compressive myelopathy approach

1. SPINAL CORD
&
COMPRESSIVE DISORDERS
Dr ANOOP.K.R
Asst prof.dept of medicine
MMCH,calicut
A
3/17/2016 6:31 PM 1

2. • Basics of spinal cord
• Determining the level of
lesion
• Special pattern of spinal
cord diseases
• Compressive disorders of3/17/2016 6:31 PM 2

3. oncept of spinal segments
• Length of spinal cord giving origin to
rootlets of one spinal nerve
• 31 spinal segments
• C - 8
• T - 12
• L - 5
• S - 5
• C - 1
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4. • Important for localising lesions causing spinal cord compression
• For eg, sensory loss below umbilicus – T10 – involvement of
cord adjacent to 7th or 8th thoracic vertebral body
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5. Determining the level of lesion
1. The presence of a horizontal level below
which sensory ,motor and autonomic
function is impaired is a hallmark of
spinal cord disease.
2. Sensory loss below a particular level is
due to damage to spinothalamic tract on
the opposite side one or two segments
higher in case of a unilateral lesion.
SENSORY!
MOTOR!
SPHINCTER!
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6. • 2nd order neurons ascend for for one or
two levels as they cross anterior to the
central canal to join the opposite STT3/17/2016 6:31 PM 6

7. • Sensory symptoms include numbness,
tingling ,pins and needles, dermal
hypersensitivity, burning sensation, altered
temperature sensation and tight band like
sensation.
• A complete cord syndrome- loss of all
sensory modalities below the level of
lesion.
• Partial syndromes produce variable
findings3/17/2016 6:31 PM 7

8. • Posterior column – loss of joint
sense,vibration,tactile discrimination,with
positive romberg’s and ataxic gait (sensory
ataxia)
• STT – Contralateral loss of pain &
temperature sensation
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9. SENSORY LEVEL
• Zone of hyperaesthesia (dorsal column)
:level of lesion is just below it
• Girdle like sensation exaggerated by
cough and sneezing- dorsal column
• Involvement of specific dermatomes
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10. 3. At the level of lesion –
LMN signs – focal muscle wasting,
fasciculations, hypo- or areflexia due to
involvement of AHCs
Radicular pain or dermatomal sensory
loss d/t involvement of sensory roots
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11. 4. Interruption of motor tracts (pyramidal
/extrapyramidal)
UMN signs below the level of lesion
if corticospinal tract – pyramidal pattern of
weakness – greater in the antigravity muscles –
paraplegia in extension
if extrapyramidal tracts - progravity muscles are
affected more – paraplegia in flexion –
may be associated with ‘mass reflex’
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12. Mass reflex
• Spontaneous urination, defaecation,
sweating on scratching skin on the medial
aspect of thigh
• a/w reflex ejaculation and erection on
squeezing glans penis
3/17/2016 6:31 PM 12

13. 5.The lesions that transect the motor tracts
cause paraplegia or quadriplegia with
heightened DTRs ,babinski sign and
eventual spasticity ( Upper motor neuron
syndrome)
6. If Acute compressive lesion
(traumatic/vascular/inflammatory) : stage
of neuronal shock prior to the stage of
spasticity
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14. 7. Transverse damage to the cord produces
autonomic disturbances -absent sweating
below the implicated cord level and bowel,
bladder, sexual dysfunction
8. Most common sphincter disturbances
resulting from spinal cord diseases are
urgency,frequency, urge incontinence.
retention
a /c transverse lesions –retention is
3/17/2016 6:31 PM 14

15. Localising the uppermost level of a
spinal cord lesion
‘segmental signs’
• Band of altered sensation
(hyperalgesia/hyperpathia) at the upper end of
sensory disturbance
• Fasciculations or muscle atrophy in muscles
supplied by that sement
• Absent DTR at this level
How to differenciate from focal root or peripheral
nerve disorder?3/17/2016 6:31 PM 15

