spinal cord disorders

1. Spinal Cord Disorders
(Myelopathy)

2. Pain modulation
One of the important function of the reticular
formation is in the modulation of pain
stimuli
For pain from the periphery to reach the
cerebral cortex to be brought to conscious
attention, pain signals travel through the
reticular activating system through an
ascending tract
The reticular activating system also projects
descending pathways that play a role in
the analgesic pain pathway, modulating
the sensation of pain in the periphery and
blocking transmission from the spinal cord
to the cortex.

3. • The analgesic pain pathway works through the gate-control
mechanism present in the spinal cord, in which presynaptic
inhibition of pain stimulation occurs in zone II of the substantia
gelatinosa of the spinal cord before it can be transmitted to a
secondary neuron and ascend to the cerebral cortex via the
spinothalamic tract
Pain modulation

4. Pain modulation
these ascending pain signals reaching
the reticular formation in the
medulla also play a modulatory role
in autonomic function with a major
impact on cardiovascular control as
well as motor control as part of the
flight or fight sympathetic reaction
The thought is that nociceptive
stimuli reaching the reticular
formation are responsible for
the many behavioral and
defensive responses to pain.

5. Pain
• Understanding the pain and analgesic pathways that are
modulated by various regions of the cerebral cortex,
brainstem, and spinal cord can provide crucial insights into the
phenomenon of neuropathic pain.
• The thought is that since the reticular formation and other
pain modulating regions of the brain have extensive
connections to the limbic and memory centers, chronic
central pain can persist despite the cessation of the noxious
peripheral stimulus

6. Vertebrogenic Pain
• Like a modern skyscraper, the human spine defies
gravity, and defines us as vertical bipeds.
• It forms the infrastructure of a biological machine that
anchors the kinetic chain and transfers biomechanical
forces into coordinated functional activities.
• The spine acts as a conduit for precious neural
structures and possesses the physiological capacity to
act as a crane for lifting and a crankshaft for walking.

7. Vertebrogenic pain

9. Normal Spinal MRI

10. Cervical Spondylosis
Cervical spondylosis is characterized by any or
all of the following:
1. Pain and stiffness in the neck
2. Pain in the arms, with or without a
segmental motor or sensory deficit
3. Upper motor neuron deficit in the legs

11. Cervical Spondylosis - Pathogenesis
• Cervical spondylosis results from chronic cervical
disk degeneration, with herniation of disk
material, secondary calcification, and associated
osteophytic outgrowths.
• It can lead to impingement on one or more nerve
roots on either or both sides and to myelopathy
related to compression, vascular insufficiency, or
recurrent minor trauma to the cord.

12. Cervical Spondylosis - Clinical Findings
• Patients often present with neck pain and limitation of head
movement or with occipital headache. In some cases, radicular pain
and other sensory disturbances occur in the arms, and there may be
weakness of the arms or legs;
• Examination commonly reveals restricted lateral flexion and rotation
of the neck. There may be a segmental pattern of weakness or
dermatomal sensory loss in one or both arms, along with depression
of those tendon reflexes mediated by the affected root(s);
• Cervical spondylosis tends to affect particularly the C5 and C6 nerve
roots, so there is commonly weakness of muscles (eg, deltoid, supra-
and infraspinatus, biceps, brachioradialis) supplied from these
segments, pain or sensory loss about the shoulder and outer border
of the arm and forearm, and depressed biceps and brachioradialis
reflexes.

13. Cervical Spondylosis

14. Cervical Spondylosis With Myelopathy

15. Treatment
• Treatment with a cervical collar to restrict neck
movements may relieve severe pain;
• Pain may also respond to simple analgesics,
nonsteroidal anti-inflammatory drugs, muscle relaxants,
tricyclic antidepressants (taken at night), or
anticonvulsants;
• Operative treatment may prevent further progression if
there is a significant neurologic deficit; it may also be
required if the root pain is severe, persistent, and
unresponsive to conservative measures and root
compression is present on imaging studies.

