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Retro exion injuries of the head and neck are the ones most often associated with the central cord syndrome, but hematomyelia, necrotizing myelitis, brocartilagenous embolism, and infarction due to dissection or compression of the vertebral artery in the medullary-cervical region are other causes (Morse) According to Dickman and colleagues, approximately 4 percent of patients who survive injuries of the very rostral cervical cord demonstrate a related syndrome referred to by these authors as cruciate paralysis The state is similar to the central cord syndrome except that the weakness is even more selective, being practically limited to the arms, a feature that is attributable to the segregation of corticospinal bers to the arms (rostral) and to the legs (caudal) within the pyramidal decussation The arm weakness may be asymmetrical or even unilateral; sensory loss is inconsistent The patients described have had injuries, basically contusions, of the C1 C2 region.

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The latter is the more distinctive syndrome (described originally by DennyBrown); it is characterized by a loss of all modalities of sensation spreading from the distal to the proximal segments of the limbs and eventually to the trunk and face There is severe ataxia and loss of tendon re exes, but motor power is retained More recently, it has been appreciated that the sensory loss in the beginning may have a multifocal distribution The illness reaches its peak in a few weeks or months, and in a very few instances as mentioned the development has been as rapid as that of GBS The pathologic changes are those of an in ammatory and destructive sensory neuronopathy (ganglionitis) and are sometimes part of a more widespread disorder of the nervous system related to the anti-Hu antibody (also termed antinuclear neuronal antibody); see page 585.

A large number of neurologic disorders are associated with alcoholism. The factor common to all of them, of course, is the abuse of alcohol, but the mechanism by which alcohol produces its effects varies widely from one group of disorders to another and in many cases, the essential problem is one of nutritional de ciency as discussed in the preceding chapter. The classi cation that follows is based for the most part on known mechanisms. I. Alcohol intoxication drunkenness, coma, excitement ( pathologic intoxication ), blackouts II. Abstinence or withdrawal syndrome tremulousness, hallucinosis, seizures, delirium tremens III. Nutritional diseases of the nervous system secondary to alcoholism (Chap. 41) A. Wernicke-Korsakoff syndrome B. Polyneuropathy C. Optic neuropathy ( tobacco-alcohol amblyopia ) D. Pellagra IV. Diseases of uncertain pathogenesis associated with alcoholism A. Cerebellar degeneration B. Marchiafava-Bignami disease C. Central pontine myelinolysis D. Alcoholic myopathy and cardiomyopathy E. Alcoholic dementia F. Cerebral atrophy V. Fetal alcohol syndrome VI. Neurologic disorders consequent upon cirrhosis and portal-systemic shunts (Chap. 40) A. Hepatic stupor and coma B. Chronic hepatocerebral degeneration VII. Traumatic brain lesions consequent to intoxication subdural hematoma, cerebral contusion, etc.

Whether the lesion lies strictly within the decussating corticospinal tract or involves central gray matter is not always clear; MRI imaging has implicated the latter anatomic region (Inamasu et al) Sensory evoked potentials are normal, while magnetic stimulation of the corticospinal tract may be abnormal Examination and Management of the Spine-Injured Patient The level of the spinal cord and vertebral lesions can be determined from the clinical ndings Diaphragmatic paralysis occurs with lesions of the upper three cervical segments (an unrelated transient arrest of breathing is common in severe head injury) Complete paralysis of the arms and legs usually indicates a fracture or dislocation at the fourth to fth cervical vertebrae If the legs are paralyzed and the arms can still be abducted and exed, the lesion is likely to be at the fth to sixth cervical vertebrae.

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Paralysis of the legs and only the hands indicates a lesion at the sixth to seventh cervical level Below the cervical region, the spinal cord segments and roots are not directly opposite their similarly numbered vertebrae (Fig 44-1) The spinal cord ends at the rst lumbar vertebra, usually at its rostral border Vertebral lesions below this point give rise predominantly to cauda equina syndromes; these carry a better prognosis than injuries to the lower thoracic vertebrae, which involve both cord and multiple roots The level of sensory loss on the trunk, determined by perception of pinprick, is an accurate guide to the level of the lesion, with a few quali cations (See Figs 9-2 and 9-3 for maps of the sensory dermatomes.

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