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Diseases of Spinal Cord

Spinal cord related problems

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Diseases of Spinal Cord

  1. 1. SPINAL CORD & TRACTS: APPLIED Presenter Dr. ATM HASIBUL HASAN MD Neurology Student(Final part) Department of neurology, DMCH
  2. 2. TOPIC - AT A GLANCE • Anatomical aspect • Imaging in spinal cord disease • Classification of spinal cord pathology • Clinical approach to spinal cord pathology • Localization in spinal cord disease • Special pattern of spinal cord diseases • Case scenarios
  3. 3. Arrangement of tracts in the spinal cord
  4. 4. Imaging of Spine and Spinal Cord Plain X-Ray Computed Tomography o Traditional o Reconstructed o Myelo-CT MRI DSA
  5. 5. X-Ray
  6. 6. X-Ray
  7. 7. CT SPINE
  8. 8. Myelo-CT
  9. 9. MRI- Spine
  10. 10. Spinal Cord Pathology I. Vertebral cause- 1) Trauma 2) Disc prolapse 3) Tumour- primary e.g. MM; secondary e.g. breast, thyroid, prostate, bronchus 4) Spinal TB-(Pott’s disease) II. Meningeal cause- 1) Epidural abscess 2) Tumor - meningioma, neurofibroma, lymphoma, leukaemia
  11. 11. Spinal Cord Pathology III) Spinal cord itself- Developmental: o Syringomyelia, o Meningomyelocoele o Tetherd cord syndrome Degenerative: o MND o FA o SCD o HSP Demyelinating/ Inflamatory: o Transverse myelitis o Multiple Sclerosis o Neuromyelitis Optica
  12. 12. Spinal Cord Pathology Infective: o Bacterial-TB, Syphilis o Viral-EBV, Polio, HIV, VZV, HSV o Parasitic- Schistosomiasis, Toxoplasmosis Deficiency: o Vitamin B12 deficiency o Vitamin E deficiency o Copper deficiency o Lathyrism
  13. 13. Spinal Cord Pathology Vascular: oVasculitis oInfarction oHaemorhage oAVM Physical agents: oRadiation oLightening injury Paraneoplastic :
  14. 14. Localization in Spinal Cord Disease
  15. 15. The Hallmark of spinal cord disease Presence of horizontally defined level below which there will be impairment of sensory, motor and autonomic function.
  16. 16. Cervical Cord Above C5: Spastic Quadriplegia and diaphragm weakness C5-T1: Quadriplegia (LMN signs and segmental sensory loss in the arms & UMN signs in the legs) and respiratory (intercostal) muscle weakness
  17. 17. At C5-C6:Loss of power & reflex of biceps  At C7: Weakness in finger and wrist extensors and triceps.  At C8: Finger & wrist flexion are impaired.  Horner’s syndrome may accompany Cervical Cord
  18. 18. Thoracic Cord Spastic Paraplegia with a sensory level on the trunk  Bowel & Bladder involvement Abdominal reflex (T8-T12) lost above T8 lesion (segmental lesion T8-T9:above the umbilicus; T10-T12:below the umbilicus)
  19. 19. Lumbar Cord L2-L4: Weakness of flexion & adduction of thigh.  Weakness in leg extension at knee  Absent Knee jerks (L3-L4) L5-S1:  Weakness of foot & ankle and flexion at the knee & extension of the thigh  Absent ankle jerks (S1)
  20. 20. Sacral Cord/ Conus Medullaris Saddle anesthesia (s3-s5)  Prominent bowel & bladder dysfunction and impotence.  Absent bulbocavernous (s2-s4) and anal reflex (s4-s5).
  21. 21. Myotomes : •Important in determining level of lesion •Upper limbs: C5 - Deltoid C6 - Wrist extensors C7 - Elbow extensors C8 - Long finger flexors T 1 - Small hand muscles
  22. 22. • Lower Limbs : L2 - Hip flexors L3,4 - Knee extensors L4,5 – S1 - Knee flexion L5 - Ankle dorsiflexion S1 - Ankle plantar flexion
  23. 23. Basic Features of Spinal Cord Disease • UMN findings below the lesion (spasticity, hyper-reflexia). May be flaccid in acute presentation. • Sensory and motor involvement that localizes to a spinal cord level. • Bowel and Bladder dysfunction.
