What is the most likely diagnosis for a 16-year-old male patient with no pre-existing medical conditions, who presents with lower back pain, inability to move his legs, loss of pain and temperature sensation below the umbilicus, but retains sensation to fine touch, vibration, pressure, and proprioception, after a football injury causing severe hyperflexion of his back?

Anterior Cord Syndrome

This patient has anterior cord syndrome, characterized by the classic triad of motor paralysis, loss of pain and temperature sensation below the lesion, with preserved posterior column functions (fine touch, vibration, pressure, and proprioception). 1, 2

Clinical Presentation Analysis

The patient's neurological findings are pathognomonic for anterior cord syndrome:

• Motor deficits: Complete inability to move legs indicates damage to the corticospinal tracts in the anterior spinal cord 1, 3
• Dissociated sensory loss: Loss of pain and temperature sensation (spinothalamic tract damage) with preserved fine touch, vibration, pressure, and proprioception (intact posterior columns) is the hallmark finding 1, 2, 4
• Mechanism: Severe hyperflexion injury during football trauma caused vascular compromise of the anterior spinal artery, leading to ischemia of the anterior two-thirds of the spinal cord 2, 3

Anatomical Basis

The anterior spinal artery supplies the anterior two-thirds of the spinal cord, including:

• Corticospinal tracts (motor function) 1
• Spinothalamic tracts (pain and temperature sensation) 1, 3

The posterior columns (dorsal columns) are spared because they receive blood supply from the paired posterior spinal arteries, explaining the preserved fine touch, vibration, and proprioception 1, 3

Why Other Syndromes Don't Fit

• Brown-Séquard syndrome: Would cause ipsilateral motor weakness and loss of proprioception with contralateral loss of pain/temperature—not bilateral motor paralysis with preserved proprioception 1
• Central cord syndrome: Typically causes greater upper extremity weakness than lower extremity weakness, often from hyperextension injuries in older patients with cervical stenosis—this patient has complete lower extremity paralysis from hyperflexion 5
• Dorsal cord syndrome: Would affect posterior columns causing loss of proprioception and vibration—opposite of this presentation 5

Immediate Management Considerations

Urgent MRI of the thoracolumbar spine without contrast is the diagnostic imaging of choice to confirm anterior spinal artery territory infarction and rule out compressive lesions requiring surgical decompression 6, 4. The level of sensory loss at the umbilicus (T10 dermatome) suggests a thoracic cord lesion 3.

Critical Time-Sensitive Actions:

• High-dose methylprednisolone may be considered within 8 hours of injury, though evidence is controversial 7
• Maintain mean arterial pressure >85-90 mmHg to optimize spinal cord perfusion 7
• Consider anticoagulation if vascular etiology is confirmed and no contraindications exist 2

Prognosis

The prognosis for anterior cord syndrome is generally poor, with most patients experiencing persistent neurological deficits despite aggressive treatment 4, 7. Recovery of motor function is uncommon, and patients who develop spasticity may have slightly better outcomes than those who remain flaccid 1.