16. Uppercervical cord
lesion:
Quadriplegia
Weakness of
diaphragm(above C4)
Arnold chiari -
downbeating nystagmus
& cerebellar ataxia
Lower cervical cord lesions
Atrophy and weakness of
corresponding muscles
Spastic paralysis of trunk
and lower limb
Absent biceps,radial jerk
Horner’s syndrome
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17. Lumbar cord lesions
L2-L4:weakness of
Flexion and
adduction of thigh
Loss of knee jerk
Spastic paralysis
below,exaggerated
ankle jerk
Extensor plantar
Thoracic cord lesions
Sensory level on the
trunk,
Site of midline back
pain
Beevor’s sign positive –
lesion at T9,T10
Spastic paralysis of
lowerlimbs
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18. Cauda equina and conus medullaris
lesions
CONUS MEDULLARIS CAUDA EQUINA
B/L saddle anaesthesia asymmetric leg weakness and
sensory loss
Prominent bowel,bladder
symptoms,impotence
Relative sparing of bowel-bladder
function
Bulbocavernous ( S2-s4) and anal
reflexes (s4-s5) are absent
Variable areflexia in lower extremities
Muscle strength largely preserved Low back and radicular pain
3/17/2016 6:31 PM 18

19. BROWN SEQUARD
SYNDROME
• HEMICORD SYNDROME
• I/L corticospinal,dorsal
column,spinothalamic
tract
• I/L – weakness,loss of
joint and vibration
sense
• C/L – loss of pain,temp
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20. 3/17/2016 6:31 PM 20

21. Central cord syndrome
• Selective damage to grey matter and
crossing spinothalamic tracts
• Syringomyelia,intrinsic tumors of spinal
cord,trauma
• Dissociated anaesthesia
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22. Shoulders,lower neck,upper
trunk –cape distribution
3/17/2016 6:31 PM 22

23. Anterior spinal artery syndrome
• Infarction d/tanterior spinal
artery occlusion
• B/L tissue destruction which
spares posterior column
• All spinal cord functions –
motor,sensory and autonomic
– are lost below the lesion
• Striking exception of retained
vibration and position sense
3/17/2016 6:31 PM 23

24. FORAMEN MAGNUM SYNDROME
• Lesions in this area interrupt
decussating pyramidal fibres
destined for the legs,which
cross caudal to those of the
arms resulting in weakness of
the legs :CRURAL PARESIS
• Around the clock pattern of
weakness
• Suboccipital pain
spreading to neck and
shoulders
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25. Compressive myelopathies
• Acute compressive Myelopathy / Chronic
Myelopathy
• Extramedullary / intramedullary
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26. Compressive Myelopathy
Intra medullary
Intradural
Extradural
Extramedullary
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27. • Cord compression
Extramedullary (95 %) Intramedullary(5%)
Intradural Extradural
(15%) (80%)
MENINGIOMA
NEUROFIBROMA
PATCHY ARACHNOIDITIS
AV MALFORMATIONS
NEOPLASMS
POTT’S SPINE
IVDP
EPIDURAL ABSCESS
TRAUMA
SYRINGOMYELIA
GLIOMA,EPENDYMOMA OF
CORD
3/17/2016 6:31 PM 27

28. Extramedullary lesions
• Long duration of history
• Root pain (+)
• Vertebral body tenderness (+)
• Motor involvement usually asymmetrical
• Sensory level, all sensations diminished
below this level
• Early loss of sensation in the saddle area (
S3,S4,S5)
• Autonomic involvement late3/17/2016 6:31 PM 28

29. Intramedullary lesions
• Short duration,painless onset
• early bladder involvement
• Motor – usually symmetrical
• Jacket sensory loss
• Dissociative sensory loss
• Sacral sparing
3/17/2016 6:31 PM 29

30. SUMMARY
• A 42 yr female old operated case of right solid ovarian tumor,
presented with low back pain with root pain with numbness &
tingling sensation over abdomen & both lower limbs with
gradual onset progressive asymmetrical paraparesis with
predominant right lowerlimb weakness without upper limb &
bladder bowel involvement.
• On examination,
Presence of dermal neurofibroma with asymmetrical
Paraparesis with b/l extensor plantar with absent abdominal
reflex & impaired primary modalities of sensation at & below
T-6 spinal segment without bladder involvement and without
any spinal tenderness or deformity

31.  Functions lost:
 Paraparesis.
 All modalities of sensation impaired from T-6 spinal
segment level downward B/L.
 Structures involved
 B/l corticospinal tract at T-6 segment.
 B/l spinothalamic tract (anterior and lateral) &
posterior columns at T6 segment

32. PROVISIONAL DIAGNOSIS
• Extramedullary Intradural Compressive
thoracic myelopathy at T-6 spinal segment---
• Most probably d/t neurofibromatosis.

