Spinal cord related problems

1. SPINAL CORD &
TRACTS:
APPLIED
Presenter
Dr. ATM HASIBUL HASAN
MD Neurology Student(Final part)
Department of neurology, DMCH

2. TOPIC - AT A GLANCE
• Anatomical aspect
• Imaging in spinal cord disease
• Classification of spinal cord pathology
• Clinical approach to spinal cord pathology
• Localization in spinal cord disease
• Special pattern of spinal cord diseases
• Case scenarios

3. Arrangement of tracts in the spinal cord

4. Imaging of Spine and Spinal Cord
Plain X-Ray
Computed Tomography
o Traditional
o Reconstructed
o Myelo-CT
MRI
DSA

5. X-Ray

6. X-Ray

7. CT SPINE

8. Myelo-CT

9. MRI- Spine

10. Spinal Cord Pathology
I. Vertebral cause-
1) Trauma
2) Disc prolapse
3) Tumour- primary e.g. MM; secondary e.g. breast,
thyroid, prostate, bronchus
4) Spinal TB-(Pott’s disease)
II. Meningeal cause-
1) Epidural abscess
2) Tumor - meningioma, neurofibroma, lymphoma,
leukaemia

11. Spinal Cord Pathology
III) Spinal cord itself-
Developmental:
o Syringomyelia,
o Meningomyelocoele
o Tetherd cord syndrome
Degenerative:
o MND
o FA
o SCD
o HSP
Demyelinating/ Inflamatory:
o Transverse myelitis
o Multiple Sclerosis
o Neuromyelitis Optica

12. Spinal Cord Pathology
Infective:
o Bacterial-TB, Syphilis
o Viral-EBV, Polio, HIV, VZV, HSV
o Parasitic- Schistosomiasis, Toxoplasmosis
Deficiency:
o Vitamin B12 deficiency
o Vitamin E deficiency
o Copper deficiency
o Lathyrism

13. Spinal Cord Pathology
Vascular:
oVasculitis
oInfarction
oHaemorhage
oAVM
Physical agents:
oRadiation
oLightening injury
Paraneoplastic :

14. Localization in Spinal Cord
Disease

15. The Hallmark of spinal cord disease
Presence of horizontally defined level below
which there will be impairment of sensory, motor
and autonomic function.

16. Cervical Cord
Above C5: Spastic Quadriplegia and diaphragm weakness
C5-T1: Quadriplegia (LMN signs and segmental sensory
loss in the arms & UMN signs in the legs) and respiratory
(intercostal) muscle weakness

17. At C5-C6:Loss of power & reflex of biceps
 At C7: Weakness in finger and wrist extensors and
triceps.
 At C8: Finger & wrist flexion are impaired.
 Horner’s syndrome may accompany
Cervical Cord

18. Thoracic Cord
Spastic Paraplegia with a sensory level on the trunk
 Bowel & Bladder involvement
Abdominal reflex (T8-T12) lost above T8 lesion
(segmental lesion T8-T9:above the umbilicus;
T10-T12:below the umbilicus)

19. Lumbar Cord
L2-L4:
Weakness of flexion & adduction of thigh.
 Weakness in leg extension at knee
 Absent Knee jerks (L3-L4)
L5-S1:
 Weakness of foot & ankle and flexion at the knee &
extension of the thigh
 Absent ankle jerks (S1)

20. Sacral Cord/ Conus Medullaris
Saddle anesthesia (s3-s5)
 Prominent bowel & bladder dysfunction
and impotence.
 Absent bulbocavernous (s2-s4) and anal
reflex (s4-s5).

21. Myotomes :
•Important in determining level of lesion
•Upper limbs:
C5 - Deltoid
C6 - Wrist extensors
C7 - Elbow extensors
C8 - Long finger flexors
T 1 - Small hand muscles

22. • Lower Limbs :
L2 - Hip flexors
L3,4 - Knee extensors
L4,5 – S1 - Knee flexion
L5 - Ankle dorsiflexion
S1 - Ankle plantar flexion

23. Basic Features of Spinal Cord Disease
• UMN findings below the lesion (spasticity,
hyper-reflexia). May be flaccid in acute
presentation.
• Sensory and motor involvement that localizes to
a spinal cord level.
• Bowel and Bladder dysfunction.

