primarily involving center of cervical cord (acting
physiologically like a large syrinx); may occur due to intrinsic
cord lesions or compressive lesions

Weakness in the arms more than legs; upper motor neuron signs and
posterior column loss primarily in legs; pin sensation loss may be
seen in arms and legs, but sacral sensation may be spared.

Conus medullaris syndrome

Dysfunction of the tip of the spinal cord, affecting sacral motor
(autonomic) and sensory fibers

Perianal (sacral) sensory loss; incontinence of bowel and
bladder; loss of anal sphincter tone.

Cauda equina syndrome

Dysfunction of nerve roots in the lumbosacral spinal canal below
L-2 usually due to compressive lesions of the lumbosacral

Weakness and sensory loss in legs below the level of the lesion;
loss of bowel and bladder function (flaccid and areflexic). Because
only lower motor neurons (nerve roots) are affected, no upper motor
neuron signs should be


  • The motor examination of patients with spinal cord disorders may
    show weakness in muscles below the level of the cord lesion. Depending on the
    severity of the process, the weakness may be mild or severe. The highest level
    of major root innervation of the weak muscles (see Tables
    and 26-1) represents the lowest possible
    superior aspect of the spinal cord lesion. In other words, if there is
    weakness in C6-innervated muscles and below, the spinal cord lesion must start
    at or above C6.

  • The sensory examination of a patient with spinal cord dysfunction
    may show bilateral sensory loss to any modality below the level of the lesion.
    Sensory testing should particularly focus on looking for diminished pin
    sensation below a dermatomal level, by marching the pin down from superior to
    inferior dermatomes on each side of the body, asking the patient if there is
    any decrease in the pin sensation as you go down. March the pin down the chest
    and abdomen when assessing for a thoracic pin sensation level or between
    dermatomes of the arm looking for a cervical pin level. If a sensory level is
    found, the pin level represents the lowest possible superior aspect of the
    spinal cord lesion. In other words, if there is diminished pin sensation from
    the T4 level and down (i.e., normal above T4), the spinal cord lesion must
    start at or somewhere above T4. Cervical cord lesions may, therefore,
    sometimes cause a thoracic sensory level.

  • The sensory examination of patients with spinal cord disorders
    usually also shows loss of vibration sensation (and, if severe, proprioceptive
    loss) below the level of the lesion. These signs of posterior column
    dysfunction are helpful in assessing the severity of a lesion (i.e., the more
    severe the lesion, the worse the vibration or proprioceptive sensation loss
    below the lesion) but are not as helpful in defining the possible level of the
    lesion as pin sensation.

  • Patients with spinal cord dysfunction typically have upper motor
    neuron signs (hyperreflexia) below the level of the lesion, as well as upgoing
    toes (Babinski sign). Patients with chronic spinal cord disorders also
    typically have increased tone (spasticity) below the level of the

  • P.177

  • When a hemi-spinal cord (Brown-Séquard) syndrome is suspected, in
    addition to assessing for asymmetric weakness, look for side-to-side
    differences in vibration and proprioception, as well as side-to-side
    differences in pin and temperature sensation below the level of the lesion. To
    test temperature sensation, simply touch an area of skin on each side of the
    patient’s body with the side of a (nonvibrating) tuning fork, because a metal
    tuning fork usually feels cold against the skin. Ask the patient if he or she
    feels the coldness the same on each side. A sensory level to temperature
    sensation can also be tested in the Brown-Séquard syndrome (or in any
    potential spinal cord syndrome) simply by marching the side of the tuning fork
    from superior dermatomes down to inferior dermatomes.

  • Anal sphincter tone should be examined in patients when a
    significant spinal cord disorder (particularly due to possible spinal cord
    compression) is suspected. Sphincter tone can be assessed by performing a
    digital lubricated rectal examination and feeling the resistance to insertion
    of your finger during insertion and after asking the patient to squeeze down.
    Any decrease you perceive in sphincter tone is potentially abnormal. Another
    test of sphincter function that may be helpful in the assessment of severe
    spinal cord disorders is the anal wink reflex. This consists of stroking the
    perianal skin lightly with a wooden stick and looking for reflex contraction
    of the anal sphincter; this reflex can be lost with severe spinal cord

  • Table 51-1 summarizes the characteristic
    signs and symptoms of various common spinal cord syndromes, as well as the
    cauda equina syndrome (due to lesions affecting the lumbosacral roots below
    the spinal cord).

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