Unifying Concepts

Clinical Syndromes of Acute Spinal Cord Compression

The cardinal features of acute spinal cord compression are relatively symmetric paralysis of the limbs, urinary retention or incontinence, and a circumferential boundary below which there is loss of sensation, referred to as the “sensory level”.

Hyperreflexia and Babinski signs, which are characteristic of intrinsic diseases of the spinal cord, may not be evident in cases of acute and severe cord compression, particularly if the cause is trauma. The limbs may instead be flaccid and areflexic, accompanied by systemic hypotension, a combination of findings that constitutes the syndrome of spinal shock. Localized back or neck pain is an additional characteristic of most acute types of cord compression. Variations and partial presentations of the typical syndromes are common. The spinal cord ends near the L1–L2 level, where it transitions to spinal roots that make up the cauda equina. Acute compression of the cauda equina by lesions in the lumbar spine causes flaccid paraparesis and early incontinence, findings that are similar to those in patients with the syndrome of spinal shock.

Clinical Syndromes of Acute Spinal Cord Compression
Complete transverse myelopathy (lesion affecting both sides and anterior and posterior spinal cord at one or more segments)

  • Bilateral paralysis below lowest affected segment of spinal cord
  • Loss or reduction of all sensation below affected level of spinal cord (sensory level)
  • Sphincter dysfunction with urinary or bowel urgency, retention, or incontinence
  • Segmental loss of reflexes at affected level
  • Hyperreflexia and Babinski signs

Spinal shock (acute destruction of spinal cord at one or more cervical or upper thoracic segments)

  • Paralysis of limbs below the affected segment of the spinal cord
  • Hypotonia and areflexia of limbs below the level of the lesion
  • No Babinski signs
  • Loss of sphincter function
  • Reduced autonomic function below affected level
  • Systemic hypotension

Central cord syndrome (predominant gray-matter damage, typically involving cervical spine, from trauma)

  • Weakness and reflex loss in arms; less severe weakness or no weakness in legs
  • Reduced pain and thermal sense in arms, typically with hyperesthesia, sparing sensation of vibration and proprioception in arms and legs
  • Variable hyperreflexia in legs

Hemicord (Brown–Séquard) syndrome

  • Paralysis, hyperreflexia, and reduced sensation of vibration on one side of body
  • Babinski sign on paralyzed side
  • Loss of pain and thermal sense on opposite side

Conus medullaris syndrome (cord compression at the level of L1–L2 vertebral bodies)

  • Weakness of feet and legs
  • Variable reflexes in legs
  • Early loss of sphincter function
  • Loss of sensation at sacral and lower lumbar (perineal) dermatomes; sensory level at or below waist
  • Variable Babinski signs

Cauda equina syndrome (compression between L2 and S1 vertebral bodies)

  • Sciatic or other radicular pain
  • Areflexic weakness of feet and legs, depending on level of compression
  • Sphincter dysfunction
  • Reduced sensation from saddle region and legs up to groin

ASIA Impairment Scale for Traumatic Spinal Cord Injury

Grade Impairment

  • A Complete: no sensory or motor function is preserved in segments S4–S5.
  • B Sensory incomplete: sensory but not motor function is preserved below the neurologic level of injury and includes the S4–S5 segments; no motor function is preserved more than three levels below the motor level on either side of the body.
  • C Motor incomplete: motor function is preserved at the most caudal sacral segments for voluntary anal contraction, or sensory function is preserved at the most caudal sacral segments (S4–S5), with some sparing of motor function more than three levels below the motor level on either side of the body.
  • D Motor incomplete: motor function is incomplete as defined above, with muscle power >3 for at least half the key muscle functions below the neurologic level of injury.*
  • E Normal: sensory and motor function are normal.

* Muscle power is graded on a scale from 0 (no muscle contraction) to 5 (normal power).



  1. Ropper AE, Ropper AH. Acute Spinal Cord Compression. N Engl J Med. 2017 Apr 6;376(14):1358-1369. [Medline]
  2. O’Phalen KH, Bunney EB, Kuluz JW. Emergency Neurologic Life Support: Spinal Cord Compression. Neurocrit Care. 2015 Dec;23 Suppl 2:S129-35. [Medline]


Created Jul 7, 2017.

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