Compressive Myelopathy


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Compressive Myelopathy

  1. 1. CME on Spinal cord Diseases Compressive Myelopathy<br />By<br />Prof .TITO`s Unit<br />
  2. 2. Compressive Myelopathy<br />Intra medullary<br />Intradural<br />Extramedullary<br />Extradural<br />
  3. 3.
  4. 4. COMPRESSIVE MYELOPATHY – CAUSES (mode compression based) <br />
  5. 5. Spondylosis<br /><ul><li>spondylosis is a general term encompassing a number of degenerative conditions
  6. 6. Degenerative disc disease (DDD)
  7. 7. Spinal stenosis
  8. 8. With or without degenerative facet joints
  9. 9. With or without the formation of osteophytes
  10. 10. With or without a herniated disc
  11. 11. One single component as a diagnosis is rare</li></li></ul><li>Disc degeneration <br />Annulus Fibrosis <br />Dehydration of disc<br />Loss shock absorbing capacity<br />Articular Facet Hypertrophy<br />Load ti Posterior elements of vertebra<br />Prolapse of annulus<br />Rupture of annulus<br />Herniation of Nucleouspulposus<br />Intraforaminalhermiations<br />Posterolateralherniations<br /> Central disk herniations<br />
  12. 12. <ul><li>narrow canal
  13. 13. decreased disk height
  14. 14. posterior osteophytes
  15. 15. disk protrusions
  16. 16. buckled posterior longitudinal ligamentandligamentumflavum
  17. 17. posterior subluxation</li></li></ul><li>Clinical Aspects of Spondylosis:<br />Cervical Spondylosis:<br /> common cause of progressive myelopathy<br /> commonly affects at cervical level;C5-C6 disc commonly involved<br /> &gt;40yrs;M&gt;F<br /> Neck pain,Root pain and LMN signs corresponding to compression<br /> UMN signs and Post colmn involvement below the compression level<br />Lhermitte&apos;s Sign<br />(Barber Chair phenomenon) Finger Escape sign <br />Axial compression test <br />Spurling’s test <br />Shoulder abduction relief sign <br />
  18. 18. Cervical Spine - AP, lateral, and oblique <br /><ul><li>disk space height
  19. 19. Facet status
  20. 20. Osteophyte formation
  21. 21. Spinal alignment </li></ul>MRI SPINE<br /><ul><li>low signal intensity – degenerated disc
  22. 22. focal extension of disc material – herniation
  23. 23. Herniated disc may extend above and below
  24. 24. Ligaments calcification and changing contour
  25. 25. Occlude the canal
  26. 26. Compress the spinal cord </li></li></ul><li>MANAGEMENT:<br />Conservative:<br /><ul><li>Nonsteroidal anti-inflammatory
  27. 27. Tricyclic antidepressants for chronic case
  28. 28. short courses of collar
  29. 29. stretching (traction),dynamic, isometric, strengthening exercises, aerobic exercise
  30. 30. Lifestyle modification- low high pillows</li></ul>SURGERY<br /> Indications: Moderate to severe myelopathy<br /> progressive motor/gait impairment<br /> Static deficits with significant pain<br /><ul><li>Anterior Cervical Diskectomy With Fusion
  31. 31. Multiple – Level Laminectomy</li></li></ul><li>LUMBAR DISC PROLAPSE<br />Age 20-40 yrs; L4-L5 common site<br />Acute or chronic Back ache<br />Sciatic pain – S1compPostero lateral calf and heel<br /> L5comanterolateral aspect of leg and ankle<br />Femoral pain-L2-L3 to front of thigh<br />Bragaard test<br />lasegue test <br />Most of the time it needs Surgery – Fenestration,<br />Laminotomy,Hemilaminectomy,Laminectomy<br />Manage ment similar to Cerspondylosis<br />SLR test<br />
  32. 32. LUMBAR CANAL STENOSIS<br /><ul><li>Congenital narrowing of lumbar canal