33. EXTRAMEDULLARY INTRADURAL COMPRESSIVE
THORACIC MYELOPATHY
POINTS FOR
 gradual onset
 Asymmetrical paraparesis
 No bladder involvement.
 H/O root pain
 No spinal tenderness or
deformity.
POINTS AGAINST

34. DIFFERENTIAL DIAGNOSIS
• Metastases to spine
• T.B. Spine

35. METASTASIS TO SPINE
POINTS AGAINST
No Spinal tenderness or
deformity
POINTS FOR
1.h/o solid ovarian tumor
2.paraparesis

36. T.B. SPINE
POINTS FOR
 paraparesis
 Upper level of sensory
impairement
POINTS AGAINST
 No spinal tenderness.
 No past history of
pulmonary tuberculosis.

37. INVESTIGATIONS
1) Hb- 12.0 gm%
TLC- 8,400/mm3
DLC- N77L23E0B0 M0
ESR- 10mm/1st hr
2) FBS-115 mg%
2hr PPBS--142
2) Blood urea- 29 mg%
Sr Creat- 0.5 mg%
• Sr Na- 136 mEq/L
Sr K- 5.1 mEq/L
5) Urine R/M- Alb trace
pus cell-12-15
6) HIV,HBV,HCV --Neg
 X-Ray thoracic spine (AP & Lat
views) centering T3 vertebra---
Normal
X-Ray chest (PA view)—WNL
 USG ABDOMEN & PELVIS—
BULKY UTERUS
 B/L OVARIES NOT VISUALISED
 SPLEEN NOT VISUALISED
 .MRI Lumbosacral spine—
 L4—L5 Disc desication
&diffuse posterior bulge
indenting thecal sac
 MRI THORACIC SPINE---

38. FINAL DIAGNOSIS
• Extramedullary Intradural compressive
thoracic myelopathy at T-6 spinal segment---
most probably d/t Neurofibromatosis type
1.

39. • A 40 yrs hindu female presented with sudden onset
weakness of both the lower limbs with band like
sensation in the upper trunk and diminished
sensation below umbilicus with early bladder
involvement.
On examination pt had decreased tone and loss of
power in both lower limbs with absent DTR in both
lower limbs, B/L plantar extensor, absent abdominal
reflex with loss of all modalities of sensation below T8
spinal segment.
• Loss of spinal prominence and presence of
tenderness at T6 vertebral level
SUMMARY

40. • Functions lost:
 Paraplegia.
 Absent vibration and joint position sensation
below T8 spinal segment level.
 Absent pain and temperature sensation below T8
spinal segment.
Retention of urine
 Structures involved:
 Bilateral corticospinal tract .
 Bilateral dorsal column at T8 spinal segment.
 Bilateral Spinothalamic tract at T8 spinal
segment.
 Autonomic nervous system.

41. PROVISIONAL DIAGNOSIS
• Extradural compressive thoracic
myelopathy at T8 spinal level probably
due to prolapse intervertibral disc in
neuronal shock.

42. COMPRESSIVE MYELOPATHY
• Points in favour:
i. Sensory level.
ii. Band like sensation .
iii. Spinal tenderness.
iv. Early bladder involvement.
v. Presence of spinal deformity and tenderness.
 Points against:
 Sudden onset.
 No root pain.
 Symmetric involvement.

43. EXTRADURAL LESION
• Points in favour:
i. Spinal tenderness and deformity.
ii. Symmetrical weakness present.
• Points against:
i. No root pain.

44. Differential diagnosis:
• Prolapsed inter vertebral disc.
• Potts paraplegia.
• Acute transverse myelitis
• Guillain-barre syndrome
• Anterior spinal artery thrombosis.

45. Prolapsed inter vertebral disc
Points in favour:
i. Sudden onset of weakness.
ii. Sensory level.
iii. Girdle like sensation .
iv. Early bladder involvement.
v. Presence of spinal deformity and tenderness.
Points against:
1. No h/o trauma.
2. Uncommon site.

