Diseases of the spinal cord


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Diseases of the spinal cord

  1. 1. Diseases of the Spinal Cord By Dr. Mohamed Abdel-Fattah ElKilany MD Neurology
  2. 2. General considerations: • Spinal cord segments. • Meninges of the cord. • Roots. • Blood supply. • Lamination and arrangement of fibers of all tracts within the cord follows the low of the eccentricity of the long fibers i.e. the longest fibers lies most lateral while the shortest lies most central.
  3. 3. This lamination pattern explains why in the progressive extramedullary cervical cord compression, pyramidal and sensory signs appear in legs before arms.
  4. 4. Spinal cord diseases occur in two major pathological states: 1- Compression: extramedullary or intramedullary. 2-Myelopathy .
  5. 5. 1- Spinal Cord Compression  Etiology:  1-Vertebral causes:  2-Meningeal causes:  3-Spinal cord causes (intramedullary):
  6. 6. Clinical Picture : 1-Onset 2-Pain: radicular 3-Parasthesia: it is due to interruption of the ascending spinothalamic tracts. 4-Weakness: •At the level of the lesion : lower motor neuron weakness. • Below the level of the lesion: There are signs of upper motor neuron weakness. 5- Sphincteric disturbance: urgency or hesitancy and constipation as well as impotence in males.
  7. 7. 6- Brown-Sequard syndrome: occurs as a result of damage confided to one side of the cord. There is ipsilateral upper motor neuron weakness and deep sensory loss and contralateral hemihyposthesia for pain and temperature. The distribution of these signs varies with level of the lesion. Levels most frequently encountered in practice are: 1-Above the 5th cervical segment: all signs of cord transaction appear in the whole body musculature below the neck; there is no detectable LMN signs in the upper. 2-At the 5th cervical segment: the same as in 1 in addition to the presence of LMN weakness affecting the biceps muscles and appearance of the inverted supinator reflex (during eliciting the biceps reflex, the reflex is diminished and replaced by finger flexion).
  8. 8. 3-At the 8th cervical and 1st dorsal segments: there is weakness and wasting of the small muscle of the hands in addition to the other below-level manifestations. 4-Below the 1st dorsal segment: Upper limbs are spared in addition to the below-level manifestations. 5-At the 10th dorsal segment: the below-level manifestations in the lower limbs, upper abdominal reflexes are intact but the lower reflexes are lost.
  9. 9. Investigations 1- Plain radiography: of the spine 2- MRI examination 3- Myelography may reveal partial or complete block of the outflow of the dye in the spinal subarachniod space at the level of the lesion. 4- CSF examination: Sample obtained from the spinal canal below the level of obstruction shows characteristic changes known as Froin’s syndrome, these changes are; 1) low pressure, 2) yellow coloration or xanthochromia, 3) cytoalbuminous dissociation (normal cell count + high protein content).
  10. 10. 2- Myelopathy  The term myelopathy refers to the affection of the spinal cord substance by any pathological conditions other than compression. Myelopathy could be primary (of unknown etiology) or secondary to a known pathology. Both forms of myelopathies result in bilateral and almost symmetrical spinal cord manifestations. Examples for myelopathy include:
  11. 11. 1-Primary myelopathies: motor neuron disease, hereditary spastic paraplegia and Friedreich’s and Mare’s ataxia. 2-Secondary myelopathies: transverse myelitis, multiple sclerosis, vascular disorders (ant. spinal artery occlusion), subacute combined degeneration of the cord due to vitamin B12 deficiency) and myelopathy associating chronic liver disease.
  12. 12. Treatment  1-Surgical relief of the compression in cases of disc prolapse, extramedullary tumors and urgent drainage of spinal epidural abscess usually followed by marked functional recovery.  2- Radiotherapy for malignant intramedullary tumors and metastatic deposits.  3- Specific pharmacological treatment in cases of Pott’s disease.  4- Treatment of underlying pathology.
  13. 13. General care of the paralyzed patients  Paraplegic patients are liable for many serious complications, which may in themselves, lead to death such as pressure sores, urinary tract infection, renal calculi and muscular contructure, these can all be avoid by:
  14. 14. 1-Skin care: The patients must be nursed on a rubber mattress and his position should be changed every 2-4 hours. The skin must be kept clean and dry, skin grafting may be needed for big ulcers. Nutrition must be maintained by a well balanced diet rich in protein, vitamin C and iron. 2-Bladder and bowel care: If retention occurs, aseptic intermittent catheterization must be carried out. A permanent indwelling urinary catheter is not recommended since it predisposes to infection, reduces bladder capacity and promotes calcium formation. It is not advisable to give antibiotics prophylactically, but if infection develops, it must be treated promptly. Constipation must be prevented by suitable diet laxatives. When occurs it must be relieved by enema; otherwise the feces will become hard and impacted and may require manual removal.
