Spine Trauma, Fractures & Cord Syndromes

ABPN Neurocritical Care Study Guide Exam

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1 Chapter 1: Neurologic Examination & Coma Assessment in the ICU

Current Examination, Blueprint & Preparation Neurologic Examination in Critically Ill Patients Coma Evaluation & Consciousness Alterations Delirium & Toxic-Metabolic Encephalopathy in the ICU

2 Chapter 2: Cerebral Physiology & Intracranial Dynamics

Cerebral Blood Flow, Metabolism & Autoregulation Intracranial Pressure & Compliance Cerebral Edema & Herniation Syndromes

3 Chapter 3: Intracranial Hypertension & Cerebral Perfusion Management

Tiered ICP Management Protocols Hyperosmolar Therapy & Fluid Management Advanced & Refractory ICP Interventions

4 Chapter 4: Airway, Mechanical Ventilation & Pulmonary ICU Management

Emergency Airway Management & Neuro-Intubation Mechanical Ventilation Strategies in Acute Brain Injury Tracheostomy & Ventilator Weaning in Neurocritical Care Pulmonary Complications in the Neuro-ICU Obstructive Lung Disease, Pulmonary Hypertension & Bronchoscopy

5 Chapter 5: Hemodynamics, Shock & Cardiovascular Management

Hemodynamic Monitoring & Blood Pressure Targets Vasoactive Agents: Inotropes, Vasopressors & Antihypertensives Cardiac Complications of Brain Injury

6 Chapter 6: Neuropharmacology, Analgesia & Sedation

ICU Sedation & Analgesia Neuromuscular Blockade & Monitoring Propofol Infusion Syndrome & Drug Toxicities Antiseizure Drug Pharmacology in the ICU

7 Bleeding, Thrombosis & Hematologic Emergencies

Warfarin & Heparin Reversal Direct Oral Anticoagulant (DOAC) Reversal Antiplatelet Management & Platelet Dysfunction Venous Thromboembolism Prophylaxis & Management Transfusion, Coagulopathy, TMA & Cellular-Therapy Neurotoxicity

8 Chapter 8: Systemic ICU Care, Fluids, Electrolytes & Endocrine

Hyponatremia & Osmoregulation: SIADH vs Cerebral Salt Wasting Diabetes Insipidus, Hypernatremia & Endocrine Crises Critical Care Prophylaxis, Nutrition & Infection Prevention

9 Systemic Trauma & Environmental Injury

Polytrauma, Chest Injury & Abdominal Hemorrhage Burns, Electrical Injury & Hanging

10 Cardiac Emergencies & Mechanical Support

IABP, Ventricular Devices & ECMO Acute Coronary, Valvular, Rhythm & Aortic Emergencies

11 Kidney Injury, Acid–Base & Renal Replacement

Acute Kidney Injury & Renal Drug Clearance Acid–Base Disorders, Electrolytes & Renal Replacement

12 Systemic Infection & Endocrine Emergencies

Sepsis, Endocarditis & Antimicrobial Principles Thyroid, Adrenal & Dysglycemic Emergencies

13 Gastrointestinal & Hepatic Emergencies

Acute Abdomen, GI Bleeding & Abdominal Compartment Syndrome Acute Liver Failure, Cirrhosis & Hepatic Drug Effects

14 Chapter 9: Neuroimaging in the Neuro-ICU

Non-Contrast CT & CT Angiography CT Perfusion & Advanced Perfusion Imaging Magnetic Resonance Imaging in Critical Illness

15 Chapter 10: Electrophysiology & Neuromonitoring

Continuous EEG & ACNS Standardized Critical Care Terminology Invasive Neuromonitoring: ICP & External Ventricular Drains Multimodal Monitoring: PbtO2, Microdialysis & Transcranial Doppler

16 Angiography, Electrodiagnosis & CSF Analysis

Conventional Angiography & Cranial–Spinal Shunts EMG, Nerve Conduction & Acute Muscle Disease CSF Analysis: Infection, Inflammation & Hemorrhage

17 Chapter 11: Bedside Procedures, Ultrasound & Death by Neurologic Criteria

Critical Care Procedural Skills Critical Care Ultrasound & Echocardiography Determination of Death by Neurologic Criteria