  33. 33. L4-L5 commonly affected
  34. 34. Caudaequina lesion
  35. 35. M>F;40-50 yrs
  36. 36. Neurogenicclaudication
  37. 37. Stoop test positive
  38. 38. Usually surgery needed- laminectomy</li></li></ul><li>CRANIOVERTEBRAL JUNCTION ANOMALIES<br />CONGENITAL MALFORMATIONS<br /><ul><li>Malformations of occipital boneBasilar invagination, Remnants around foramen magnum,Clivus segmentations)
  39. 39. Malformations of atlasFailure of atlas segmentation from occiput, Atlantoaxial fusion
  40. 40. Malformations of axis</li></ul>Atlantoaxial segmentation failure<br /> Segmentation failure of C2-C3<br /> Dens dysplasias – osodontoideum, odontoidhypoplasia/apla<br />ossiculumterminalepersistens<br />
  42. 42. CV junction malformation Vs Neurological symptoms<br />Mechanisms:<br />Bone and soft tissues compress directly on medulla or upper cervical cord<br />Associated CNS developmental anomalies <br />Raised ICT due to impaired CSF flow<br /><ul><li>Around 20-25 yrs; both sexes
  43. 43. Painful or restricted cervical movements
  44. 44. Pyramidal signs with varying motor disabilities in one or mostly all limbs. Muscle wasting in UL;progressive over 5yrs
  45. 45. Cerebellar signs usually;sensory symptoms(lat and Pos)
  46. 46. Neuro vascular symptoms rare. transient reversible weakness may present</li></li></ul><li>CHAMBERLAIN’S LINE<br /><ul><li>joins posterior tip of hard palate to posterior rim of foramen magnum dense 3.6mm below it
  47. 47. Basillarinvagination</li></ul>McRae’s LINE<br />Joins anterior and posterior edges of foramen magnum: sagittal diameter of foramen magnum. (Avg – 35mm);dense below the line<br /> foramen stenosis<br />MCGREGOR’S LINE (Basal line)-<br />Joins hard palate to lowest point of occipital bone<br />Tip of dens should not exceed 5 mm above this line<br />FISHGOLD’S DIGASTRIC LINE – paramedian abnormality<br />HEIGHT INDEX OF KLAUS – dense to tuberculam line &lt; 30<br />basillarinvagination<br />
  48. 48. Spinolamellar line – atlas not intersected in ant fusion of atlas<br />atlanto axial dislocation<br />CLIVUS CANAL LINE – basillarinvagination<br />
  49. 49. KLIPPEL FEIL SYNDROME<br /><ul><li>Congenital fusion of cervical vertebrae
  50. 50. Failure of normal segmentation of the cervical vertebrae/somite between 3rd and 8th weeks of fetal development (rather than a secondary fusion)
  51. 51. Incidence – 1 in 42,000 births ;more in females
  52. 52. Autosomal dominant inheritance – C2-C3 fusion. Autosomal recessive – C5- C6 fusion</li></ul>FEIL’S TRIAD :<br />Low posterior hair line(&lt;L4)<br />Short neck<br />Limitation of head and neck <br />movements / decreased range of <br />motion in cervical spine<br />
  53. 53. <ul><li>upper cervical spine  earlier age
  54. 54. Rotational loss and lateral bending is usually more pronounced than loss of flexion and extension
  55. 55. Scoliosis, Sprengel deformity/ high scapula
  56. 56. pterygiumcolli - Webbing of soft tissues on each side of the neck ; Assocdtorticollis
  57. 57. Facial asymmetry
  58. 58. Cardiovascular- VSD, PDA
  59. 59. Urinary tract abnormalities – agenesis of kidney, horseshoe kidney, hydronephrosis,
  60. 60. Deafness (absence of auditory canal and microtia)
  61. 61. Neurologic deficit- facial nerve Palsy, rectus muscle palsy, ptosis of eye, cleft palate, etc
  62. 62. Cervical spine routine x-ray followed by flexion/extension lateral X-rays. - flattening and widening of vertebrae, hemivertebrae or block vertebrae, instability.
