Spinal cord,spinal cord lesions,compressive myelopathy

1. SPINAL CORD
&
ITS COMPRESSIVE DISORDERS
SHRUTHI.S.JAYARAJ
53rd, Calicut Medical College
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2. • Basics of spinal cord
• Determining the level of lesion
• Special pattern of spinal cord diseases
• Compressive disorders of spinal cord
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3. SPINAL CORD
• Most important content of the vertebral
canal
• Extension : medulla,upper border of C1 till
lower border of L1 /upper border of L2
(termination is variable)
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4. •
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Normal spine has a cervical and lumbar
lordosis and thoracic kyphosis
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5. • Cervical enlargement : C3 to T2
• Lumbar enlargement : L1 to S3
• Lowest conical part : conus medullaris
( S3,S4,S5)
• Conus continuous as a fibrous cordfilum terminale - extend to coccyx
• Lower end of central canal expand to
form terminal ventricle- conus
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6. 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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7. • During embryological dvpt, growth of the cord lags behind
that of vertebral column
• Lower spinal nerves have to taka an increasingly downward
course to enter the corresponding intervertebral foraminabundle of nerves- cauda equina
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8. • 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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9. • MENINGES
• Dura,Arachnoid – second
sacral vertebra
• Ligamentum denticulatumto the inner aspect of dura
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12. Determining the level of lesion
SENSORY !
MOTOR !
SPHINCTER
!
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.
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13. • 2nd order neurons ascend for for one or two levels as they
cross anterior to the central canal to join the opposite STT
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14. • 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 findings
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15. • 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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16. SENSORY LEVEL
• Zone of hyperaesthesia (dorsal column) :level of lesion is
just below it
• Girdle like sensation exaggerated by cough and sneezingdorsal column
• Involvement of specific dermatomes
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17. 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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18. 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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19. 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
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21. 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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22. 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 the rule
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23. 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?
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24. Uppercervical cord lesion:
Quadriplegia
Weakness of diaphragm(above
C4)
Arnold chiari - downbeating
nystagmus & cerebellar ataxia
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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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25. 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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Lumbar cord lesions
L2-L4:weakness of Flexion
and adduction of thigh
Loss of knee jerk
Spastic paralysis
below,exaggerated ankle
jerk
Extensor plantar
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26. 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
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27. SPECIAL PATTERNS OF SPINAL CORD DISEASES
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28. 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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30. 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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31. Shoulders,lower neck,upper
trunk –cape distribution
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32. 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
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33. 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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34. COMPRESSIVE DISORDERS OF SPINAL CORD
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35. Compressive myelopathies
• Acute compressive Myelopathy / Chronic
Myelopathy
• Extramedullary / intramedullary
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36. Compressive Myelopathy
Intra medullary
Intradural
Extramedullary
Extradural
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37. •
Cord compression
Extramedullary (95 %)
Intradural
(15%)
MENINGIOMA
NEUROFIBROMA
PATCHY ARACHNOIDITIS
AV MALFORMATIONS
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Intramedullary(5%)
Extradural
(80%)
SYRINGOMYELIA
GLIOMA,EPENDYMOMA OF
CORD
NEOPLASMS
POTT’S SPINE
IVDP
EPIDURAL ABSCESS
TRAUMA
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38. Extramedullary lesions
•
•
•
•
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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 late
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39. Intramedullary lesions
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Short duration,painless onset
early bladder involvement
Motor – usually symmetrical
Jacket sensory loss
Dissociative sensory loss
Sacral sparing
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40. 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
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41. • Clear cut sensory level is usual
• Neurological symptoms may fluctuate over time
• MRI demonstrate the cord compression due to disc
prolapse.
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42. •
•
•
•
Treatment :
immobilising in a cervical collar
If highly symptomatic – surgical decompression
Complication of cervical disc surgery – irreversible
paraplegia due to cord infarction
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43. 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 sequelae
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44. • 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 osteotomies
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45. • S.aureus, Streptococcus, anaerobes, gram neg bacilli, fungi
• MRI ,sometimes LP
• Treatment :
Surgical evacuation, decompressive laminectomy , long
term antibiotics
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46. TUMORS AND COMPRESSIVE MYELOPATHY
Metastasis - epidural
Thracic is common;
 Lumbar & Sacral – Prostate and ovarian
Breast > Lung > Prostate > Kidney > Lymphoma
 old age pt :Vertebral pain with a/c onset of
neurological deficit
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47. MRI – hypointense lesion in
T1; does not cross the
adjacent disc space
Bone scan may be useful to
detect the all other
metastasis
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48. PAIN !!
Recent onset,particularly thoracic
(aching,localised,sharp,radiating quality)
Typically worsens with movement, coughing,
sneezing and
Characteristically awakens the patient at night
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49.  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 with RT)
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50.  Prognosis:
•
Ambulatory pt – good response with RT
•
Fixed motor deficit once established
<12hr good response
>12hr chance to improve
>48hr no improvement
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51. POTT`S DISEASE
Common in paediatric and adolescent group
Incidence Reduced with pasteurisation – bovine bacillus
THORACIC cord – most common
Infective process begins in the vertebral body and spreads
to adjacent bodies leading to their collapse and angulation of
spine
Conservative treatment with anti tuberculous chemotherapy
if severe- surgical decompression
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53. 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
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54. REFERENCE
• Brain’s book of neurology
• Harrison’s Principles of internal medicine, 18th
E
• Neuroanatomy,inderbir singh,8th edition
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