  15. 15. 3-Care of paralyzed parts: spasticity could be reduced by regular passive movements, administration of Dantroline tablets 50 mg or Baclofen 10 every 8 hours, if there is no hope for recovery, flexor spasm may be abolished by intrathecal injection of phenol in glycerin or by section of the anterior nerve roots. 4-Rehabilitation: when the cause of the paraplegia is not progressive, patients may be learned to walk with calipers or to use a wheel chair. There is a hope that computer-programmed muscle electrical stimulation will enable paraplegic patients to obtaine limited muscle functions sufficient to permit standing or even walking.
  16. 16. 3- Specific spinal cord syndromes A- Paraplegia Definition The term paraplegia means paralysis confined to the lower limbs due to damage of their motor supply at any point.
  17. 17. Causes 1- Cerebral causes: damage of the motor area of the lower limbs in the cerebral cortex. Cerebral paraplegia may be produced by parasagittal meningioma, thrombosis of the superior sagittal sinus or by congenital lesions. 2- Spinal cord causes: spinal paraplegia is very much commoner than cerebral, it may be associated with either extension or flexion of the lower limbs. 3- Other lesions: paraplegia may also caused by a lesion of the anterior horn cells of the lumbosacral region , e.g. poliomyelitis or, motor neuron disease or by lesion of the cauda equina, or of the peripheral nerves as in polyneuropathy, or of the muscles, as in myopathy.
  18. 18. Stages of paraplegia 1-Spinal shock After spinal cord transection, all deep, superficial and autonomic reflexes as well as tone are suppressed. All body segments below the level of transection become paralyzed and anesthetic. Shock stage is usually transient (lasts for few days or weeks) and followed by a period of increased reflexes. Typically, the patient in spinal shock stage is severely paralyzed, flaccid, areflexic and has retention with overflow.
  19. 19. 2- Paraplegia-in-extension After a partial lesion of the cord two mutually antagonistic reflex activities emerge, extensor hypertonia and flexor withdrawal reflex, the former is dependent upon the reticulospinal tract. The flexor withdrawal reflex, on the other hand, depends on short spinal reflex arcs. In paraplegia-in-extension, hypertonia predominates in the extensors of the leg (the antigravity muscles) and in adductors. Thus, Lower limbs are extended and adducted. Knee and ankle reflexes are exaggerated and there may be contraction of the opposite adductor muscles when eliciting the knee reflex.
  20. 20. 3- Paraplegia-in-flexion When the lesion progresses to involve the reticulospinal tract, extensor hypertonia disappears and the flexor withdrawal reflex dominates the picture. The lower limbs are always in position of flexion and adduction. Paraplegia in flexion is associated with appearance of the mass reflex, e.g. stimulation of the skin of the leg evokes reflex flexion of the lower trunk muscles, evacuation of the bladder and rectum, and sweating.
  21. 21. B- Cervical disc herniation  Cervical intervertebral discs are bounded on their lateral margins by articulation known as the apophyseal joint which lies near the intervertebral foramen. The cervical roots may therefor be compressed, either by posterior-lateral protrusion of the disc into the spinal canal or within the intervertebral foramen. Very frequently, narrowing of the foramen occurse as a result of osteophytic formation in the apophyseal joints (spondylosis). Age, manual work and recurrent minor trauma are the chief factors. These changes may affect one disc only, most commonly that between sixth and seventh cervical vertebra, or there may be involvement of several discs
  22. 22. Clinical picture Acute herniation is usually laterally situated and causes compression of a nerve root but does not typically involves the spinal cord. Chronic degeneration of the disc may be associated with midline herniation and so spinal cord compression may result. A- Acute herniation Occurs at any age. Usually following trauma to the neck. Pain in the neck shooting to a skin area supplied by one of the lower cervical nerve roots (usually the 5th cervical root over the shoulder) with or without hyposthesia or hyperalgesia.
  23. 23. Limitation of the cervical mobility with pain provoked by passive rotation of the neck towards the side of herniation. Diminished tendon reflexes supplied by the affected root. Weakness and wasting of the involved muscles develop late as the patient usually presents in the acute phase of the disease.