  24. 24. Some terminology Myelopathy Radiculopathy Definition Any pathological process in the spinal cord (intrinsic and extrinsic) Pathological process in the exiting nerve root Feature • Hypertonia • Pyramidal type weakness • Brisk reflex • Extensor plantar response • Loss of sensation ( with a specific level) • Loss of sphincter control • Autonomic dysfunction • Hypotonia • Muscle wasting • Weakness • Fasciculation • Loss of reflex • Loss of sensation
  25. 25. Compressive and non compressive myelopathy CM (surgical) NCM (Medical) 1. Pain - usual 1. Rare 2. Onset - sub acute (2-6 wks) 2. Acute or chronic (≥ 6 wks) 3. Paralysis - Asymmetrical 3. Symmetrical 4. Bowel bladder – Occasionally late involvement 4. May be involved early 5. Sensory limit - asymmetrical 5. Symmetrical or absent 6. Temporal profile - Progressive 6. Non progressive
  26. 26. Intramedullary and extra medullary syndrome Trait Intramedullary Extramedullary 1. Early symptoms Motor features Sensory features 2. Pain Poorly localized Prominent radicular 3. Sacral sensation Sacral sparing Early sacral sensory loss 4. Motor weakness Upper limb may be affected early Lower limb affected early 5. Sphincter disturbance Appears early Appears late
  27. 27. Extradural Intramedullary Intradural Extramedullary DuraCord
  28. 28. Epiconus and Conus Syndrome Epiconus Conus 1. Lesion is between L4-S2 1. Lesion between S3-Co1 2. Motor deficit usually above the knee 2. Motor deficit in lower limb less likely 3. Weakness of hip extensor and knee flexor 3. Not such type 4. Pain may not be present 4. Pain may be present 5. Bladder is involved late 5. Early bladder involvement
  29. 29. Conus and Cauda syndrome Trait Conus Cauda 1. Onset Sudden and bilateral Gradual and unilateral 2. Pain Less common Severe, radicular 3. Location of pain Symmetric, perineum or thigh Asymmetric, perineum, thigh, leg or back 4. Motor loss If occurs, Symmetric, less marked Asymmetric, more marked 5. Reflex Absent ankle Variable- Absent ankle and knee 6. Sensory deficit Saddle distribution (S3-5), symmetric Saddle but asymmetric 7. Bowel and bladder disturbance Early and marked Late and less marked 8. Sexual dysfunction Occurs Less prominent
  30. 30. PARAPLEGIA IN FLEXION PARAPLEGIA IN EXTENSION Following complete transection of SC Following incomplete transection of SC Muscle tone reappears in flexor muscles first (reticulospinal tract) Muscle tone reappears in extensor muscles first (Intact vestibulospinal tract) Flexor reflexes are first to return (eg, Planter response) Extensor reflex returns first (eg, crossed extensor reflex) Occurs late Occurs early Higher lesion Lower lesion
  31. 31. Spinal shock Neurogenic shock Definition Immediate temporary loss of total power, sensation and reflexes below the level of injury Sudden loss of the sympathetic nervous system signals BP Hypotension Hypotension Pulse Bradycardia Bradycardia Bulbocavernosus reflex Absent Variable Motor Flaccid paralysis Variable Time 48-72 hrs immediate after SCI Mechanism Peripheral neurons become temporarily unresponsive to brain stimuli Disruption of autonomic pathways  loss of sympathetic tone and vasodilation
  33. 33. Type of Spinal Cord lesion Complete or transverse lesion Incomplete lesion a) Anterior cord syndrome b) Posterior cord syndrome c) Hemi cord syndrome d) Central cord syndrome e) Foramen magnum syndrome f) Conus medullaris syndrome g) Cauda equina syndrome
  34. 34. Complete cord transection syndrome • Bilateral spastic paraparesis/ quadriparesis • Bilateral loss of all modalities of sensation. • Bowel &bladder dysfunction. • LMN feature at the level of lesion • Cause : o Trauma o Vasculitis o ATM
  35. 35. Brown-sequard syndrome (Hemi cord syndrome) Motor- • Ipsilateral spastic weakness • LMN sign at the level of lesion Sensory: • Ipsilateral loss of proprioception. • Contralateral loss of pain and temperature sensation
  36. 36. Anterior cord syndrome • All cord function are lost below the level of lesion with retained position & vibration sense. • Cause : o Disc prolapse o Ant. Spinal artery occlusion