24. Some terminology
Myelopathy Radiculopathy
Definition Any pathological process in the spinal
cord (intrinsic and extrinsic)
Pathological process in the exiting
nerve root
Feature • Hypertonia
• Pyramidal type weakness
• Brisk reflex
• Extensor plantar response
• Loss of sensation ( with a specific
level)
• Loss of sphincter control
• Autonomic dysfunction
• Hypotonia
• Muscle wasting
• Weakness
• Fasciculation
• Loss of reflex
• Loss of sensation

25. Compressive and non compressive
myelopathy
CM (surgical) NCM (Medical)
1. Pain - usual 1. Rare
2. Onset - sub acute (2-6 wks) 2. Acute or chronic (≥ 6 wks)
3. Paralysis - Asymmetrical 3. Symmetrical
4. Bowel bladder – Occasionally late involvement 4. May be involved early
5. Sensory limit - asymmetrical 5. Symmetrical or absent
6. Temporal profile - Progressive 6. Non progressive

26. Intramedullary and extra medullary
syndrome
Trait Intramedullary Extramedullary
1. Early symptoms Motor features Sensory features
2. Pain Poorly localized Prominent radicular
3. Sacral sensation Sacral sparing Early sacral sensory loss
4. Motor weakness Upper limb may be affected early Lower limb affected early
5. Sphincter disturbance Appears early Appears late

27. Extradural
Intramedullary
Intradural
Extramedullary
DuraCord

28. Epiconus and Conus Syndrome
Epiconus Conus
1. Lesion is between L4-S2 1. Lesion between S3-Co1
2. Motor deficit usually above the knee 2. Motor deficit in lower limb less likely
3. Weakness of hip extensor and knee
flexor
3. Not such type
4. Pain may not be present 4. Pain may be present
5. Bladder is involved late 5. Early bladder involvement

29. Conus and Cauda syndrome
Trait Conus Cauda
1. Onset Sudden and bilateral Gradual and unilateral
2. Pain Less common Severe, radicular
3. Location of pain Symmetric, perineum or thigh Asymmetric, perineum, thigh,
leg or back
4. Motor loss If occurs, Symmetric, less marked Asymmetric, more marked
5. Reflex Absent ankle Variable- Absent ankle and
knee
6. Sensory deficit Saddle distribution (S3-5), symmetric Saddle but asymmetric
7. Bowel and bladder
disturbance
Early and marked Late and less marked
8. Sexual dysfunction Occurs Less prominent

30. PARAPLEGIA IN FLEXION PARAPLEGIA IN EXTENSION
Following complete transection of
SC
Following incomplete transection
of SC
Muscle tone reappears in flexor
muscles first (reticulospinal tract)
Muscle tone reappears in extensor
muscles first (Intact vestibulospinal
tract)
Flexor reflexes are first to return
(eg, Planter response)
Extensor reflex returns first (eg,
crossed extensor reflex)
Occurs late Occurs early
Higher lesion Lower lesion

31. Spinal shock Neurogenic shock
Definition Immediate temporary loss of
total power, sensation and
reflexes below the level of
injury
Sudden loss of the sympathetic
nervous system signals
BP Hypotension Hypotension
Pulse Bradycardia Bradycardia
Bulbocavernosus
reflex
Absent Variable
Motor Flaccid paralysis Variable
Time 48-72 hrs immediate after SCI
Mechanism Peripheral neurons become
temporarily unresponsive to
brain stimuli
Disruption of autonomic pathways
 loss of sympathetic tone and
vasodilation

32. SPECIAL PATTERN OF
PRESENTATION IN
SPINAL CORD
DISEASES

33. Type of Spinal Cord lesion
Complete or transverse lesion
Incomplete lesion
a) Anterior cord syndrome
b) Posterior cord syndrome
c) Hemi cord syndrome
d) Central cord syndrome
e) Foramen magnum syndrome
f) Conus medullaris syndrome
g) Cauda equina syndrome

34. Complete cord transection
syndrome
• Bilateral spastic
paraparesis/ quadriparesis
• Bilateral loss of all
modalities of sensation.
• Bowel &bladder
dysfunction.
• LMN feature at the level
of lesion
• Cause :
o Trauma
o Vasculitis
o ATM

35. Brown-sequard syndrome (Hemi cord syndrome)
Motor-
• Ipsilateral spastic weakness
• LMN sign at the level of lesion
Sensory:
• Ipsilateral loss of proprioception.
• Contralateral loss of pain and
temperature sensation

36. Anterior cord syndrome
• All cord function are
lost below the level of
lesion with retained
position & vibration
sense.
• Cause :
o Disc prolapse
o Ant. Spinal artery
occlusion

37. Posterior cord syndrome
• Common in cervical region
• Both sided joint position and
vibration sense are lost sparing
the other sensory and motor tract
• Cause:
o DM
o Neurosyphilis
o Spondylosis
o Posterior spinal artery occlusion

