Diseases of the Spinal
Dr. Mohamed Abdel-Fattah ElKilany
• Spinal cord segments.
• Meninges of the cord.
• 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.
This lamination pattern explains why in the progressive
extramedullary cervical cord compression, pyramidal
and sensory signs appear in legs before arms.
Spinal cord diseases occur in two major
1- Compression: extramedullary or
Clinical Picture :
3-Parasthesia: it is due to interruption of the
ascending spinothalamic tracts.
•At the level of the lesion : lower motor neuron
• 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.
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
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
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.
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
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:
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.
1-Surgical relief of the compression in cases of disc
prolapse, extramedullary tumors and urgent drainage
of spinal epidural abscess usually followed by marked
2- Radiotherapy for malignant intramedullary tumors
and metastatic deposits.
3- Specific pharmacological treatment in cases of
4- Treatment of underlying pathology.
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:
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.
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
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.
3- Specific spinal cord syndromes
The term paraplegia means paralysis confined to the lower
limbs due to damage of their motor supply at any point.
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.
Stages of paraplegia
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.
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.
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.
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
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
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.
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
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
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.
Plain x-ray shows narrowing of the disc space and osteophyte
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
Cervical spondylosis syndrome should be differentiated from
other causes producing progressive paresis of the four limbs
1) motor neuron disease,
2) multiple sclerosis.
3) subacute combined degeneration of the cord
4) spinal cord tumors.
Rest in bed with intermittent neck traction.
Simple analgesics, e.g. NSAIDs
Immobilization of the neck by collar.
Surgical removal of the herniated disc.
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.
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
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
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
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
Myelography is required only if the diagnosis is in doubt or
for purpose of localization before surgery.
Rest in bed on a firm mattress for 2-4 weeks.
Back – strengthening exercises for 2 weeks.
Surgery if the protrusion is central and associated with bilateral
signs and symptoms and sphinctenic disturbance.
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.
* Hyposthesia restricted to the saddle shaped area, e.g. the
perianal skin supplied by the last four sacral segments.
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.
Compression of the cauda equina roots within the spinal canal below the level
of the first lumbar vertebra.
The most frequent causes are neoplasm, fracture of the first lumbar vertebra
or central prolapse of a lumbar disc.
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.
Investigations and management
Patients with conus medullaris and cauda equina syndromes
are investigated and managed in the same way as spinal