Spinal cord& its lesions,compressive myelopathy

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Spinal cord,spinal cord lesions,compressive myelopathy

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Spinal cord& its lesions,compressive myelopathy

  1. 1. SPINAL CORD & ITS COMPRESSIVE DISORDERS SHRUTHI.S.JAYARAJ 53rd, Calicut Medical College 12/10/2013 8:40 AM 1
  2. 2. • Basics of spinal cord • Determining the level of lesion • Special pattern of spinal cord diseases • Compressive disorders of spinal cord 12/10/2013 8:40 AM 2
  3. 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) 12/10/2013 8:40 AM 3
  4. 4. • 12/10/2013 8:40 AM Normal spine has a cervical and lumbar lordosis and thoracic kyphosis 4
  5. 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 12/10/2013 8:40 AM 5
  6. 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 12/10/2013 8:40 AM 6
  7. 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 12/10/2013 8:40 AM 7
  8. 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 12/10/2013 8:40 AM 8
  9. 9. • MENINGES • Dura,Arachnoid – second sacral vertebra • Ligamentum denticulatumto the inner aspect of dura 12/10/2013 8:40 AM 9
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  12. 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. 12/10/2013 8:40 AM 12
  13. 13. • 2nd order neurons ascend for for one or two levels as they cross anterior to the central canal to join the opposite STT 12/10/2013 8:40 AM 13
  14. 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 12/10/2013 8:40 AM 14
  15. 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 12/10/2013 8:40 AM 15
  16. 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 12/10/2013 8:40 AM 16
  17. 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 12/10/2013 8:40 AM 17
  18. 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’ 12/10/2013 8:40 AM 18
  19. 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 12/10/2013 8:40 AM 19
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  21. 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 12/10/2013 8:40 AM 21
  22. 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 12/10/2013 8:40 AM 22
  23. 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? 12/10/2013 8:40 AM 23
  24. 24. Uppercervical cord lesion: Quadriplegia Weakness of diaphragm(above C4) Arnold chiari - downbeating nystagmus & cerebellar ataxia 12/10/2013 8:40 AM Lower cervical cord lesions Atrophy and weakness of corresponding muscles Spastic paralysis of trunk and lower limb Absent biceps,radial jerk Horner’s syndrome 24
  25. 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 12/10/2013 8:40 AM Lumbar cord lesions L2-L4:weakness of Flexion and adduction of thigh Loss of knee jerk Spastic paralysis below,exaggerated ankle jerk Extensor plantar 25
  26. 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 12/10/2013 8:40 AM 26
  27. 27. SPECIAL PATTERNS OF SPINAL CORD DISEASES 12/10/2013 8:40 AM 27
  28. 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 12/10/2013 8:40 AM 28
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  30. 30. Central cord syndrome • Selective damage to grey matter and crossing spinothalamic tracts • Syringomyelia,intrinsic tumors of spinal cord,trauma • Dissociated anaesthesia 12/10/2013 8:40 AM 30
  31. 31. Shoulders,lower neck,upper trunk –cape distribution 12/10/2013 8:40 AM 31
  32. 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 12/10/2013 8:40 AM 32
  33. 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 12/10/2013 8:40 AM 33
  34. 34. COMPRESSIVE DISORDERS OF SPINAL CORD 12/10/2013 8:40 AM 34
  35. 35. Compressive myelopathies • Acute compressive Myelopathy / Chronic Myelopathy • Extramedullary / intramedullary 12/10/2013 8:40 AM 35
  36. 36. Compressive Myelopathy Intra medullary Intradural Extramedullary Extradural 12/10/2013 8:40 AM 36
  37. 37. • Cord compression Extramedullary (95 %) Intradural (15%) MENINGIOMA NEUROFIBROMA PATCHY ARACHNOIDITIS AV MALFORMATIONS 12/10/2013 8:40 AM Intramedullary(5%) Extradural (80%) SYRINGOMYELIA GLIOMA,EPENDYMOMA OF CORD NEOPLASMS POTT’S SPINE IVDP EPIDURAL ABSCESS TRAUMA 37
  38. 38. 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 late 12/10/2013 8:40 AM 38
  39. 39. Intramedullary lesions • • • • • • Short duration,painless onset early bladder involvement Motor – usually symmetrical Jacket sensory loss Dissociative sensory loss Sacral sparing 12/10/2013 8:40 AM 39
  40. 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 12/10/2013 8:40 AM 40
  41. 41. • Clear cut sensory level is usual • Neurological symptoms may fluctuate over time • MRI demonstrate the cord compression due to disc prolapse. 12/10/2013 8:40 AM 41
  42. 42. • • • • Treatment : immobilising in a cervical collar If highly symptomatic – surgical decompression Complication of cervical disc surgery – irreversible paraplegia due to cord infarction 12/10/2013 8:40 AM 42
  43. 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 12/10/2013 8:40 AM 43
  44. 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 12/10/2013 8:40 AM 44
  45. 45. • S.aureus, Streptococcus, anaerobes, gram neg bacilli, fungi • MRI ,sometimes LP • Treatment : Surgical evacuation, decompressive laminectomy , long term antibiotics 12/10/2013 8:40 AM 45
  46. 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 12/10/2013 8:40 AM 46
  47. 47. MRI – hypointense lesion in T1; does not cross the adjacent disc space Bone scan may be useful to detect the all other metastasis 12/10/2013 8:40 AM 47
  48. 48. PAIN !! Recent onset,particularly thoracic (aching,localised,sharp,radiating quality) Typically worsens with movement, coughing, sneezing and Characteristically awakens the patient at night 12/10/2013 8:40 AM 48
  49. 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) 12/10/2013 8:40 AM 49
  50. 50.  Prognosis: • Ambulatory pt – good response with RT • Fixed motor deficit once established <12hr good response >12hr chance to improve >48hr no improvement 12/10/2013 8:40 AM 50
  51. 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 12/10/2013 8:40 AM 51
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  53. 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 12/10/2013 8:40 AM 53
  54. 54. REFERENCE • Brain’s book of neurology • Harrison’s Principles of internal medicine, 18th E • Neuroanatomy,inderbir singh,8th edition 12/10/2013 8:40 AM 54
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