  63. 63. MRI with head flexed and extended - subluxation and cord compression cord anomalies. </li></li></ul><li>Occipitalization of Atlas<br />Atlando Axial Dislocation<br />Diagnosis- Atlas-Dens interval of more than 5 mm in children and more than 3 mm in adults is diagnostic<br />Platybasia &gt;135 <br />
  64. 64. Arnold-Chiari Malformation<br />1) Extension of a tongue of cerebellar tissue, posterior to the medulla and spinal cord, into the cervical canal <br />2) displacement of the medulla into the cervical canal, along with the inferior part of the<br />fourth ventricle<br />1) Increased ICTheadache,<br />2) progressive cerebellar ataxia, <br />3) progressive spastic quadriparesis,<br />4) downbeatingnystagmus<br />5) cervical syringomyelia<br />6)lower cranial nerves palsies<br />hydrocephalus,<br />Type I – Cerbellartonsilarherniation – adult onset,syrinx<br />Type II-Part of Vermis, Medulla & 4th Ventricle <br />herniatingupto mid cervical region – early ages;ass with <br />mengiomyelocele<br />Rx<br />to do nothing<br />Pregessivesymptomaticupper cervical laminectomy and<br />enlargement of the foramen magnum<br />
  65. 65. Syringomyelia (syrinx, “pipe” or “tube”)<br /> A chronic progressive degenerative or developmental disorder of<br />the spinal cord, characterized by cavitation of the central part of Cervical Canal<br /><ul><li>Associated with Vertebral and Base of Skull Anomalies
  66. 66. 90% syrinx ass with Type-I chairy malformation
  67. 67. 20-40yrs initial ;M=F
  68. 68. Insidious onset ,irregular progressive over 5-10yrs
  69. 69. Pt cant say when disease began
  70. 70. Disease depends on1.cross sectional extent 2.longitu extent.</li></ul>Classic elements: a) segmental weakness and atrophy of the hands and arms<br /> b) loss of some or all tendon reflexes in the arms<br /> c)segmental anesthesia of a dissociated type (loss of pain and thermal preservation of touch)over the neck,shoulders,and arms(cape sensation)<br />Pyramidal tract: UL : Reflexes preserved or brisk <br />amyotrophy of shoulders and hands spastic<br /> LL: Spastic type<br />Post column,spinothalamic tract involvement later<br />Horner syndrome can occur<br />Usually have tropic ulcers; vague pain may be presenting feature<br />
  71. 71. BARNETT`s Classification<br />Syringobulbia: affect the brainstem(medulla ,pons)<br />1. Vestibular nuclei  Vertigo & nystagmus<br />2. Nucleus ambiguusdysphagia & hoarseness of voice<br />3. Spinal trigeminal nucleus  Analgesia & thermal anesthesia on ipsilateral face (Onion skin pattern )<br />4. hypoglossal nucleus Weakness of lingual muscles & dysarthria<br />
  72. 72. Patho: Gardnershydrodyanamic theory<br />Inves: MRI with contrast – slow filling cavity ; look other skeleatl manifestations<br /> CT Myelogram; X ray of cervical spine and skull<br />DD for Dissociated sensory loss:<br />Pseudosyringomyelia-small fib polyneu; DM,amyloia,heriditarysensory,fabrys<br /> ant Spinal arte thrombosis<br /> PICA<br />Rx<br /> Type I-surgical decompression of foramen magnum and upper cervical canal(relieve headache, pain,mildy improve motor sym;ataxia&nystagmus persist<br />Syringostomy or Shunting by T tube by syringotomy<br /> in Type I and some II<br />Other types – surgery not useful<br />
  73. 73. INFECTIVE<br />EPIDURAL ABSCESS :<br /> Triad – Fever;Midline dorsal pain over spine;progressive limb weakness<br /><ul><li>2/3 – hematogenous spread
  74. 74. 1/3 – extension of a local infection</li></ul>Lesion mainly – compress venous plexus <br /> direct compression<br /><ul><li>Staph. Aureus is common
  75. 75. Strepto,gramneg bacilli
  76. 76. Inc ESR/CRP
  77. 77. MRI; CSF analysis
  78. 78. Bacterial culture pods <25%</li></ul>Rx: Decompressivelaminectomy /drainage + long term parentral(6-8wk) antibiotic<br /> weakness several days – not improve with surgery<br />Caudaequina – antibiotics is enough mostly<br />Empiric Abx:<br />Nafcillin plus metronidazole plus either cefotaxime or ceftazidime<br />Vancomycin (1 g every 12 hours) can be substituted for nafcillin<br />
  79. 79. ARACHNOIDITIS<br />Syndrome of painful root and spinal cord symptoms;patchy motor symptoms<br /><ul><li>adhesions between the arachnoid and dura
