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

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