Anatomical approach to spinal cord disease

1. SPINAL CORD DISORDERS
ANATOMICAL APPROACH
Dr PS Deb MD, DM
Director Neurology
Guwahati Neurological Research Institute
Assam, India

2. SPINAL CORD
 Information highway between brain and body
 Extends through vertebral canal from foramen magnum to L1
 Each pair of spinal nerves receives sensory information and issues
motor signals to muscles and glands
 Spinal cord is a component of the Central Nervous System while the
spinal nerves are part of the Peripheral Nervous System

3. SPINAL CORD FUNCTIONS
 Conduction
 bundles of fibers passing information up and down spinal cord
 Locomotion
 repetitive, coordinated actions of several muscle groups
 central pattern generators are pools of neurons providing control of flexors and
extensors (walking)
 Reflexes
 involuntary, stereotyped responses to stimuli (remove hand from hot stove)
 involves brain, spinal cord and peripheral nerves

4. SPINAL CORD - ANATOMY
 Runs through the vertebral canal
 Extends from foramen magnum to second
lumbar vertebra
 Regions
 Cervical
 Thoracic
 Lumbar
 Sacral
 Coccygeal
 Gives rise to 31 pairs of spinal nerves
 All are mixed nerves
 Not uniform in diameter
 Cervical enlargement: supplies upper
limbs
 Lumbar enlargement: supplies lower limbs
 Conus medullaris- tapered inferior end
 Ends between L1 and L2
 Cauda equina - origin of spinal nerves
extending inferiorly from conus medullaris

5. SPINAL CORD GROSS ANATOMY
Spinal cord Special Segments
Cervical enlargement C5-T1
Lumber enlargement L3-S2
Conus S3-Co
Epiconus L4-S2
Cauda equina L3-Cx

6. SPINAL CORD: LONGITUDINAL EXTENT
 Spinal cord stretches from
foramen magnum till coccyx in
fetal life then due to growth of
spine it fall short
 At 3rd fetal month up to coccyx
 At birth lower border of L3
 Adult spinal cord ends at lower
border of L1 body

7. SPINAL CORD LEVEL /SPINAL LEVEL
Spine Cord
Upper cervical same level
Lower cervical + 1
Upper
thoracic
+ 2
Lower
thoracic
+3
T12 Lower lumber
L1 Sacral cord

8. COVERING OF SPINAL CORD
 Connective tissue
membranes
 Dura mater: outermost layer;
continuous with epineurium of
the spinal nerves
 Arachnoid mater: thin and
wispy
 Pia mater: bound tightly to
surface
 Forms the filum terminale
 anchors spinal cord to coccyx
 Forms the denticulate ligaments
that attach the spinal cord to the
dura
 Spaces
 Epidural: external to the dura
 Anesthestics injected here
 Fat-fill
 Subdural space: serous fluid
 Subarachnoid: between pia
and arachnoid
 Filled with CSF

9. SPINAL CORD TRANSVERSE SECTION

10. SPINAL CORD TRANSVERSE SECTION
 Anterior median fissure and
posterior median sulcus
 deep clefts partially separating
left and right halves
 Gray matter: neuron cell bodies,
dendrites, axons
 Divided into horns
 Posterior (dorsal) horn
 Anterior (ventral) horn
 Lateral horn
 White matter
 Myelinated axons
 Divided into three columns
(funiculi)
 Ventral
 Dorsal
 lateral
 Each of these divided into
sensory or motor tracts

11. SPINAL CORD TRANSVERSE SECTION
 Commissures: connections between left
and right halves
 Gray with central canal in the center
 White
 Roots
 Spinal nerves arise as rootlets then
combine to form dorsal and ventral
roots
 Dorsal and ventral roots merge laterally
and form the spinal nerve

12. SPINAL CORD GRAY MATTER
 Dorsal half – sensory roots and ganglia
 Ventral half – motor roots
 Based on the type of neurons/cell bodies located in each horn, it is
specialized further into 4 regions
 Somatic sensory (SS) - axons of somatic sensory neurons
 Visceral sensory (VS) - neurons of visceral sensory neur.
 Visceral motor (VM) - cell bodies of visceral motor neurons
 Somatic motor (SM) - cell bodies of somatic motor neurons