  80. 80. Causes;TB,syphilis,viral & bacterial meningitis,anesthesia,LP
  81. 81. acute or delayed for weeks, months, or even years
  82. 82. Lumbo-Sacral(caudaequina) commonly involved
  83. 83. Root pain one side next sidereflex changes</li></ul> motor weaknessspasticataxia&sphincter disturbance<br /><ul><li>CSF: moderate lymphocytosis,elev protein – acute stage</li></ul> sometimes normal due to complte block<br /><ul><li>MRI:loss of normal ring of CSF,loculations
  84. 84. CT myelogram: candle gutter appearance</li></ul>Management<br /><ul><li>Steroids can be tried
  85. 85. Surgery if cyst formed
  86. 86. Pain relieving medications and surgeries</li></li></ul><li>POTT`S DISEASE<br />skeletal TB  spinal is common<br />Common in paediatric and adolscence group<br />Dorsal 42%  &gt;Lumbar&gt;Dorsolumbar , Cervical<br />  <br />Lesion could be<br /> Florid - invasive and destructive lesion <br /> Non destructive - lesion suspected clinically but identifiable by investigations <br /> Carries sicca<br /> Hypertrophied <br />Periosteal lesion. <br />Anatomically the lesion could be :<br />Paradiscal - destruction of adjacent end plates <br />Appendeceal (Posterior) - involvement of pedicles, laminae, spinous process <br /> Central - Cystic or lytic, concertina collapse <br />  Anterior –longitudinal lig<br />Synovitis in post facet <br />
  87. 87. Pathophysiology:<br />xtraspinal source of infection osteomyelitis and arthritis<br /> (anterior aspect of the vertebral body adjacent to <br /> the subchondral plate) <br />spread to adjacent intervertebral disks<br />Child may de direct invasion <br />bone destruction <br />vertebral collapse and kyphosis(throcic&gt;lumbar&gt;cervical)<br />Kyphotic deformity <br />abscesses, granulation tissue, or direct dural invasion <br />Paravertebral abscess <br />anterior longitudinal lig<br />Healing by fibrous tissue <br />spinal cord compression <br />and neurologic deficits <br />bony ankylosis vertebrae. <br />Groin abscess <br />Thoracic abscess<br />
  88. 88. Clinical Features:<br /><ul><li>Back pain is the earliest and most common symptom
  89. 89. Duration of symptoms at the time of diagnosis is 3-4 months
  90. 90. fever and weight loss
  91. 91. Pain can be spinal or radicular
  92. 92. Neurologic abnormalities - 50%</li></ul> spinal cord compression with paraplegia<br /> paresis, <br /> impaired sensation, <br /> nerve root pain, <br />caudaequina syndrome <br />Investigations<br />Mantoux;IFN release assays; sputum AFB<br />CXR;XrayThracolumbarspine;CT spine<br /> MRI<br />
  93. 93. X Ray appearances<br />Lytic destruction of anterior portion of vertebral body<br /> anterior wedging <br /> Collapse of vertebral body <br /> Reactive sclerosis <br />Intervertebral disks shrunk or destroyed <br /> Vertebral bodies may show destruction <br /> Enlarged psoas shadow with or without calcification <br />Fusiformparavertebral shadows  <br />MRI<br />
  94. 94. Tb spine with PARAPLEGIA <br />INCIDENCE 10-30% <br />Dorsal spine (MC) <br />Motor functions affected before /greater than sensory <br />Sense of position & vibration last to disappear <br />Patho of Tuberculoses Paraplegia <br />Inflammatory Edema –vascular stasis,toxin<br />Extradural Mass – Tuberculousostetis,abscess<br />Bony Disorder – Sequestra, Internal Gibbus<br />Meningeal changes – ‘dura as rule not involved’ Extradural granulation –contractcicatrizationperidural fibrosis paraplegia <br />Infarction of spinal cord - Ant spinal artery Endarteritis, Periarteritis, Thrombosis<br />Changes in Spinal cord- Myelomalacic,Syringomyelic change<br />
  95. 95. Seddon’s Classification: <br /> GROUP A_-Early onset  - in active stage of the disease within first 2 years<br />(active disease - Caseous material, debris, sequestrated disc or bone, internal gibbus,<br />stenosis and deformity can cause compression) <br /> GROUP B -Late onset- Usually after 2 years of onset of the disease<br /> (Healed disease - Usually internal gibbus and acute kyphotic deformity)<br />Kumar’s classification(paraplegia)<br /> 1 Negligible :Unaware of neural deficit, Plantar extensor/ Ankle clonus<br /> 2 Mild :Walk with support <br /> 3 Moderate :Nonambulatory, Paralysis in extention,sensory loss &lt;50% <br /> 4 Severe :3+ paralysis in flexion/sensory loss&gt;50%/ Sphinters involved <br />MANAGEMENT:<br /> ATT – prolonged pack <br /> and surgery<br />