46. POTT’S PARAPLEGIA
 Points in favour:
i. Features of extradural compressive myelopathy.
ii. Most common cause of compressive myelopathy in developing
countries.
iii. Involvement of thoracic spine.
iv. Low socioeconomic status.
 Points against:
• Sudden onset
• No history of fever or weight loss
• No past history of tuberculosis.
• No family history of tuberculosis.

47. • Compressive:
1. Injury to the spinal cord.(# dislocation or
collapse of vertebra)
2. Prolapsed intervertebral disc.
3. Spinal epidural abscess.
4. Spinal hematoma
• Non-compressive:
1. Acute transverse myelitis
2. Thrombosis of anterior spinal artery.
3. Hematomyelia
4. Post vaccinial
5. Radiation myelopathy.

48. POTT’S PARAPLEGIA- GRADES
• Grade I (negligible paraplegia)- The patient is
unaware of the neurological deficit but
examination reveals clonus and extensor
plantar response.
• Grade II (mild paraplegia)- The patient is
aware of weakness but manages to walk with
or without support.

49. Contd.
• Grade III (moderate paraplegia)- The patient is
bedridden and can not walk due to severe
weakness. Examination reveals paraplegia in
extension and sensory deficit if present is less
than 50%.
• Grade IV (severe paraplegia)- Features of
grade III with flexor spasm / paralysis in
flexion / flaccid paralysis and sensory deficit of
more than 50%.

50. TREATMENT OF POTTS PARAPLEGIA:
• waiting for 4 weeks for the paraplegia to
recover with rest and ATT. If there is no
improvement in neurological deficit then
surgical decompression should be done.
• Duration of ATT- Most authorities favour 18 -
24 months. Short course chemotherapy for 9
months is equally effective.

51. OPERATIVE INDICATIONS FOR VERTEBRAL
TUBERCULOSIS
• Decompression for neurological complications
which failed to respond to conservative
therapy.
• Debridement in failure of response after 3-6
months non operative treatment.
• Fusion for mechanical instability after healing.
• Prevention of severe kyphosis.

52. SUMMARY
• A 60 yr old Hindu male, presented with H/O
intermittent root pain(nape of neck and arm)
and weakness of left lower limb since last 3
1/2 months and weakness of left upper limb
since 3 months. Followed by weakness of both
right upper and lower limb for last 2 months
without bladder and bowel involvement .

53. On examination found to have quadriparesis
,weakness of handgrip muscle & exaggerated
knee and ankle jerk and absent triceps jerk,
with positive finger flexion, Wartenberg sign
and hoffman sign with extensor plantar
response bilaterally with absent superficial
reflex and impaired pain,temperature, touch,
vibration below C-7 dermatome level &
absent joint position sensation in lower limb
and upper limb.

54. Functions lost:
 Quadriparesis
 impairement of pain,temparature, vibration sensation below
C7 downward.
 Loss of joint position in all four limbs.
Structures involved:
 Bilateral corticospinal tract below C7.
 Bilateral posterior columns & bilateral lateral spinothalamic
tract below C7.

55. PROVISIONAL DIAGNOSIS
Extramedulary Extradural Compressive cervical
myelopathy at C7spinal segment level probably due to
cervical spondylosis

56. COMPRESSIVE MYELOPATHY
Points in favour:
 Gradual onset.
 Root pain
 Asymmetrical progression
 Upper level of sensory loss
Points against:
 No bony deformity.
 No bony tenderness.
 No Girdle like sensation.
 No bowel and bladder
involvement. .

57. EXTRAMEDULLARY LESION
Points in favor:
 Root pain.
 No bowel and bladder
involvement
 No dissociated sensory loss.
UMN involvement
Points against
No bony deformity
No vertebral tenderness

58. EXTRADURAL LESION
Points in favor
 More common.
 Root pain
Points against
 No bony deformity.
 No bony tenderness.
 Asymmetrical onset

59. DIFFERENTIAL DIAGNOSIS
• Cervical spondylosis.
• Metastasis to cervical spine
• POTT’S spine.
• Spinal Tumor(Extramedullary intradural

60. Metastatic spinal cord compression
POINTS FOR
1. Age of the patient
2. No evidence of primary lesion
3. Features of extramedullary extradural
compression
POINTS AGAINST
• No bony deformity.
• No weight loss.
• No Lymphadenopathy.
• Involvement of cervical vertebra.