13. GRAY MATTER OF SPINAL CORD
 Lamina I - posteromarginal nucleus
 Lamina II - substantia gelatinosa of
Rolando
 Lamina III, IV - nucleus proprius
 Lamina V, VI
 Lamina VII - intermediate gray
intermediolateral cell column (ILM)
Clarke’s column (Nucleus dorsal
intermediomedial cell column (IMM)
 Lamina VIII
 Lamina IX - anterior horn (motor) cell
 Lamina X - gray commissure

14. SPINAL CORD SEGMENTS

16. WHITE MATTER OF SPINAL CORD
 Divided into three funiculi (columns) – posterior, lateral, and anterior
 Columns contain 3 different types of fibers (Ascend., Descend., Trans.)
 Fibers run in three directions
 Ascending fibers - compose the sensory tracts
 Descending fibers - compose the motor tracts
 Commissural (transverse) fibers - connect opposite sides of cord
 Pathways decussate (most)
 Most consist of a chain of two or three neurons
 Most exhibit somatotopy (precise spatial relationships)
 All pathways are paired
 one on each side of the spinal cord

17. WHITE MATTER TRACTS

18. CORTICOSPINAL TRACT
 Originate in the precentral gyrus
of brain (aka, primary motr area)
 I.e., cell body of the UMN located
in precentral gyrus
 UMN synapses in the anterior
horn with LMN
 Some UMN decussate in
pyramids = Lateral corticospinal
tracts
 Others decussate at other levels
of s.c. = Anterior corticospinal
tracts
 LMN (anterior horn motor
neurons)
 Exits spinal cord via anterior root
 Activates skeletal muscles
 Regulates fast and fine (skilled)
movements

19. EXTRAPYRAMIDAL TRACTS
 Includes all motor pathways not part of the pyramidal system
 Upper motor neuron (UMN) originates in nuclei deep in cerebrum (not in cerebral
cortex)
 UMN does not pass through the pyramids!
 LMN is an anterior horn motor neuron
 This system includes
 Reticulospinal tracts – originates at reticular formation of brain; maintain balance
 Rubrospinal tracts – originate in ‘red nucleus’ of midbrain; control flexor muscles
 Tectospinal tracts - originate in superior colliculi and mediate head and eye
movements towards visual targets (flash of light)
 Vestibulospinal Tract – muscle tone in relation to head and neck movement
 Regulate:
 Axial muscles that maintain balance and posture
 Muscles controlling coarse movements of the proximal portions of limbs
 Head, neck, and eye movement

20. Extrapyramidal tracts

22. ASCENDING PATHWAY
 The central processes of first-order neurons branch diffusely as they enter
the spinal cord and medulla
 Some branches take part in spinal cord reflexes
 Others synapse with second-order neurons in the cord and medullary nuclei
 The nonspecific and specific ascending pathways send impulses to the
sensory cortex
 These pathways are responsible for discriminative touch (2 pt. discrimination) and
conscious proprioception (body position sense).
 The spinocerebellar tracts send impulses to the cerebellum and do not
contribute to sensory perception

23. CRANIAL SOMESTHETIC
SENSATION

24. DIRECT SPINOTHALAMIC TRACT
 Include the lateral and
anterior spinothalamic tracts
 Lateral: transmits impulses
concerned with pain and
temp. to opposite side of
brain
 Anterior: transmits impulses
concerned with crude touch
and pressure to opposite
side of brain
 1st order neuron: sensory
neuron
 2nd order neuron:
interneurons of dorsal horn;
synapse with 3rd order
neuron in thalamus
 3rd order neuron: carry
impulse from thalamus to
postcentral gyrus

25. INDIRECT SPINOTHALAMIC TRACT

26. SPINOHTALAMIC PAIN TYPES
 Fast Pain Slow Pain
 Sharp, pricking Dull, burning
 Group III (A) fiber Group IV (C) fiber
 Short latency Slower onset
 Well localized Diffuse
 Short duration Long duration
 Less emotional Emotional, autonomic response
 Not blocked by morphine Blocked by morphine
 Neospinothalamic Tract Paleospinothalamic Tract

27. 13-27
SPINORETICULAR TRACT
 Pain signals from tissue injury
 Decussate in spinal cord and ascend with spinothalamic fibers
 End in reticular formation (medulla and pons)
 3rd and 4th order neurons continue to thalamus and cerebral cortex