18 Chapter 12: Acute Ischemic Stroke & Reperfusion Therapies

Acute Ischemic Stroke Management & Thrombolysis Endovascular Thrombectomy & Large Vessel Occlusion Malignant Hemispheric & Cerebellar Infarction

19 Chapter 13: Spontaneous Intracerebral Hemorrhage & Intraventricular Hemorrhage

Acute Intraparenchymal Hemorrhage Management Intraventricular Hemorrhage & Hydrocephalus Surgical Evacuation & Minimally Invasive Surgery in ICH

20 Chapter 14: Aneurysmal Subarachnoid Hemorrhage & Delayed Cerebral Ischemia

Aneurysmal Subarachnoid Hemorrhage: Acute Resuscitation & Securing Delayed Cerebral Ischemia & Cerebral Vasospasm Non-Aneurysmal Subarachnoid Hemorrhage & Vascular Malformations

21 Venous, Spinal & Traumatic Vascular Disease

Cerebral Venous Thrombosis & Spinal Cord Infarction Traumatic Dissection, Carotid–Cavernous Fistula & Penetrating Injury

22 Chapter 15: Traumatic Brain & Spinal Cord Injury

Severe Traumatic Brain Injury & Contusions Acute Traumatic Spinal Cord Injury & Neurogenic Shock Spine Trauma, Fractures & Cord Syndromes

23 Chapter 16: Status Epilepticus, Seizures & Neuromuscular Emergencies

Status Epilepticus: Convulsive & Non-Convulsive Refractory & Super-Refractory Status Epilepticus Acute Neuromuscular Respiratory Failure

24 Chapter 17: Post-Cardiac Arrest Care, CNS Infections & Encephalitis

Targeted Temperature Management & Post-Cardiac Arrest Care Post-Cardiac Arrest Neuroprognostication Acute CNS Infections, Encephalitis & Inflammatory Emergencies

25 Neuroinflammation & Neurooncology

Fulminant Demyelination & Autoimmune Encephalitis Brain, Spinal & Leptomeningeal Cancer Emergencies

26 Pregnancy, Transplantation & Pediatric Care

Pregnancy, Postpartum & Post-Transplant Neurologic Care Pediatric Neurocritical Care

27 Chapter 18: Neurosurgical & Perioperative Emergencies

Postoperative Neurosurgical Complications Device Complications: EVDs, Shunts & ICP Monitors Cerebral Hyperperfusion Syndrome & Post-Interventional Emergencies

28 Chapter 19: Ethics, Palliative Care & Organ Donation in the Neuro-ICU

Communication, Surrogate Decision-Making & Conflict Resolution Neuroprognostication Ethics, Withdrawal of Life Support & Palliative Care Organ Donation & Management of the Deceased Donor

Spine Trauma, Fractures & Cord Syndromes

Key Takeaways Explain This Topic AI

Central cord syndrome produces disproportionate arm and hand weakness; the traditional medial-arm-fiber explanation is not established human corticospinal anatomy.

Sacral sparing determines incomplete injury classification; syndrome labels do not replace a documented ISNCSCI examination.

Cauda equina compression requires emergency assessment and decompression as soon as appropriate, without treating 48 hours as a safe waiting period.

Fracture management depends on morphology, ligament integrity, neurologic findings, alignment, and patient factors rather than one column or displacement threshold.

Last updated: October 2026

• Spine Trauma, Fractures, and Localization
• Examine the Cord and the Column Separately

A patient can have an unstable fracture without an initial neurologic deficit, or a substantial cord injury without an obvious fracture on CT. Maintain appropriate spinal precautions while assessing airway, circulation, associated injuries, and alignment. Obtain a baseline motor and sensory examination before and after transfers or interventions when feasible. Document confounders such as sedation, painful limb fractures, peripheral nerve injury, or inability to cooperate. Do not call an untestable muscle definitively paralyzed.

Use the International Standards for Neurological Classification of Spinal Cord Injury to record key muscles, sensory levels, sacral sensation, deep anal pressure, and voluntary anal contraction. Sacral sparing is central to distinguishing complete from incomplete injury. A syndrome description is a useful localization tool, but it cannot substitute for the formal examination or predict an individual's final recovery. Early spinal shock can obscure the expected upper motor neuron signs, so repeat assessment is necessary.