  37. 37. Posterior cord syndrome • Common in cervical region • Both sided joint position and vibration sense are lost sparing the other sensory and motor tract • Cause: o DM o Neurosyphilis o Spondylosis o Posterior spinal artery occlusion
  38. 38. Central cord syndrome (Schneider syndrome) • Dissociated sensory loss in a cape distribution. • Symptoms depend on extension of lesion around the central canal. • Weakness of muscles in arms with atrophy and hyporeflexia. • Later - Spastic weakness with brisk reflexes in the legs
  39. 39. C/F • Neck pain –radiating to shoulder • Occipital H/A • Variable sensory loss • Weakness and wasting of hand and neck muscles • Quadriparesis-round the clock (LA→LL→RL→RA) Cause- Compressive lesion (meningioma, neurofibroma) in the region of foramen magnum Foramen magnum syndrome:
  40. 40. Spinal shock syndrome • This clinical condition follows acute severe damage to the cord. • All cord function below the level of lesion becomes depressed or lost. • Usually lasts less than 24 hrs but may last for 4-6 wks • On recovery : reflex-tone-power may regain this fashion. • 5-10% patients may not recover from spinal shock
  41. 41. Phases of Spinal shock : Phase Time Physical exam. finding Underlying physiological events 1 0-1 day Areflexia/Hyporeflexia Loss of descending facilitation 2 1-3 day Initial reflex return Denervation super sensitivity 3 1-4 wks. Hyper reflexia (initial) Axon supported synapse growth 4 1-12 months Spasticity Soma supported synapse growth
  42. 42. Conus medullaris syndrome • Bilateral saddle anesthesia • Prominent bowel & bladder dysfunction (urinary retention and anal incontinence) • Impotence • Absent anal reflex.
  43. 43. Cauda equina syndrome • Radicular low back pain • Asymmetrical lower limb weakness & sensory loss • Variable areflexia • Relative sparing of bowel & bladder. • Planter may be flexor or absent. • Cause : o Disc prolapse o Tumour o Trauma
  44. 44. Combined posterior & lateral column lesion: Causes include-  Vitamin B12 deficiency  Copper deficiency  Myelopathy with AIDS  HTLV-1 associated myelopathy Thoracic cord is most commonly affected
  45. 45. Combined posterior&lateral column lesion: C/F- • Paresthesia in the feet • Loss of position and vibration sense in the legs • Sensory ataxia • Positive Romberg sign • Bladder function disturbance • Spasticity, hyperreflexia and bilateral Babinski sign
  47. 47. CLINICAL APPROACH ... POINTS TO BE CONSIDERED: •Onset e.g. acute, subacute, chronic •Progression e.g. static, improving, worsening •Bladder involvement e.g. early, late, none •Presence of pain e.g. mechanical pain, radicular pain, none •Presence of fever e.g. abscess, Potts •Flaccid/ Spastic •Other systemic features e.g. weight loss, skin/lymph nodes/joints- malignancy, vasculitic
  48. 48. CLINICAL APPROACH . . . ONSET: • Acute (minutes to hours):  Traumatic  Inflammatory  Vascular lesion •Subacute (days to weeks):  Neoplastic (compressive)  Pott’s •Chronic (months to years):  Neoplastic  Degenerative
  49. 49. CLINICAL APPROACH . . . PROGRESSION: Static:  TM Improving :  MS  Vascular lesion Worsening :  Pott’s disease  Compressive  Neoplastic  Degenerative
  50. 50. CLINICAL APPROACH . . . BLADDER INVOLVEMENT:  Early:  TM Late:  Neoplastic  Compressive  Potts No involvement:  Degenerative e.g. HSP  Nutritional e.g. SACD, lathyrism
  51. 51. CLINICAL APPROACH . . . PAIN: Mechanical: o Vertebral cause Radicular: o Meningeal cause o Inflammatory cause No pain: o Spinal cord cause
  52. 52. CLINICAL APPROACH . . . NATURE OF PARAPLAGIA: Flaccid- •Spinal shock (up to 6 wks.) •Cauda equina lesion •Conus medullaris lesion Spastic- •Lesion usually in Cervical and Dorsal cord due to any cause (after spinal shock is recovered)
  53. 53. EXAMINATION A) Types of deficit -  Motor deficit only  Sensory deficit only  Mixed deficit B) Types of motor deficit - UMN, LMN C) Pattern of sensory loss -  Posterior column loss  Spinothalamic loss  Dissociative loss D) Bladder involvement  Involved : Tumor, TM, Demyelination.  Not involved : Degenerative, Deficiency, Toxin
  54. 54. Clinical clues A) Motor deficit UMN LMN B/B+ B/B- B/B+ B/B-  Cortical paraplegia  Tumor •MND •HSP •Lathyrism •Tumor •ATM with Spinal shock •Trauma •Post vaccine •Tumor • Polio • SMA • GBS • MMNCB