28. SPINOCEREBELLAR
TRACTS
Spinocerebellar Tract
 Proprioceptive signals from limbs and
trunk travel up to the cerebellum
 Second order nerves ascend in
ipsilateral lateral column.Transmit
info. about trunk and lower limb
muscles and tendons to cerebellum
 No conscious sensation
Anterior SCbllT
(superior
cerebellar
peduncle)
anterior
spinocerebellar
tract
anterior white
commissure
posterior root
Posterior SCbllT
Inferior
cerebellar
peduncle
cuneocerebellar
tract
(upper body)
posterior
white column
posterior root

29. (A) THE DORSAL (POSTERIOR) SPINOCEREBELLAR TRACT.
(B) THE CUNEOCEREBELLAR TRACT. SEE TEXT FOR DETAILS.

30. VENTRAL SPINOCEREBELLAR TRACT

31. POST. COLUMN
Dorsal Column Tract
1. AKA Medial lemniscal pathway
2. Fibers run only in dorsal column
3. Transmit impulses from receptors in
skin and joints
4. Detect discriminative touch and
body position sense =proprioception
1st order neuron - a sensory neuron
synapses with 2nd order neuron in nucleus
gracilis and nucleus cuneatus of medulla
2nd order neuron.- an interneuron
decussate and ascend to thalamus where it
synapses with 3rd order neuron
3rd-order (thalamic neurons)
transmits impulse to somato-
sensory cortex (postcentral gyrus)

32. VASCULAR SUPPLIES OF SPINAL CORD
Posterior spinal artery Anterior spinal artery
Origin Vertebral arteries
inside the skull
Posterior inferior
cerebellar artery
Formed by the union of the 2
arteries which are arising
from the vertebral artery
inside the skull
Position Descends on the
posterior surface of
the spinal cord close
to the posterior nerve
roots
Descends on the anterior
surface of the spinal cord
within the anterior median
fissure
Supply Posterior 1/3 of the
spinal cord
Anterior 2/3 of the spinal
cord
Remark Small in the upper
thoracic region
Small in the upper and lower
thoracic segment of the
spinal cord
Risk of
ischemia
T1-T3 segments if the
segmental or radicular
arteries are occluded
T4 & L1 segments if the
segmental or radicular
arteries are occluded

33. SPINAL CORD DISORDER CLINICAL
PRESENTATION

34. FEATURES SUGGESTIVE OF SPINAL CORD DISEASE
System Features
Motor – weakness Acute Flaccid
Chronic Spastic
Sensory - Loss Spinothalamic Below the level contralateral
Post. Column Ipsilateral below the level
Autonomic - Loss Acute Retention, flaccid
Chronic Automatic, spastic
Reflex - Altered Acute – Loss of all reflex
Chronic Deep – exaggerated
Superficial – Altered – abdominal,
cremastic absent, plantar extensor
Other features Level of consciousness - maintained
Cognition - Normal
Cranial nerve - Normal

35. SPINAL CORD SYNDROMES
1. Nature of pathology
1. Compressive
1. Intramedullary
2. Extra medullary
1. Intradural
2. Extradural
2. Non compressive
2. Anatomical location of lesion
1. Transverse
2. Longitudinal
3. Progression and onset of symptoms
1. Acute
2. Chronic
4. Age of onset
1. Childhood
2. Adulthood
3. Elderly

36. SPINAL CORD: EXTRINSIC
 Radicular involvement
 Asymetric, progression in
inverted U pattern
 Ipsi Lateral Hemiplegia,
 contralateral spinothalamic
lesion
 Ipsilateral posterior column
sensory loss

37. SPINAL CORD: INTRINSIC
 Dissociated anesthesia
 Jacket Anesthesia
 Long tract sign
 Sacral sparing
 Ant. Horn cell involvement
 Symmetrical/ Asymmetrical
 Bladder involvement

38. signs intramedullary extramedullary
Radicular pain unusual common
Vertebral pain unusual common
Funicular pain common Less common
Umn Sign +, late +, early
Lmn sign +++, diffuse Unusual,
segmental
Paraesthesia progr descending ascending
sphincter early late
Trophic common unusual