61. Cervical spondylosis
POINTS IN FAVOUR
•Age
•Root pain
•Insidious onset
Asymmetrical.
No bladder and
bowel involvement
POINTS AGAINST
No zone of hypereasthesia.
No bony deformity
No restricted neck movement.

62. POTT’S cervical spine
POINTS IN FAVOUR
 Features of
extramedullary
extradural
compression.
 Endemic area.
 Low socioeconomic
stasus.
POINTS AGAINST
 No History
suggestive of
previous TB
 No gibbus.
 No h/o fever and
weight loss.
 Involvement of
cervical vertebra.

63. Spinal Tumor(Extramedullary intradural)
Features of
extramedullary extradural
compression.
Gradual onset.
asymmetric
•Involvement of cervical vertebrae
•Root pain
•No bladder bowel and bladder
involvement
POINTS IN FAVOUR POINTS AGAINST

64. INVESTIGATIONS
 Hb- 9 gm%
 DC- N87L13E0
 TLC- 11,400/mm3
 ESR- 50 mm/1st hr
 RBS- 161 mg%
 Blood urea- 32 mg%
 Sr Creat- 1.3 mg%
 Sr Na- 135 mEq/L
 Sr K- 4.7 mEq/L
 Urine R/M - Normal
 X-Ray chest (PA view)- WNL
 HIV, HBV, HCV -negative.
 X ray cervical spine
degenerative changes and
osteophytes
 MRI of CERVICAL SPINE
 Atlanto odontoid subluxation with
increased antlanto odontoid interval.
 Multilevel degenerative disc disease and
spondylosis change seen from C2-C3 TO C6-
C7 level with degenerative kyphosis
 C5-C6 posterior disc osteophytes and
ligamentum flavum buckling causing spinal
stenosis with compression of cervical spinal
cord and producing ill defined focal
increased T2 signal suggestive of
myelomelacia
 C3-C4 and C4-C5 level decreased disc height
anterior osteophytes and posterior central
disc osteophytes indenting thecal sac.

65. Acute transverse myelitis:
• Points in favour:
i. Sudden onset of symmetrical weakness.
ii. Sensory level.
iii. Early bladder involvement.
iv. Involvement of mid thoracic region.
v. Absence of root pain.
• Points in against:
i. No h/o of preceding infection.
ii. Presence of spinal deformity and tenderness.

66. Guillain-barre syndrome:
• Points in favour:
1. Paraplegia
2. Areflexia
Points against:
1. Early bladder involvement.
2. Sensory involvement.
3. Presence of bony deformity and spinal
tenderness.

67. Anterior spinal artery thrombosis:
• Points favour:
 Sudden onset
 Paraplegia
 Involvement of thoracic region.
• Points against:
 Presence of bony deformity and spinal
tenderness.
 Absence of dissociative sensory loss.

68. EXTRADURAL
EXTRAMEDULLARY CAUSES
• 1. DICS PROLAPSE :
 Cervical disc prolapse :most common
if centrally located, can cause acute or
subacute cord compression
 Thoracic disc protrusions : sub a/c or chronic
cord compression.Can cause paraparesis /
brown sequard syndrome due to
asymmetrical compression
3/17/2016 6:31 PM 68

69. • Clear cut sensory level is usual
• Neurological symptoms may fluctuate over
time
• MRI demonstrate the cord compression
due to disc prolapse.
3/17/2016 6:31 PM 69

70. • Treatment :
• immobilising in a cervical collar
• If highly symptomatic – surgical
decompression
• Complication of cervical disc surgery –
irreversible paraplegia due to cord
infarction
3/17/2016 6:31 PM 70

71. 2. Spinal epidural abscess
clinical triad : Midline dorsal pain (Over
spine / Radicular)
Fever (WBC,ESR,CRP
elevation)
Progressive limb weakness
Prompt recognition to prevent permanent
sequelae3/17/2016 6:31 PM 71

72. • Abscess expand – venous congestion and
thrombosis – further cord damage
• Rapid progression once the features of
myelopathy develops
• a/w impaired immune status, IV drug
abuse,skin and tissue infections
(furunculosis,pharyngeal/dental abscess/bacterial
endocarditis,pott’s spine,)
local causes :epidural anaesthesia, LP ,decubitus
ulcer ,vertebral osteotomies3/17/2016 6:31 PM 72