  96. 96. Surgical indications:<br /> 1. No sign of Neurological recovery after trial of 3-4 weeks therapy <br /> 2. Neurological complication during treatment <br /> 3. Neuro deficit becoming worse <br /> 4. Recurrence of neuro complication <br /> 5. Prevertebral cervical abscesses,neurological signs <br /> 6. Advanced cases- Sphincter involvement, flaccid paralysis, Severe flexor spasms<br /> 7.severe neurodeficcit<br />Surgical techniques:<br /> 1. Decompression -Failed response<br /> 2 .Debridement+/- Failed response after 3-6 fusion months,<br /> 3 .Debridement +/- Recrudescence of disease DECOMP+/- fusion 4 Debridement+/- Prevent severe Kyphosis fusion <br /> 5 .Anterior Severe Kyphosis +neural deficit- Transposition <br /> 6 .LaminectomySTS,secondarystenosis, posterior disease <br /> 7. Costotransversectomy– in tense paravertebral abscess <br />
  97. 97. VASCULAR – Compressive myelopathy<br />Epidural Haematoma:<br /> predisposing factors:<br /> Anticoagulation therapy,Trauma,Bleedingdisorder,tumor<br /> Acute focal &/ radicular Pain <br /> Acute Spastic paraparesis or conusmedularis syndrome<br /> Surgical decompression<br />Haematomyelia: <br />Haemorrhage into the substances of spinal cord<br />Trauma,parenchymal vascular malformations,vasculitis,tumors<br /> ACUTE PAINFUL TRANSVERSE MYELOPATHY – INTRAMEDULLARY<br /> subarachnoid hgecan occur <br /> MRI; Spinal Angiography<br /> Conservative management only<br /> surgery if AVM is the cause<br />
  98. 98. AV Malformation of cord:<br /><ul><li>Reversible cause of paraparesis
  99. 99. located posteriorly along the surface of the cord or within the dura
  100. 100. at or below the midthoracic level</li></ul>Clinical features:<br />middle-aged man<br />progressive myelopathy that worsens slowly or intermittently with periodic remissions<br />incomplete sensory, motor, and bladder disturbances<br />mixture of upper and restricted lower motor neuron signs<br />Pain over the dorsal spine, dysesthesias, or radicular pain<br />symptoms that change with posture, exertion such as singing, menses<br />Foix-Alajouanine syndrome - progressive thoracic myelopathy with paraparesis<br />Investigation:MRIcontrast;CTmyelogram;Selective spinal angiography<br />Management: Endovascular embolization of feeding vessels<br /> surgical if ruptured <br />
  101. 101. TUMORS AND COMPRESSIVE MYELOPATHY<br />METASTASIS:<br /><ul><li>Metastasis is common tumor(high marrow)
  102. 102. Epidural type of compression is common
  103. 103. Throacic is common; Lumbar&Sacral – Prostate and ovarian
  104. 104. Breast>Lung>Prostate>Kidney>Lymphoma>Plasmacelldyscrasia
  105. 105. old age pt Vertebral pain with acute onset of neurological deficit
  106. 106. MRI – hypodense in T1;doesnot cross the adjacent disc space
  107. 107. Bone scan may be useful to detect the all other metastasis
  108. 108. Management:</li></ul> -Glucocorticoid – upto 40mg/d Dexamethasone<br /> -RT – 3000cGy in 15 daily fractions<br /> -Surgery- laminectomy or vertebral resection<br /> (neuro signs worsen even with RT)<br /><ul><li>Prognosis:</li></ul> Ambulatory pt – good response with RT<br /> Fixed motor deficit<br /> &lt;12hr good response<br /> &gt;12hr chance to improve <br /> &gt;48hr no improvement<br />
  109. 109. Primary tumors of spinal cord common in cervical<br />Intradural : Benign and slow growing ; progressive compression signs<br />Meningioma,Neurofibroma,chordoma,lipoma<br />dermoid,sarcoma<br />MENINGIOMA: benign<br />throcic cord level or near foramen magnum<br /> from arachonoid cells <br /> forms Psommama bodies<br /> Radiation therapy- Gammma Knife, proton beam treatment<br /> external beam<br />NEUROFIBROMA: from schwwan cells<br /> arises near posterior root<br /> begins with radicular symptoms<br />asymetric progressive spinal cord syndrome<br /> need surgical treatment<br />INTRAMEDULLARY: uncommon<br /> cervical commonly<br /> central cord syndrome or hemicord syndrome<br />Ependymoma,Haemangioblastoma,secondaries<br />astrocytoma(lowgrade)<br />Microsurgical debulking can be tried<br />RT is not useful<br />
  110. 110. THANK YOU<br />