39. Extramedullary Intramedullary
Motor
a)UMN signs Common Late
b)LMN signs 1or2segments at the site of
root compression
wide (Ant horn cell)
Sensory
a)Pain Root pain Funicular pain
b)Dissociated sensory loss Absent present
c)Sacral sensation Lost Preserved
d)Joint sensation Lost Late involvement
e)Lhermitte`s sign present absent
Autonamic involvement –
Bowel and Bladder
Late Early
Intradural Extradural
Mode of onset Asymmetrical , acute,rapid
malignant
Symmetrical,slow,
progressive
benign
Vertebral No Pain and gibbus Pain and Gibbus

40. COMPRESSIVE MYELOPATHIES
 Extradural
 Bone
 Neoplastic
 Secondries
 Osteosarcoma
 Infection
 Tuberculosis
 Pyogenic
 Disc
 Prolapse
 Stenosis
 Anomalies
 Meningies
 Inflammation
 Arachnoiditis
 Tubercular
 Syphilitic
 Toxic
 Abscess
 AIDS
 Tumor
 Dermoid
 Epidermoid
 Lipoma

41. COMPRESSIVE MYELOPATHY
 Intradural
 Meningioma
 Neurofibroma
 Intramedullary
 Glioma
 Ependymoma
 AVM
 Hemangioblastoma
 Developmental Traction
 Diastomatomyelia
 Tethered Cord

42. MYELO-OPTIC NEURITIS
 Demyelinating
 Multiple sclerosis
 Devic’s disease
 Nutritional
 Subacute combined degeneration
 Pellagra
 Tropical spastic paraplegia
 Toxic
 Lathyrism
 SMON
 Hereditary
 Familial spastic paraplegia with optic atrophy

43. MYELORADICULITIS
 Infection
 Tubercular (Arachnoiditis, Pott’s spine)
 Pyogenic
 Syphilitic
 Spine
 CV junction anomaly
 Narrow canal
 Toxic

44. TRANSVERSE CORD SYNDROMES

45. A. TRANSACTION OF CORD
 Etiology
 Trauma
 Demyelination
 Vascular
 Tumor
 Infection
 Radiation

46. CLINICAL FEATURES
 At the level of lesion
 Band like radicular pain or
 Segmental paraesthesia
 Lower motor signs
 Localised vertebral spine pain- destructive lesions
 Below the level of lesion
 Sensory loss (all modalities)
 Motor loss (Paraplegia, Quadriplegia)
 Arflexia -> hypereflexia
 Bladder bowel involvement

47. STAGES OF ACUTE CORD SYNDROME (RIDDOCH)
 Stage of spinal shock
 Motor autonaumic areflexia for 1-6weeks
 Sometimes last longer or permanent with minimal recovery
 Mechanism
 Release of supraspinal control
 Vascular
 Stage of hightended activity
 Below the lesion
 Tendon hyperreflexia
 Babinski sign
 Flexor spasm
 Reflex bladder bowl mass reflex
 Increased by infection and nociceptive stimuli
 Above the lesion
 Autonaumic dysreflexia- Disinhibited sympathetic adrenal and medullary discharge->
sweating flussing hypertension, bradycardia

48. B. CENTRAL CORD SYNDROME
 Etiologies
1. Trauma: Especially with
1. Cervical arthritis
2. Older patients
3. Spondylitic myelopathy
2. Syringomyelia
3. Neoplasm:
1. Metastatic, Glioma, lymphoma

49. CLINICAL FEATURES
 Sensory loss
 Pain & temperature (crossing fiber of spinothalamic tract) > Thermo
anaesthesia, analgesia in a ”vest like” or “suspended” bilateral
distribution with preservation soft touch sensation and proprioception--
- dissociation of sensory loss
 Sparing: Sacral
 Weakness: Arms > legs (Man in Barrel)
 May occur in absence of spinal fracture

50. PROGRESSION OF CENTRAL CORD
 Forward extension of disease
anterior horn cells inv- segmental neurogenic atrophy, paresis,
areflexia
 Lateral extension
I/L horner syndrome
kypho scoliosis
spastic paralysis
 Dorsal extension
I/L position sense, vibratory loss
 Extreme venterolateral extension
thermo anaesthesia, analgesia with sacral sparing
 Neuropathic arthropathy
 Pain

