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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.

Corticospinal Tract Lesion

Authors
Isabella C. Van Wittenberghe1; Diana C. Peterson2.

Affiliations
 High Point University
1

 Philadelphia College of Osteopathic Medicine

2

Last Update: August 26, 2021.

Continuing Education Activity

The corticospinal tract controls primary motor activity for the somatic
motor system and is a major pathway for voluntary movements. The
lateral corticospinal tract can be injured in a number of ways. The most
common types of injury include central cord syndrome, Brown-Sequard
syndrome, and anterior spinal cord syndrome. Improved patient outcome
measures may be facilitated by prompt diagnosis and management of
spinal cord trauma. Physical therapy and occupational therapy are highly
suggested to help patients preserve and regain motor function. This
activity describes the evaluation and management of cortical spinal tract
lesions and highlights the role of the interprofessional team in improving
care for patients with this condition. Steroids are a medication used in the
treatment and management of corticospinal lesions within the first eight
hours to reduce swelling and pressure on the spinal cord. However,
steroids should not be administered to patients with Brown-Sequard
syndrome because it can lead to infection. This activity reviews the
indications, contraindications, and activity of steroids pertinent for the
members of the interprofessional team in the management of patients
with corticospinal tract lesions and related conditions. Decompression
surgery can be performed in patients with a traumatic injury or with cord
compression resultant from a tumor or abscess. This activity outlines and
highlights the role of the interprofessional team in managing patients
who undergo decompression surgery.
Objectives:
 Identify the types of spinal cord injuries that can influence the
corticospinal tract.
 Describe the type of radiological result you would expect to
observe in a patient with Brown-Sequard syndrome.
 Outline specific tests that can be performed to examine the motor
function and coordination for patients with suspected spinal cord
lesions.
 Review interprofessional team strategies for improving
coordination of patient care to improve corticospinal lesion patient
outcome measures.
Access free multiple choice questions on this topic.

Introduction
The corticospinal tract controls primary motor activity for the somatic
motor system from the neck to the feet. It is the major spinal pathway
involved in voluntary movements. The tract begins in the primary motor
cortex, where the soma of pyramidal neurons are located within cortical
layer V. Axons for these neurons travel in bundles through the internal
capsule, cerebral peduncles, and ventral pons. They stay in the ventral
position within the medulla as the pyramids. A majority of the axons
cross the midline at the pyramidal decussation between the brainstem and
spinal cord to form the lateral corticospinal tract (Figure 1A). This
crossover causes the left side of the brain to control the right side of the
spinal cord and the right side of the brain to control the left side of the
spinal cord. A small number of axons remain on the ipsilateral side to
form the anterior corticospinal tract. Axons of both anterior and lateral
corticospinal tracts move into the gray matter of the ventral horn to
synapse onto lower motor neurons. These lower motor neurons exit the
spinal cord to contract muscle.[1] While the anterior corticospinal tract
assists with axial muscle motor control, the lateral corticospinal tract is
the primary pathway for motor information to the body. Injuries to the
lateral corticospinal tract results in ipsilateral paralysis (inability to
move), paresis (decreased motor strength), and hypertonia (increased
tone) for muscles innervated caudal to the level of injury.[2] The lateral
corticospinal tract can suffer damage in a variety of ways. The most
common types of injury are central cord syndrome, Brown-Sequard
syndrome, and anterior spinal cord syndrome.

Etiology
There are numerous causes for spinal cord injuries: trauma, ischemic
events, and disease are the most common methods of damage. Central
cord syndrome (Figure 1B) affects the central portion of the spinal cord.
It results from hyperextension of the cord, typically within the cervical
region. This type of injury is common in shaken baby syndrome. Another
cause can be motor vehicle accidents where the head hyper-extends due
to contact with the vehicle or air-bag or high impact contact sports such
as football.[3]
Anterior spinal cord syndrome is the result of damage or obstruction of
the anterior spinal artery (Figure 1C). The spinal cord has one anterior
spinal artery and two posterior spinal arteries. The anterior spinal artery
supplies the anterior 2/3 of the spinal cord.[4] Thrombosis or an
embolism can lead to damage. One of the more common sites of anterior
spinal injury is at the artery of Adamkiewcz. This radicular artery
branches from the aorta at the level of the 9 to 12 intercostal spaces in
most individuals. In a small percentage of people, it originates between
L1-L2 or T5-T8.[5] The artery of Adamkiewcz terminates at an acute
angle that makes it more prone to damage. Because the artery of
Adamkiewcz is prone to damage from surgical procedures that involve
the retroperitoneal space, identification and preservation of the artery is
important for numerous surgical procedures (e.g., thoracoabdominal
aortic aneurysm repair, thoracic or lumbar spine surgery, removal of
intramedullary tumors, and retroperitoneal procedures).[6] Other forms
of damage that cause anterior spinal cord syndrome include
atherosclerotic disease, spinal muscular atrophy, multiple sclerosis, or
infections (e.g., West Nile virus, poliomyelitis).[7]
Brown-Sequard syndrome is a condition in which the left or right half of
the spinal cord is damaged (Figure 1D). Its typical cause is traumatic
injuries such as gunshot and stabbing wounds, motor vehicle accidents,
or fractured vertebra due to falls.[7] Other causes for this disorder
include vertebral disc herniation, cervical spondylosis, tumors, multiple
sclerosis, decompression sickness, cystic disease, as well as infections
(e.g., meningitis, tuberculosis, transverse myelitis, and herpes zoster).[8]