Incomplete Syndromes

Central cord syndrome describes greater upper than lower limb motor impairment, often especially affecting hand function, with variable sensory and bladder abnormalities. Cervical hyperextension in a stenotic degenerative canal is a common setting; younger patients can have other traumatic mechanisms. MRI evaluates cord injury, ongoing compression, disc injury, and ligament disruption. The older explanation that arm corticospinal fibers are concentrated centrally and sacral fibers laterally is not a reliable description of human tract organization. Recognize the clinical pattern without treating that proposed anatomy as proven.

Anterior cord syndrome classically combines weakness and impaired pain/temperature below a lesion with relative preservation of dorsal-column modalities. Trauma and anterior spinal arterial ischemia can produce this pattern. Actual lesions are often mixed, and complete preservation of every light-touch or proprioceptive response is not required. A negative early MRI does not exclude every vascular cord injury. Assess aortic disease and other causes when the onset and context suggest ischemia rather than mechanical trauma.

Brown-Séquard syndrome classically causes ipsilateral motor and dorsal-column impairment with contralateral pain/temperature loss beginning below the lesion. Spinothalamic fibers cross over several nearby segments, so sensory boundaries do not always match a single textbook level. Pure hemisection is uncommon; partial or mixed patterns are frequent. These distinctions guide localization, but outcome depends on injury completeness, level, mechanism, complications, and rehabilitation rather than a fixed syndrome-specific walking percentage.

Conus and Cauda Equina Emergencies

The conus usually terminates near the L1–L2 vertebral level, with normal variation. Its injury may combine cord and root findings, early sphincter dysfunction, and saddle sensory change. Cauda equina injury affects descending lumbosacral roots and can cause radicular pain, flaccid weakness, reduced reflexes, saddle sensory impairment, and urinary dysfunction. Neither symmetry nor timing of incontinence reliably separates every case. Bladder retention is concerning; preserved voiding or a modest residual does not by itself exclude evolving compression.

New saddle symptoms, progressive bilateral deficits, or urinary dysfunction require emergency evaluation, usually urgent MRI and spine surgical consultation. Identify compressive disc disease, fracture, hematoma, tumor, or infection. Decompression should occur as soon as clinically appropriate after diagnosis and coordination, rather than waiting for a supposed protected 48-hour window. Record symptom progression, examination, imaging, consultation, and any reasons for delay. A patient already beyond a quoted research interval still needs urgent assessment and may benefit from treatment.

Stability and Fracture Patterns

Denis's anterior, middle, and posterior columns are a historical framework for thoracolumbar injury. They help describe structural involvement, but middle-column injury alone does not make every fracture an operative emergency. Contemporary assessment incorporates morphology, posterior ligamentous complex integrity, neurologic status, alignment, and validated classification systems. Some neurologically intact burst fractures can be treated without surgery; translation, distraction, progressive deformity, or significant neural compression changes the decision.

For a C1 burst fracture, assess the transverse atlantal ligament and associated injuries. Lateral mass overhang can raise concern for ligament disruption but does not reliably prove or exclude it; CT and selected MRI findings inform management. Odontoid fractures are classified as tip, base, or extension into the C2 body. Type II base fractures have important nonunion risk. Treatment depends on displacement, stability, age, frailty, bone quality, symptoms, and surgical risk. A collar can be appropriate in selected patients, and a halo is not an automatic preferred treatment in older adults because complications can be substantial.

C2 pars injuries and subaxial facet dislocations require specialist assessment of the disc and ligaments as well as bone. Facet dislocation can coexist with major cord injury, radiculopathy, or a preserved examination. Reduction is an urgent specialist procedure with a planned airway, monitoring, imaging strategy, and rescue pathway. Awake closed reduction and operative reduction have different prerequisites. MRI use depends on examination reliability, suspected disc material, local expertise, and urgency; do not attempt unsupervised traction based on a simplified rule. Repeat the neurologic examination after alignment, immobilization, and surgery.

Source: ACS spine injury best practices and 2024 spinal cord injury guidance .

Decision Review

• Pattern Localization clue
• Central cord Arm and hand motor impairment greater than leg impairment
• Anterior cord Motor and pain/temperature impairment with relative dorsal-column preservation
• Brown-Séquard Ipsilateral motor/proprioception and contralateral pain/temperature changes
• Cauda equina compression Root deficits, saddle symptoms, and bladder dysfunction requiring urgent assessment