51. C. ANTERIOR CORD SYNDROME
 Etiology:
 Anterior spinal artery territory ischemia
 Disc: osteophytes
 Clinical Feature
 Loss: Motor function Legs > Arm (Corticospinal tract)
 Pain & temperature sensation loss with preservation: Position sense
(Dissociated anesthesia)

52. D. ANTERIOR HORN CELL SYNDROME
 Aterior horn cell, cranial motor
nuclei involved
 Autosomal recessive spinomuscular
atrophy
 Diffuse weakness and atrophy,
fasciculations of trunk and
extremities
 Muscle tone& DTR ↓
 Sensation intact

53. COMBINED ANTERIOR HORN CELL AND PYRAMIDAL TRACT
DISEASE
 Progressive diffuse LMN signs with
UMN dysfunction
 Striated muscles except pelvic floor
mucles affected
 U/L, muscles of hands and foot are
involved
 Sparing rectal and urethral sphincter
 Bulbar and pseudobulbar inv super
imposed

54. E. POSTERIOR CORD SYNDROME
 Etiology
 Posterior spinal artery damage
 Diffuse atherosclerosis: Deficient collateral perfusion
 B12 deficiency
 Lipoma
 Ligamentum flavum hypertrophy
 Bimondo’s post column degeneration
 Tabes dorsalis
 Clinical Features
 Loss: Position sense
 Relative preservation: Motor, pain & temperature
 Prognosis: Better than anterior syndrome

55. F. POSTERO LATERAL COLUMN DISEASE
 Etiology
 SACD- B12 def
 Vacuolar myelopathy- AIDS-HTLV
1, tropical spastic paraparesis
 Cervical spondylosis
 Clinical
 paraesthesia,
 diffficulty with gait , balance,
 loss of vibration and
proprioception, sensory ataxia,
rombergs +,
 bladder atony,
 reflexes lost or hypo active –
super imposed peripheral
neuropathy

56. G. ANTERIOR HORN CELL SYNDROME
 Aterior horn cell, cranial motor
nuclei involved
 Autosomal recessive
spinomuscular atrophy
 Diffuse weakness and atrophy,
fasciculations of trunk and
extremities
 Muscle tone& DTR ↓
 Sensation intact

57. H. COMBINED ANTERIOR HORN CELL AND PYRAMIDAL
TRACT DISEASE
 Progressive diffuse LMN signs
with UMN dysfunction
 Striated muscles except pelvic
floor mucles affected
 U/L, muscles of hands and foot
are involved
 Sparing rectal and urethral
sphincter
 Bulbar and pseudobulbar inv
super imposed

58. I. BROWN-SÉQUARD: HEMICORD INJURY
 Etiologies
 Tumor: Dumbbell
Facet; Luschka joint
 Trauma: Penetrating
 Radiation
 Decompression sickness
 Clinical Features
 Ipsilateral loss
 Weakness
 Position sense
 Contralateral loss
 Pain & temperature

59. LONGITUDINAL CORD SYNDROMES

60. FORAMEN MAGNUM SYNDROME & LESIONS OF UPPER
CERVICAL CORD:
 Sub occipital pain in C2 distribution, neck stiffness, electric shock like sensation
sub occipital paraesthesia, syringo myelic type of sensory dissociation, finger tip
numbness and tingling
Spastic tetraparesis, long tract sensory findings, lower cranial nerve palsy
“around the clock presentation of UMN type of weakness
foramen magnum lesion- down beat nystagmus, papilloedema ,cerebelar ataxia
causes: tumour,cx spondylosis, basilar invagination in pagets disease , syrinx,
C1C2 subluxation, chiari, MS

61. Pyramidal tract decussates at cervicomedullary jn- lesion at
this place causes HEMIPLEGIA CRUCIATA, onion skin
pattern of facial sensory loss, respiratory insufficiency,
bladder dysfunction
Compressive lesion of C1-C5 cord segment may compromise
the cranial nerve 11
C3-C5 lesion produces diaphragmatic paralysis
High cervical cord lesion- respiratory arrest