38. Central cord syndrome (Schneider syndrome)
• Dissociated sensory loss in
a cape distribution.
• Symptoms depend on
extension of lesion around
the central canal.
• Weakness of muscles in
arms with atrophy and
hyporeflexia.
• Later - Spastic weakness
with brisk reflexes in the
legs

39. C/F
• Neck pain –radiating to shoulder
• Occipital H/A
• Variable sensory loss
• Weakness and wasting of hand and
neck muscles
• Quadriparesis-round the clock
(LA→LL→RL→RA)
Cause- Compressive lesion
(meningioma, neurofibroma) in the
region of foramen magnum
Foramen magnum syndrome:

40. Spinal shock syndrome
• This clinical condition follows acute severe damage to
the cord.
• All cord function below the level of lesion becomes
depressed or lost.
• Usually lasts less than 24 hrs but may last for 4-6 wks
• On recovery : reflex-tone-power may regain
this fashion.
• 5-10% patients may not recover from spinal shock

41. Phases of Spinal
shock :
Phase Time Physical exam. finding Underlying physiological
events
1 0-1 day Areflexia/Hyporeflexia Loss of descending facilitation
2 1-3 day Initial reflex return Denervation super sensitivity
3 1-4 wks. Hyper reflexia (initial) Axon supported synapse growth
4 1-12 months Spasticity Soma supported synapse growth

42. Conus medullaris syndrome
• Bilateral saddle anesthesia
• Prominent bowel & bladder
dysfunction (urinary retention
and anal incontinence)
• Impotence
• Absent anal reflex.

43. Cauda equina syndrome
• Radicular low back pain
• Asymmetrical lower limb
weakness & sensory loss
• Variable areflexia
• Relative sparing of bowel &
bladder.
• Planter may be flexor or absent.
• Cause :
o Disc prolapse
o Tumour
o Trauma

44. Combined posterior & lateral column
lesion:
Causes include-
 Vitamin B12 deficiency
 Copper deficiency
 Myelopathy with AIDS
 HTLV-1 associated myelopathy
Thoracic cord is most commonly affected

45. Combined posterior&lateral column
lesion:
C/F-
• Paresthesia in the feet
• Loss of position and vibration sense in the legs
• Sensory ataxia
• Positive Romberg sign
• Bladder function disturbance
• Spasticity, hyperreflexia and bilateral Babinski sign

46. CLINICAL APPROACH TO
SPINAL PATHOLOGY

47. CLINICAL APPROACH ...
POINTS TO BE CONSIDERED:
•Onset e.g. acute, subacute, chronic
•Progression e.g. static, improving, worsening
•Bladder involvement e.g. early, late, none
•Presence of pain e.g. mechanical pain, radicular pain, none
•Presence of fever e.g. abscess, Potts
•Flaccid/ Spastic
•Other systemic features e.g. weight loss, skin/lymph nodes/joints-
malignancy, vasculitic

48. CLINICAL APPROACH . . .
ONSET:
• Acute (minutes to hours):
 Traumatic
 Inflammatory
 Vascular lesion
•Subacute (days to weeks):
 Neoplastic (compressive)
 Pott’s
•Chronic (months to years):
 Neoplastic
 Degenerative

49. CLINICAL APPROACH . . .
PROGRESSION:
Static:
 TM
Improving :
 MS
 Vascular lesion
Worsening :
 Pott’s disease
 Compressive
 Neoplastic
 Degenerative

50. CLINICAL APPROACH . . .
BLADDER INVOLVEMENT:
 Early:
 TM
Late:
 Neoplastic
 Compressive
 Potts
No involvement:
 Degenerative e.g. HSP
 Nutritional e.g. SACD, lathyrism

51. CLINICAL APPROACH . . .
PAIN:
Mechanical:
o Vertebral cause
Radicular:
o Meningeal cause
o Inflammatory cause
No pain:
o Spinal cord cause

52. CLINICAL APPROACH . . .
NATURE OF PARAPLAGIA:
Flaccid-
•Spinal shock (up to 6 wks.)
•Cauda equina lesion
•Conus medullaris lesion
Spastic-
•Lesion usually in Cervical and Dorsal cord due to any
cause (after spinal shock is recovered)

53. EXAMINATION
A) Types of deficit -
 Motor deficit only
 Sensory deficit only
 Mixed deficit
B) Types of motor deficit - UMN, LMN
C) Pattern of sensory loss -
 Posterior column loss
 Spinothalamic loss
 Dissociative loss
D) Bladder involvement
 Involved : Tumor, TM, Demyelination.
 Not involved : Degenerative, Deficiency, Toxin

