Causes of Quadriplegia
Quadriplegia results from damage to the cervical spinal cord, with traumatic injury being the most common cause, followed by degenerative disease (spondylotic myelopathy), vascular pathologies, inflammatory conditions, and tumors. 1
Traumatic Causes
Motor vehicle accidents account for approximately half of all traumatic spinal cord injuries leading to quadriplegia, with falls, sports injuries, and assaults comprising most of the remainder. 2
- Males are affected five times more often than females, with peak incidence occurring between ages 15-34 years 2
- Traumatic spinal cord injury has an annual incidence of approximately 3 per 100,000 population in developed countries 2
- Central cord syndrome is becoming the most common form of acute traumatic spinal cord injury, particularly in older adults following low-energy trauma or falls in the context of pre-existing cervical spondylosis 1
- Falls from heights represent a significant mechanism, particularly in elderly patients with osteoporotic or pathologic fractures causing vertebral retropulsion and cord compression 1
Non-Traumatic Causes
Compressive Pathologies
Degenerative disease (spondylotic myelopathy) is the most common cause of extrinsic spinal cord compression in the acute setting, predominantly affecting the cervical spine. 1
- Contributing factors include spinal degenerative changes, disc herniations, malalignment, and congenitally short pedicles 1
- Epidural pathology including abscess or hematoma can cause acute compression 1
- Primary or metastatic tumors of the extradural and intradural extramedullary spaces can result in progressive or acute quadriplegia 1
- Postoperative complications including seromas, pseudomeningoceles, hematomas, and epidural abscesses may develop throughout the postoperative course 1
Vascular Causes
Spinal cord ischemia, though infrequent, results most commonly from atheromatous disease or complications of aortic surgery in adults. 1
- Other predisposing factors include systemic hypotension, thoracoabdominal aneurysms or dissection, sickle cell disease, and spinal arteriovenous malformations 1
- Hematomyelia from intramedullary AVM or spinal artery aneurysm rupture is a rare cause 1
- Fibrocartilaginous embolic disease can cause acute ischemic myelopathy 1
- Brainstem strokes at specific midline locations (medulla oblongata and pons) involving bilateral pyramidal pathways can present with acute quadriplegia, typically from atherothrombosis of the intradural vertebral artery 3
Inflammatory and Infectious Causes
Demyelinating diseases including multiple sclerosis, neuromyelitis optica, and acute disseminated encephalomyelitis are important inflammatory causes. 1
- Systemic inflammatory conditions including systemic lupus erythematosus, Sjögren syndrome, mixed connective tissue disorder, Behçet disease, and sarcoidosis 1
- Infectious diseases affecting the spinal cord can result in acute or progressive myelopathy 1
Neurodegenerative Causes
Amyotrophic lateral sclerosis (ALS) ultimately progresses to functional quadriplegia through degeneration of motor neurons in the brain and spinal cord, typically within 3-5 years of diagnosis. 4
Autoimmune Causes
Guillain-Barré syndrome typically presents with areflexia, though rare cases with hyperreflexia have been reported presenting as acute-onset quadriplegia. 5
Important Clinical Pitfalls
- Approximately 10% of traumatic spinal cord injury cases have combined head injury impairing consciousness, making initial neurological assessment unreliable 6
- Up to 4.3% of cervical fractures may be missed initially, with 67% of these patients suffering neurological deterioration and 29.4% developing permanent deficits from delayed diagnosis 1
- Functional quadriplegia from severe rheumatoid arthritis can occur as an initial presentation, though this is rare and underreported 7
- The presence of severe head injury increases the relative risk of cervical spine injury by 8.5 times, and a Glasgow Coma Scale score <8 increases the incidence to 7.8% 1