Epidemiology
Central cord syndrome (Figure 1B) has a bimodal distribution (young
and old age groups), mostly affecting males, and accounts for 9.0% of
adult spinal cord injuries and 6.6% of pediatric spinal cord injuries.
[3] Central cord syndrome is prevalent among patients with cervical
stenosis and the elderly with spinal diseases. However, it is more
common in younger patients with cervical spine fractures, disk
herniation, or shaken baby syndrome.[9]
Anterior spinal cord syndrome is most common in adults as a result of
postoperative complications.[10] It is most prevalent after either
retroperitoneal surgeries or spinal surgeries. 
Brown-Sequard syndrome is rare, estimated to account for 2 to 4% of
spinal cord injuries.[2] Eleven thousand new cases are reported yearly
within the United States.[8] Some form of penetrating trauma is the most
common cause.

Pathophysiology
Patients with central cord syndrome have compression of the dorsal
column tracts, lateral corticospinal tracts, and spinothalamic tracts. The
compression of the dorsal column tracts causes bilateral sensory
impairments below the level of injury. Sensory impairment is typically
experienced in a “cape-like’ distribution across the upper back and down
the posterior side of the upper limbs.[11] Damage to the lateral
corticospinal tracts causes bilateral weakness of the upper body, but
patients retain strength in the lower limbs.[3] Compression of the
spinothalamic tracts results in the bilateral loss of pain/temperature for
the upper body more than the lower body. Deficits affecting upper body
functions more than the lower body result from compression of the
central aspect of the cord. Both corticospinal and spinothalamic tracts
have homunculi in which the upper body is located centrally while the
lower body is located more peripherally within the spinal cord.[11] 
Patients with anterior spinal cord syndrome have bilateral deficits to the
corticospinal tracts and spinothalamic tracts. They experience bilateral
paralysis and paresis below the site of the lesion.[10] They also
experience bilateral pain/temperature and light touch deficits due to the
injury of the spinothalamic tract.[12] Sacral sparing of the spinothalamic
tract occurs due to a dual blood supply by the posterior spinal arteries.
The posterior spinal arteries wrap around the peripheral aspect of the
cord. This secondary supply enables the full functionality of the
peripheral spinothalamic tract, which transmits pain, temperature, and
light touch for the feet.
Patients with Brown-Sequard syndrome have a unilateral deficit of the
lateral cord.[8] Deficits associated with this syndrome include ipsilateral
paralysis, paresis, and hypertonia; ipsilateral proprioception loss; and
contralateral loss of pain and temperature sensation.[2][8] 
In any of these syndromes, the locus of the injury can cause additional
symptoms. If the injury is at or above T1-L2, a compression will disrupt
sympathetic neurons within the intermediolateral nucleus in the lateral
horn of the spinal cord and cause an ipsilateral Horner syndrome.
Similarly, injuries within the lower lumbar region can cause autonomic
dysfunction that induces bladder, bowel, or sexual dysfunction.[8][10]

History and Physical

For any spinal cord lesion, the extent of trauma needs to be evaluated. If
the injury involves the cervical region, cervical immobilization should be
performed during the initial evaluation to prevent additional injury to the
cord. An exam should include all primary functions of the spinal cord
(i.e., motor, primary touch, proprioception, autonomic function, and pain,
temperature, and light touch). Assessment of sensory function for
primary touch as well as pain and light touch can be performed by
touching a patient at various dermatome regions of the body with a blunt
or sharp object. To assess corticospinal tract function, examine muscle
tone and spasticity for extensors and flexors of the arms and legs. Test
for motor strength and function by having the patient move different
groups of muscles with and without resistance — test for proprioception
with a finger to nose test, rapid alternating movements test, or Romberg
test. If the patient is ambulatory, examine their gate for motor ability and
coordination.[13] If the injury occurs in the lower lumbar region, the
bowel and bladder can be affected.[8] In these cases, the rectal tone can
be assessed to determine the severity of autonomic compromise.