  55. 55. Clinical clues B) Sensory deficit only C) Mixed deficit • Posterior cord syndrome ● Tumour • Foramen magnum syndrome ● Cauda equina syndrome • Tabes ● Conus syndrome • Paraneoplastic • MS
  56. 56. Spinal cord disease Acute Subacute Chronic UMN Motor LMN Sensory Mixed B/B + B/B - -Cortical lesion -Tumour -Tumour -Vascular B/B + B/B - -Tumour -Spinal shock -GBS -AHC eg Polio -SMA Posterior column Spinothalamic -Trauma -Tumour -Spondylosis -Partial cord syndrome -Trauma -Tumour -Vascular -ATM -Infective Approach to Spinal cord disease
  57. 57. Spinal cord disease Subacute Chronic UMN Motor LMN Sensory Mixed B/B + B/B - -Tumour -Chronic infection -MND -Toxic eg Lathyrism -Tumour B/B + B/B - -Tumour -Vascular -CIDP -MMNCB -SMA Posterior column Spinothalamic -Trauma -Tumour -Spondylosis -Partial cord syndrome -Infection -Tumour -Degenerative -Demyelinating Approach to Spinal cord disease
  58. 58. Case scenarios
  59. 59. A 17 yr old boy presented with tingling, numbness and paresthesia in hand and leg. Examination revealed dissociated and suspended sensory loss. Syringomyelia
  60. 60. A 38 yr old man presented with chronic back pain, low grade fever and progressive weakness of both the lower limbs. Examination revealed a gibbus at D1 level. Potts Disease
  61. 61. A 62 old man, known case of psoriasis, presented with new onset back pain and high grade fever. Lower cervical and upper thoracic spine was tender on palpation. Investigation revealed neutrophilic leucocytosis with high ESR and CRP. Spinal Epidural Abscess
  62. 62. A 25 yr old man presented with progressive weakness of both the lower limb along with a severe sensory loss up to mid chest and bladder problem for last 2 weeks following a H/O vaccination against Hepatitis B. Acute Transverse Myelitis (Vaccine related)
  63. 63. A 35 yr old lady presented with progressive paraparesis with impaired sensorium extending to D4 level. Two weeks later she developed dimness of vision in both eyes. Neuromyelitis Optica
  64. 64. A 17 yr old boy presented with sudden weakness of all 4 limbs along with difficulty in speech and deglutition with impaired level of consciousness following an episode of flu like illness. ADEM
  65. 65. A 24 yr old lady presented with sensory disturbance of both the lower limbs. She had a H/O visual disturbance in one eye and weakness of all four limbs a couple of years back. Multiple Sclerosis
  66. 66. Differentiating by MRI
  67. 67. Differentiating by MRI Short segment: o MS Long segment: o TM o NMO
  68. 68. Differentiating by MRI
  69. 69. A 34 yr old man presented with gait ataxia, tingling and numbness in all four limbs, brisk reflexes but absent ankle jerk with extensor planter response. He gave H/O illeal resection 10 years back. PBF showed megalocyte and there was decreased Vit B12 level. Subacute combined degeneration of spinal cord
  70. 70. A 42 yr old woman noticed chronic pain in cervico-thoracic region followed by progressive weakness of all four limbs and mild bladder disturbance for last 11 months. Extradural Meningioma
  71. 71. A 28 yr old man presented with pain in neck and shoulder and numbness in limbs followed by progressive weakness of all four limbs (Lt arm-Lt leg-Rt leg-Rt arm). Foramen magnum syndrome Neurofibroma
  72. 72. A 3 yr old boy presented with cervical pain and weakness of all four limbs without any bowel or bladder problem. Astrocytoma
  73. 73. A 65 yr old woman presented with radicular pain and distal weakness of both upper limb. She is a known case of apical lung tumour. Multiple Metastasis to spine and spinal cord
  74. 74. Tumours of Spinal cord
  75. 75. A 22 yr old lady presented with progressive weakness of both lower limbs along with retention of urine for last two years. Examination revealed spastic paraplegia with ill defined sensory deficit up to umbilicus. Spinal AVM
  76. 76. A 42 yr old man presented with radiating low back pain, progressive difficulty in walking along with tingling and numbness in limbs, urinary retention and erectile dysfunction for last two years. Spinal DAVF
  77. 77. THANK YOU