Can a patient with a history of a fall, who ambulates without difficulty, plays badminton, and walks up and down stairs, still have a spinal cord injury or other neurological condition, given symptoms of incomplete bladder emptying, numbness, and pain?

Spinal Cord Injury Can Present with Preserved Ambulation

Yes, this patient can absolutely still have a spinal cord injury despite normal ambulation and athletic activity—incomplete bladder emptying, numbness, and pain following a fall are red flags for spinal cord or cauda equina pathology that require emergency MRI evaluation. 1

Why Ambulation Does Not Rule Out Spinal Cord Injury

The ability to walk does not exclude significant spinal cord pathology. The critical evidence here is that:

• Bladder dysfunction is the key diagnostic feature, not motor function. Incomplete bladder emptying indicates sacral nerve root or spinal cord involvement at the S2-S4 level, which houses the parasympathetic neurons controlling detrusor contraction and sphincter coordination 1

• Up to 50% of patients with spinal cord compression remain ambulatory at presentation despite having significant cord pathology 2

• Research demonstrates that 68.7% of patients with incomplete spinal cord injury who can ambulate have abnormal urodynamics, and 37.5% require changes in urological management despite no appreciable neurological deterioration 3

• Bladder-filling sensation is preserved in 82.4% of patients with complete spinal cord lesions below T10, allowing them to maintain some bladder awareness while still having significant cord injury 4

The Critical Red Flags in This Patient

Do not attribute bladder dysfunction to age, urinary tract infection, or benign causes in a patient with recent trauma and neurological symptoms—this represents spinal cord or cauda equina pathology until proven otherwise. 1

The constellation of symptoms demands immediate action:

• Incomplete bladder emptying is a critical red flag indicating potential spinal cord or nerve root compression requiring immediate imaging and intervention 1

• Numbness suggests sensory pathway involvement at a specific spinal level 2, 5

• Pain is present in approximately 90% of patients with spinal cord compression and is often the earliest symptom 2

• Falls in adults, even ground-level falls, can cause significant spinal cord injury, particularly in patients with pre-existing spinal stenosis or degenerative changes 1

Immediate Management Algorithm

Obtain MRI of the entire spine emergently (within hours) when bladder dysfunction is present, as this indicates potential cauda equina or conus medullaris syndrome 1

The specific steps are:

1. Emergency neurosurgical consultation immediately—any bladder or bowel dysfunction following trauma requires this 1

2. MRI of the entire spine without and with contrast is the preferred imaging modality with sensitivity 0.44-0.93 and specificity 0.90-0.98 for detecting spinal cord compression 1, 5

3. Do not delay imaging—spinal cord compression requires urgent surgical decompression within hours to prevent permanent neurological deficit 5

4. Early surgical decompression within 24 hours is associated with better functional outcomes in compressive myelopathy 5

Why This Matters for Prognosis

Pretreatment ambulatory status is the most important prognostic factor for functional outcome—patients who are ambulatory at presentation have significantly better outcomes than those with paralysis 2

However, the natural history if untreated is relentless:

• Untreated spinal cord compression progresses to paralysis, complete sensory loss, and sphincter dysfunction 2

• Treatment delay directly impacts functional outcomes, particularly preservation of ambulation 2

• In ambulatory patients with incomplete spinal cord injury, 47.5% who initially could void spontaneously deteriorated such that clean intermittent catheterization was required, demonstrating that bladder dysfunction can worsen even without obvious neurological progression 3

Common Pitfall to Avoid

The most dangerous error is assuming that normal walking ability excludes serious spinal pathology. The evidence is clear that patients with incomplete spinal cord injury can maintain excellent motor function while having significant autonomic (bladder/bowel) and sensory dysfunction 6, 3. Patients have consistently reported that recovery of bowel, bladder, and sexual function is of equal or greater importance than walking 6.