54. Clinical clues
A) Motor deficit
UMN LMN
B/B+ B/B- B/B+ B/B-
 Cortical
paraplegia
 Tumor
•MND
•HSP
•Lathyrism
•Tumor
•ATM with
Spinal shock
•Trauma
•Post vaccine
•Tumor
• Polio
• SMA
• GBS
• MMNCB

55. Clinical clues
B) Sensory deficit only C) Mixed deficit
• Posterior cord syndrome ● Tumour
• Foramen magnum syndrome ● Cauda equina syndrome
• Tabes ● Conus syndrome
• Paraneoplastic
• MS

56. Spinal cord disease
Acute Subacute Chronic
UMN
Motor
LMN
Sensory Mixed
B/B + B/B -
-Cortical lesion
-Tumour
-Tumour
-Vascular
B/B + B/B -
-Tumour
-Spinal shock
-GBS
-AHC eg Polio
-SMA
Posterior
column
Spinothalamic
-Trauma
-Tumour
-Spondylosis
-Partial cord syndrome
-Trauma
-Tumour
-Vascular
-ATM
-Infective
Approach to Spinal cord disease

57. Spinal cord disease
Subacute Chronic
UMN
Motor
LMN
Sensory Mixed
B/B + B/B -
-Tumour
-Chronic
infection
-MND
-Toxic eg
Lathyrism
-Tumour
B/B + B/B -
-Tumour
-Vascular
-CIDP
-MMNCB
-SMA
Posterior
column
Spinothalamic
-Trauma
-Tumour
-Spondylosis
-Partial cord syndrome
-Infection
-Tumour
-Degenerative
-Demyelinating
Approach to Spinal cord disease

58. Case scenarios

59. A 17 yr old boy presented with tingling, numbness and paresthesia in hand and
leg. Examination revealed dissociated and suspended sensory loss.
Syringomyelia

60. A 38 yr old man presented with chronic back pain, low grade fever and
progressive weakness of both the lower limbs. Examination revealed a gibbus at
D1 level.
Potts Disease

61. A 62 old man, known case of psoriasis, presented with new onset back pain and
high grade fever. Lower cervical and upper thoracic spine was tender on palpation.
Investigation revealed neutrophilic leucocytosis with high ESR and CRP.
Spinal Epidural Abscess

62. A 25 yr old man presented with progressive weakness of both the lower limb
along with a severe sensory loss up to mid chest and bladder problem for last 2
weeks following a H/O vaccination against Hepatitis B.
Acute Transverse Myelitis (Vaccine related)

63. A 35 yr old lady presented with progressive paraparesis with impaired
sensorium extending to D4 level. Two weeks later she developed dimness of
vision in both eyes.
Neuromyelitis Optica

64. A 17 yr old boy presented with sudden weakness of all 4 limbs along with
difficulty in speech and deglutition with impaired level of consciousness
following an episode of flu like illness.
ADEM

65. A 24 yr old lady presented with sensory disturbance of both the lower limbs.
She had a H/O visual disturbance in one eye and weakness of all four limbs a
couple of years back.
Multiple Sclerosis

66. Differentiating by MRI

67. Differentiating by MRI
Short segment:
o MS
Long segment:
o TM
o NMO

68. Differentiating by MRI

69. A 34 yr old man presented with
gait ataxia, tingling and
numbness in all four limbs, brisk
reflexes but absent ankle jerk
with extensor planter response.
He gave H/O illeal resection 10
years back. PBF showed
megalocyte and there was
decreased Vit B12 level.
Subacute combined degeneration of spinal cord

70. A 42 yr old woman noticed chronic pain in cervico-thoracic region followed by
progressive weakness of all four limbs and mild bladder disturbance for last 11
months.
Extradural Meningioma

71. A 28 yr old man presented with pain in neck and shoulder and numbness in
limbs followed by progressive weakness of all four limbs (Lt arm-Lt leg-Rt
leg-Rt arm).
Foramen magnum syndrome
Neurofibroma

72. A 3 yr old boy presented with
cervical pain and weakness of
all four limbs without any
bowel or bladder problem.
Astrocytoma

73. A 65 yr old woman presented with radicular pain and distal weakness of both
upper limb. She is a known case of apical lung tumour.
Multiple Metastasis to spine and spinal cord

74. Tumours of Spinal cord

75. A 22 yr old lady presented with progressive weakness of both lower limbs
along with retention of urine for last two years. Examination revealed spastic
paraplegia with ill defined sensory deficit up to umbilicus.
Spinal AVM

76. A 42 yr old man presented with radiating low back pain, progressive difficulty
in walking along with tingling and numbness in limbs, urinary retention and
erectile dysfunction for last two years.
Spinal DAVF

77. THANK
YOU