1) The document discusses various causes of compressive myelopathy including spondylosis, herniated discs, spinal stenosis, and tuberculosis. It describes the clinical features and treatments for different levels of involvement in the cervical and lumbar spine. 2) Imaging techniques like MRI, CT myelogram, and X-rays are used to identify compression of the spinal cord or nerve roots from conditions like herniations, osteophytes, and tuberculosis lesions. 3) Surgical intervention may be indicated for moderate to severe myelopathy, progressive neurological deficits, or failure of conservative treatment. The goal is to decompress the spinal cord and relieve compression.

1. CME on Spinal cord Diseases Compressive Myelopathy By Prof .TITO`s Unit

2. Compressive Myelopathy Intra medullary Intradural Extramedullary Extradural

4. COMPRESSIVE MYELOPATHY – CAUSES (mode compression based)

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

13. decreased disk height

14. posterior osteophytes

15. disk protrusions

16. buckled posterior longitudinal ligamentandligamentumflavum

19. Facet status

20. Osteophyte formation

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

27. Tricyclic antidepressants for chronic case

28. short courses of collar

29. stretching (traction),dynamic, isometric, strengthening exercises, aerobic exercise

33. L4-L5 commonly affected

34. Caudaequina lesion

35. M>F;40-50 yrs

36. Neurogenicclaudication

37. Stoop test positive

39. Malformations of atlasFailure of atlas segmentation from occiput, Atlantoaxial fusion

40. Malformations of axisAtlantoaxial segmentation failure Segmentation failure of C2-C3 Dens dysplasias – osodontoideum, odontoidhypoplasia/apla ossiculumterminalepersistens

41. DEVELOPMENTAL AND ACQUIRED ABNORMALITIES

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)

47. BasillarinvaginationMcRae’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

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 fusionFEIL’S TRIAD : Low posterior hair line(<L4) Short neck Limitation of head and neck movements / decreased range of motion in cervical spine

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.

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

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

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

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

85. Surgery if cyst formed

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

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

99. located posteriorly along the surface of the cord or within the dura

100. at or below the midthoracic levelClinical 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

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

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