62.  Lesions of C5-C6:
LMN signs at corresponding segment level. UMN sign below the lesion, LMN paresis
of arm associated with spastic para paresis of lower extremities.
C5 level:
Diaphragmatic function compromised
BJ&BRJ –ve
TJ & FFR ++++
Inversion of brachio radialis reflex
Sensory loss entire body below neck and anterior shoulder
C6 level:
BJ,BRJ,TJ –ve & FFR ++++
Sensory loss samme as that of C5 lesion sparing the lateral part of arm

63.  Lesion at C7:
Diaphragm fn normal
Paresis of flexors and extensors of wrist and fingers
BJ,BRJ-Normal, FFR++++
Paradoxical triceps jerk
Sensory loss at /below 3rd 4th finger
 Lesion at C8 T1:
Weakness of small muscles of hands with spastic paraparesis
C8 inv- TJ &FFR-ve
T1 inv-TJ –Normal, FFR-ve
U/L or B/l horner syndrome
Sensory loss starts from fifth digit

64.  Lesion of thoracic segment level:
Root pain , paraesthesia mimicking intercostal neuralgia
Segmental LMN paralysis
Paraplegia and sensory loss below a thoracic level
Bladder, bowel sexual dysfunction
Lesion above T5- orthostatic hypotension, episodic autonomic
dysreflexia
Lesion at T10- +ve Beevors sign
Lesion at T6- abdominal reflex –ve
Lesion at T10 – upper, middle part +ve
Lesion at T12- abdominal reflex intact

65.  Lesion at L1:
All muscles of lower extremities – weak
Lower abd musc- Internal oblique, tr abd weak
Sensory loss – both lower limbs up to groin, to a level above buttocks
Chronic lesion- patellar++++, ankle++++
 Lesion at L2:
Spastic paraparesis
Cremasteric reflex↓↓, patellar reflex ↓↓
Ankle jerk ++++
Sensation in upper anterior aspect preserved

66.  Lesion at L3:
Some preservation of hip flexion, adduction
KJ ↓↓, ankle++++
Sensation upper anterior aspect of thigh normal
 Lesion at L4:
Better hip flexion, adduction
Able to stand stabilising knee
KJ↓↓ , ankle++++
Sensation normal in anterior aspect of thigh, superomedial aspect of knee
 Lesion at L5:
Normal hip flexion, adduction
KJ- normal, ankle++++ pt extends knee against resistance
Sensation normal in antr aspect of thigh, medial aspect of legs ankle and sole

67.  Lesion at S1:
Weakness of triceps surae, flexors of foot, and small muscles of foot
Ankle reflex↓↓, KJ-normal
Sensory loss- sole, heel, outer aspect of foot and ankle, medial aspect of calf, posterior
thigh, outer aspect of saddle area also anaesthetic
 S2 lesion:
Triceps surae spared, flexors of toes, small muscles of foot weakness
Ankle jerk ↓↓
Sensory loss- upper part of dorsal aspect of calf, dorsolateral aspect of thigh and
saddle area

68. ROOT SYNDROMES
Root Sensation Index Muscle Reflex Comments
C3/4
Pain or hypalgesia in
shoulders
Paresis of diaphragm,
occasionally rhomboids
None
C3 anterior diaphragm,
C4 posterior diaphragm
C5
Pain or hypalgesia laterally
over upper arm and shoulders
Paresis of deltoid,
supraspin-atus, infra-
spinatus, rhomboids
Diminished
biceps reflex
Common causes include
brachial neuritis, upper
plexus injury, cervical
spondylosis
C6
Pain or hypalgesia of radial
forearm, thumb, and index
finger
Paresis of biceps,
brachialis, brachiorad-ialis,
Extensor carpi radialis
Diminished
biceps,
brachiorad ialis
reflex
Common causes include
spondylosis, acute disc
lesion (20%)
C7
Pain or hypalgesia over
triceps, mid- forearm and
middle finger
Paresis of triceps,
latissimus dorsi, pectoralis
major, ext. carpi ulnaris ,
flex. carpi radialis
Diminished or
absent triceps
reflex
Common causes
includes acute disc
lesions (70%),
spondylosis, DDX
includes CTS (triceps
reflex present)
C8
Pain or hypalgesia over ulnar
forearm, 4th/5th digits
Paresis of flex. dig. sup. &
profundus, flex. poll.
longus, flex. carpi ulnaris
Diminished
finger jerk
(Hoffmans or
Tromner)
Caused rarely by
spondylosis or acute
disc lesion; DDX
includes ulnar nerve
palsy