Evaluation
Examination of spinal cord injury caused by trauma should include
radiographs to reveal fractures and dislocations of the spine. In addition,
computed tomography (CT) or magnetic resonance imaging (MRI) can
be performed to identify impingement in these cases.[10]
[11] Impingement in Brown-Sequard syndrome will appear as an “owl’s
eye” configuration in the anterior horns.[4] If the anterior spinal
syndrome is suspected, a spinal cord angiogram may also be a
consideration.[10] 
If there is no observable evidence of trauma in the physical exam, a
purified protein derivative and sputum for acid-fast bacilli along with a
chest X-ray should be performed to ensure that an infectious etiology is
not the cause of the symptoms.[8]

Treatment / Management
Treatment of corticospinal lesions involves steroid (methylprednisolone
or corticosteroids) administration within the first 8 hours to reduce
swelling and pressure on the cord.[11] However, steroids are not
recommended for Brown-Sequard syndrome patients because they may
make the patient more prone to subsequent infections.[8] If the injury is
in the high thoracic or cervical regions, respiratory support may be
required, with recommendations for respiratory therapy treatment.[8]
Decompression surgery can be a consideration for patients with a
traumatic injury or with a tumor or abscess that causes cord compression.
[8][11] After stabilizing the spine, physical rehabilitation is needed to
preserve motor activity, muscle strength and to maintain coordination.
[10] Wheelchairs, limb supports, and splints can assist the patient with
ambulation.[8] Occupational therapy may also be needed to improve and
maintain the activity of the upper limbs, specifically in performing daily
actions.[10]

Differential Diagnosis
The differential diagnosis for spinal cord syndromes:[8][11]
 Bilateral brachial plexus injuries
 Cysts
 Dislocations
 Epidural abscesses or hematomas
 Fractures
 Infection
 Other spine pathologies and traumas
 Strokes
 The trauma of peripheral nerve roots leading to avulsion in a
bilateral distribution
 Tumors
 Vascular injuries

Prognosis
Most patients with central cord syndrome have some recovery of
function. Patients who receive treatment soon after the injury have better
outcomes. A typical patient will recover in stages. Improvement usually
originates in the legs, followed by bladder/bowel, and finally, the arms
and hands. Patients with central cord syndrome have a good prognosis
but, some factors can put the patient at risk for a lower likelihood of
recovery (e.g., advanced age and severity of injury).[3] 
The prognosis of patients with Brown-Sequard syndrome depends on the
cause and severity of the spinal cord injury. More than half of patients
recover and regain motor function.[8] Motor recovery is faster on the
contralateral side versus the ipsilateral side.[8] In 90% of cases where
bowel and bladder function were affected, patients regain these
functions.[8] Recovery typically occurs within 3 to 6 months to two
years.[8]
Of the spinal cord syndromes, anterior spinal cord syndrome cases have
the worst prognosis. Only 39% of patients recover motor function.
[2] Fifty percent of individuals diagnosed with this disorder show no
improvement of symptoms over time.[14]

Complications
Complications associated with spinal cord injuries include autonomic
dysregulation, neurogenic bladder, and chronic pain.[11]  If left
untreated, additional symptoms such as hypotension, spinal shock,
pulmonary embolism, and infections of the lung or urinary tract can
occur.[8]

Postoperative and Rehabilitation Care

In all cases of corticospinal tract lesions, strong recommendations are for
physical and occupational therapy. Therapy sessions will help patients
regain motor function and adjust to daily life post-injury. Wheelchairs,
limb supports, and splints may be utilized to assist the patient to
ambulate.[8] Patients and their families will need education on their
specific limitations, therapies, and home safety precautions.[10]

Deterrence and Patient Education

Patients and their families need counseling and education on
dysfunctions, deficits, complications, and patient limitations associated
with their condition. They need to understand how to manage ambulation
and functions of daily living and complications such as neuropathic pain,
neurogenic bowel and bladder, and sexual dysfunction.[10] The patient
will need to identify strategies on how to return to daily life after injury.
Clinicians should also educate the family in specific physical,
psychological, and social methods to assist the patient in recovery.

Enhancing Healthcare Team Outcomes

The diagnosis and management of corticospinal tract lesions are made
with an interprofessional team consisting of a neurologist, neurosurgeon,
trauma physician, emergency department physician, physical therapist,
occupational therapist, and internist.[11] It is crucial to have surgeons
involved early on in the case, as surgery can lead to early decompression
and stabilization when necessary.[8] After spinal cord stabilization,
physical and occupational therapists, nurses, and pharmacists will be
instrumental in assisting in long-term recovery that focuses on improving
daily life for the patient.[8]
Corticospinal trace lesions require an interprofessional team approach,
including physicians, specialists, specialty-trained nurses, and physical
and occupational therapists, all collaborating across disciplines to
achieve optimal patient results. [Level V]

Review Questions
 Access free multiple choice questions on this topic.
 Comment on this article.

References
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Figures

Corticospinal tract lesion locations (A) Normal spinal cord cross section.
(B) Area affected by central cord syndrome (C) Area affected by anterior
cord syndrome (D) area affected by Brown-Sequard syndrome.
Contributed by Diana Peterson, Ph.D.
Comparison of spinal cord lesions and syndromes with corresponding
sensory/motor deficits. Contributed by Rian Kabir, MD
Copyright © 2021, StatPearls Publishing LLC.

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