Spinal cord& its lesions,compressive myelopathy
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Spinal cord& its lesions,compressive myelopathy

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Spinal cord,spinal cord lesions,compressive myelopathy

Spinal cord,spinal cord lesions,compressive myelopathy

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Spinal cord& its lesions,compressive myelopathy Spinal cord& its lesions,compressive myelopathy Presentation Transcript

  • SPINAL CORD & ITS COMPRESSIVE DISORDERS SHRUTHI.S.JAYARAJ 53rd, Calicut Medical College 12/10/2013 8:40 AM 1
  • • 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
  • 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
  • • 12/10/2013 8:40 AM Normal spine has a cervical and lumbar lordosis and thoracic kyphosis 4
  • • 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
  • 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
  • • 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
  • • 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
  • • MENINGES • Dura,Arachnoid – second sacral vertebra • Ligamentum denticulatumto the inner aspect of dura 12/10/2013 8:40 AM 9
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  • 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
  • • 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
  • • 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
  • • 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
  • 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
  • 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
  • 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
  • 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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  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • SPECIAL PATTERNS OF SPINAL CORD DISEASES 12/10/2013 8:40 AM 27
  • 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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  • 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
  • Shoulders,lower neck,upper trunk –cape distribution 12/10/2013 8:40 AM 31
  • 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
  • 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
  • COMPRESSIVE DISORDERS OF SPINAL CORD 12/10/2013 8:40 AM 34
  • Compressive myelopathies • Acute compressive Myelopathy / Chronic Myelopathy • Extramedullary / intramedullary 12/10/2013 8:40 AM 35
  • Compressive Myelopathy Intra medullary Intradural Extramedullary Extradural 12/10/2013 8:40 AM 36
  • • 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
  • 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
  • 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
  • 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
  • • 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
  • • • • • 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
  • 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
  • • 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
  • • 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
  • 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
  • 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
  • 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
  •  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
  •  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
  • 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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  • 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
  • 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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