73. • S.aureus, Streptococcus, anaerobes,
gram neg bacilli, fungi
• MRI ,sometimes LP
• Treatment :
Surgical evacuation, decompressive
laminectomy , long term antibiotics
3/17/2016 6:31 PM 73

74. TUMORS AND COMPRESSIVE MYELOPATHY
Metastasis - epidural
Thracic is common;
 Lumbar & Sacral – Prostate and ovari
Breast > Lung > Prostate > Kidney > L
 old age pt :Vertebral pain with a/c ons
neurological deficit
3/17/2016 6:31 PM 74

75. MRI – hypointense
lesion in T1; does not
cross the adjacent
disc space
Bone scan may be
useful to detect the
all other metastasis
3/17/2016 6:31 PM 75

76.  Management:
-Glucocorticoid – upto 40mg/d
Dexamethasone
-RT – 3000cGy in 15 daily fractions
Newer : IMRT (INTENSITY
MODUALTED RT)
-Surgery- laminectomy or vertebral
resection
(IF neuro signs worsen even with3/17/2016 6:31 PM 76

77.  Prognosis:
• Ambulatory pt – good response with RT
• Fixed motor deficit once established
<12hr good response
>12hr chance to improve
>48hr no improvement
3/17/2016 6:31 PM 77

78. NEUROFIBROMA:
• arises near posterior root
• May or may not be a/w generalised NF
• Can occur at any level of spinal cord
• Equally in both sexes
MENINGIOMA:
• Benign -thoracic cord level
more common in females
3/17/2016 6:31 PM 78

79. Diagnosis
• Thorough physical examination
– Palpation
– Gentle percussion over bony areas
– Neurologic exam
• Laboratory data – Increased alkaline
phosphatase may indicate bony involvement

80. Diagnosis
• Radiographs- may reveal erosion of the
pedicle,
– Lytic lesions of the vertebral body
– Collapse of the vertebral body
• Bone scan- 20% of scans reveal lesions missed
on plain films
• CT
– Used to determine extent of tumor

81. Diagnosis
• MRI ( Tool of choice)
– Able to determine prevertebral, vertebral,
extradural, intradural, extramedullary and
intramedullary lesions
– Provides better anatomic visualization with
sagittal and axial images of the spinal cord
• Fine needle aspiration
– May provide tissue confirmation

82. Treatment
• Criteria:
–Primary tumor type
–Level of myelopathy
–Degree of spinal block
–Potential for neurologic reversibility

83. Treatment
• Surgery
– Radical resection if an a candidate
– Complete block
– Single lesion where complete removal is possible
– Diagnosis is uncertain
– Mild deficits
– New data supports surgery over treatment with
RT if patient is a good surgical candidate

84. Treatment
• Radiation therapy
– If not a surgical candidate
– Incomplete block
– Severe deficits
– Relapse in area of prior radiation if short survival
is expected

85. Treatment
Radiation- often initiated as an emergency if not
a surgical candidate
– Therapy
• Treatment field extends 1-2 vertebral bodies
above and below level of compression
• 3000-4000 cGy over 2-4 weeks
• 2/3 of patients remain stable or improve
• 65-75% achieve pain relief

86. Treatment
• Steroids
– Dexamethasone
• Bolus IV 10 mg
• Oral 4-6 mg q 6 hours for 2 days then a slow taper
• 25% of patients with cord compression require
maintenance to maintain neurologic function
• Steroid related side effects may occur
– Hyperglycemia
– GI bleeding
– Psychosis

87. Treatment
• Chemotherapy
– May be given in highly sensitive tumors
– Always given with other modalities

88. Outcome
• Pretreatment ambulatory ability is the
main determinant of post treatment
ambulatory ability
• 90% of patients ambulatory before
therapy are after
• Only 10% of paraplegics become
ambulatory after therapy

89. Prognosis
• Median survival is 6 months if patient
presents as a paraplegic
• 50% of patients who walk in with a cord
compression are alive at 1 year
• If patient was ambulatory prior to RT survival
is 8-10 months

90. Recurrent Disease
• Options
–If RT given may be a surgical candidate if
survival of > 12 months predicted
–Repeat RT
• Risks of repeat RT
–Radiation myelopathy
–Collateral damage

91. 3/17/2016 6:31 PM 91