  24. 24. B- Cervical spondylosis: The highest incidence is in the fifth or sixth decades of life. The symptoms are of two types depending on whether the protrusion is lateral or dorsomedial. 1-Lateral herniation: causes symptoms like those of the acute disc syndrome, but the onset may be subacute or insidious and involvement of more than one root on one or both sides is common. 2-Central herniation: causes pressure on the spinal cord and the anterior spinal artery. The onset is insidious with upper motor neuron weakness of one or more limbs due to interruption of the pyramidal tracts. Sensory loss is most common in the upper limbs where it has a dermatomal pattern. Involvement of the spinothalamic tracts cause sensory level below the affected cord segment, sometimes there may be urinary urgency or hesitancy.
  25. 25. Investigations Plain x-ray shows narrowing of the disc space and osteophyte formation. Myelography may show partial or complete obstruction of the dye at the level of the protruded disc. MRI allows good visualization of the disc and cord and confirms the diagnosis Differential Diagnosis Cervical spondylosis syndrome should be differentiated from other causes producing progressive paresis of the four limbs such as: 1) motor neuron disease, 2) multiple sclerosis. 3) subacute combined degeneration of the cord 4) spinal cord tumors.
  26. 26. Treatment Rest in bed with intermittent neck traction. Simple analgesics, e.g. NSAIDs Immobilization of the neck by collar. Surgical removal of the herniated disc.
  27. 27. C- Low back pain and Sciatica sciatica can be defined as a benign syndrome characterized by pain beginning in the lumbar region and spreading down the back of one lower limb to the ankle, usually intensified by coughing and sneezing. Etiology The most common cause is a herniation of an intervertebral disc. Other causes are less common but important to recognize. They include spinal tumors, ankylosing spondylitis, malignant disease in the pelvis and tuberculosis of the vertebral bodies. Herniation is often precipitated by trauma such as twisting the spine or lifting a heavy weight. The protruded disc causes congestion of or pressure on the nerve roots, usually the 5th lumbar and 1st sacral roots
  28. 28. Clinical Picture The onset may be sudden or gradual. Low back pain may precede sciatica by months or years. Sciatic pain is felt in the buttock and radiate down to the posterior aspect of the thigh and calf to the outer border of the foot. Parasthesia, numbness and hyposthesia over the lateral Aspect of the leg and foot. Weakness of the dorsiflexion of the big toe and foot and loss of the ankle jerk Muscle spasm causes scoliosis and loss of the lumber lordosis with tenderness over the affected vertebra. Positive kerning’s sign, i.e. trial to extend the knee while the hip is flexed at 90 degrees produce spasm of the hamstring muscles.
  29. 29. Investigation Plain x-ray of the lumbo-sacral region may be normal in acute stage, later on, there may be reduced disc space between L4-5 or L5-S1 . Also there may be osteophyte formation at the margin of the vertebral bodies. MRI is an accurate and reliable method to confirm the diagnosis. Myelography is required only if the diagnosis is in doubt or for purpose of localization before surgery. Treatment Rest in bed on a firm mattress for 2-4 weeks. Back – strengthening exercises for 2 weeks. Analgesics. Surgery if the protrusion is central and associated with bilateral signs and symptoms and sphinctenic disturbance.
  30. 30. D-The conus medullaris syndrome The last four sacral segments of the spinal cord constitute a relatively small part at the end of the cord and lies opposite the first lumbar vertebra. It is liable for compression due to the same causes as for cauda equina roots, there are no motor or sensory signs or any other symptoms in the lower limbs. The most common causes are fracture or malignant deposits involving the first lumbar vertebra. The syndrome consists of the following triad: * Overflow urinary incontinence. * Impotence. * Hyposthesia restricted to the saddle shaped area, e.g. the perianal skin supplied by the last four sacral segments.
  31. 31. E- The cauda equina syndrome Normal adult spinal cord ends at the level of the first lumbar vertebra, the rest of the spinal canal is occupied by the lumbar and sacral roots (the cauda equina roots). Each root leaves the canal below the corresponding vertebra, for example, the first lumbar root leaves the canal through the intervertebral foramen below the first lumbar vertebra.
  32. 32. Definition Compression of the cauda equina roots within the spinal canal below the level of the first lumbar vertebra. Causes The most frequent causes are neoplasm, fracture of the first lumbar vertebra or central prolapse of a lumbar disc. Clinical picture Clinical manifestations depend upon the site and extent of the compression, the lower roots are more likely to be compressed than the upper. Most Frequently the patient feels: Pains: along the distribution of one or more lumbosacral roots, e. g. gluteal region, back of the thigh, lateral aspect of the leg and dorsum of the foot. The pain is usually aggravated by straining or movement of the back. Motor manifestations: flaccid paralysis of the lower limbs of LMN type which usually is asymmetrical. Autonomic disturbance: urine and stool incontinence and impotence.
  33. 33. Investigations and management Patients with conus medullaris and cauda equina syndromes are investigated and managed in the same way as spinal cord compression.