69. ROOT SYNDROMES
Root Sensation Index Muscle Reflex Comments
T1
Pain or hypalgesia from axilla to
olecranon
Paresis of all small
hand muscles and
hypothenar wasting
None
Common causes
include outlet
syndrome, pancoast
tumor, metastatic Ca of
deep cervical nodes
L3
Pain or hypalgesia across upper
anterior thigh
Paresis of quadriceps
femoris
Patellar reflex
decreased or
absent
DDX includes femoral
nerve palsy
L4
Pain or hypalgesia from lateral
thigh, over patella to medial calf and
inner foot
Paresis of quadriceps
femoris, and tibialis
anterior
Patellar reflex
diminished
5% lumbar discs, DDX
includes femoral nerve
palsy
L5
Pain or hypalgesia from postero-
lateral thigh to lateral calf to dorsum
of foot
Paresis of EHL, occ
EDB
Posterior tibial
reflex decreased;
useful only if
elicitable on other
side
40% lumbar discs; DDX
includes peroneal
nerve palsy
S1
Pain or hypalgesia from posterior
thigh down to lateral aspect and
sole of foot
Paresis of triceps
surae, hamstrings,
gluteus maximus
Achilles tendon
reflex decreased
45% lumbar discs

70. I. CONUS MEDULLARIS: INFERIOR CORD
Etiology
1. Tumor
2. Compression
3. Ischemia
Clinical features
1. Onset: Rapid
2. Symmetric defects
3. Pain: Inconstant; Perineum & thighs
4. Weakness: Sacral
5. Sensory
6. Saddle (sacral distribution)May be dissociated
7. Tendon reflex loss: Ankle > Knee
8. Bladder involvement; Impotence: Consistent; Early

71. J. CAUDA EQUINA
Etiology
1. Compression: Tumor
2. Arachnoiditis
Clinical features
1. Onset: Progressive; Slow; Unilateral
2. Asymmetric
3. Pain: Severe; Radicular distribution
4. Sensory loss
1. All modalities
2. Lumbar > sacral
5. Weakness: Lumbar > sacral
6. Fasciculations: Common
7. Tendon reflex loss: Knee > Ankle
8. Bladder involvement: Occasional; Late
9. Spinal injury: Below L2
 Rule out: Lumbosacral plexus lesion

72. CONUS /CAUDA LESIONS
Conus lesion Cauda lesion
Spont pain -ve, B/L +ve, severe,
Radicular, U/L
sensory Saddle, B/L saddle., U/L
deficit dissociation All forms affected
Motor loss Symmetric, Asymmetric , atro
fasciculations Phy, no fasciculn
DTR Ankle -ve KJ, ankle -ve
Bowel,bld early late
trophic +ve -ve
Sex fn impaired Less impaired
onset Sudden. b/l Gradual, u/l

73. ANTERIOR SPINAL ARTERY SYNDROME:
 Territory – anterior funiculi, anterior horn, base of the dorsal horn, peri ependymal
area, antero medial aspect of lateral funiculi
 Lower thoracic sement and conus- vulnerable
 Abrupt onset of radicular pain, girdle pain
 Flaccid quadriplegia, paraplegia
 Bowel bladder dysfunction
 Thermo anaesthesia analgesia
 Position vibration light touch preserved
 Painful burning dysasthesia
 Watershed boundary zoneT1-T4, L1, central white matter of anterior funiculi

74. POSTERIOR SPINAL ARTERY SYNDROME:
 Uncommon
 Loss of position , proprioception, vibration
 Loss of segmental reflexes
 Pain , temperature – preserved
 Motor function- preserved
 Rarely – U/L posterior horn, lateral spinal cord inv
 Lacunar infarct:
 Isolated focal motor/sensory deficits in extremities
 Hypoxic myelopathy:
 Slowly progressive paraparesis/quadriparesis
 Hemoynaemic TIA:
 spinal cord claudication

75. VENOUS SPINAL CORD INFARCTION:
 Impaired venous drainage, insitu thrombosis
 Retrograde emboli
 Chronic venous hypertension- irreversible spinal injury
 Slowly progressive myelopathy, varying degrees of pain and sensory
disturbances in the extremities, bladder bowel disturbances

76. THANKS