16. Cervical Spondylosis With Radiculopathy

17. Lumbar Spondylosis With Radiculopathy
L4 - L5 disc herniation with
radiculopathy
L5 - S1 disc herniation with
radiculopathy

18. Lumbar Spondylosis With
Radiculopathy
• Lumbar disc herniation with radiculopathy,
axial image
Canal
Spinal cord
Herniated disc

19. Myelopathy - overview
• Cord lesions can lead to motor, sensory, or sphincter
disturbances or to some combination of these deficits;
• Depending on whether it is unilateral or bilateral, a
lesion above C5 may cause either an ipsilateral
hemiparesis or quadriparesis;
• With lesions located lower in the cervical cord,
involvement of the upper limbs is partial, and a lesion
below T1 affects only the lower limbs on one or both
sides.

20. Myelopathy - overview
• Spasticity is a common accompaniment of upper
motor neuron lesions and may be especially
troublesome below the level of the lesion in
patients with myelopathies;
• When the legs are weak, the increased tone of
spasticity may help to support the patient in the
upright position. Marked spasticity, however, may
lead to deformity, interfere with toilet functions,
and cause painful flexor or extensor spasms.

21. Traumatic Myelopathy
• Spinal cord damage may result from whiplash
(recoil) injury, severe injury to the cord usually
relates to fracture-dislocation in the cervical,
lower thoracic, or upper lumbar region,
which is commonly associated with local pain.
• The most common site for traumatic spinal
cord injury is in the cervical region.

22. Total Cord Transection
• Total transection results in immediate
permanent paralysis and loss of sensation
below the level of the lesion.
• In the acute stage, there is flaccid paralysis
with loss of tendon and other reflexes,
accompanied by sensory loss and by urinary
and fecal retention. This is the stage of spinal
shock.

23. Total Cord Transection
• Over the following weeks, as reflex function
returns, the clinical picture of a spastic paraplegia
or quadriplegia emerges, with brisk tendon
reflexes and extensor plantar responses;
• Flexor or extensor spasms of the legs may become
increasingly troublesome and are ultimately
elicited by even the slightest cutaneous stimulus,
especially in the presence of bedsores or a urinary
tract infection.

24. Spinal MRI - Traumatic Injury
Cervical T2W images

25. Spinal MRI - Traumatic Injury
Lumbar T1W and T2W images

26. Treatment
• Immobilization, decompression and stabilization;
• A clear airway must be ensured and the circulation,
blood pressure, and ventilation maintained;
• Corticosteroids (eg, methylprednisolone 30 mg/kg by
intravenous bolus followed by intravenous infusion at
5.4 mg/kg/h for 24 hours) may improve motor and
sensory function at 6 months when treatment is begun
within 8 hours of traumatic spinal cord injury.

27. Treatment
• Painful flexor or extensor spasms can be treated with drugs that
enhance spinal inhibitory mechanisms (baclofen, diazepam) or
uncouple muscle excitation from contraction (dantrolene);
 Baclofen should be given 5 mg orally twice daily, increasing up
to 30 mg four times daily;
 Diazepam, 2 mg orally twice daily up to as high as 20 mg three
times daily;
 Dantrolene, 25 mg/d orally to 100 mg four times daily;
 Tizanidine, a central α2-adrenergic receptor agonist, may also
be helpful

28. Demyelinating Myelopathies
• Multiple sclerosis is one of the most common neurologic
disorders;
• The disorder is characterized pathologically by the
development of focal—often perivenular— scattered
areas of demyelination, together with reactive gliosis,
axonal damage, and neuronal degeneration;
• These lesions occur in both white and gray matter of the
brain and spinal cord and in the optic (II) nerve.

29. MS - Myelopathy
MRI - brain T2W; Spinal cord T1W and T2W images

30. Spinal Epidural Abscess
• Epidural abscess may occur as a sequel to skin
infection, septicemia, vertebral osteomyelitis,
intravenous drug abuse, spinal trauma or
surgery, epidural anesthesia, or lumbar
puncture.
• Predisposing factors include acquired
immunodeficiency syndrome (AIDS) and
iatrogenic immunosuppression.

31. Clinical Findings
• Fever, backache and tenderness, pain in the
distribution of a spinal nerve root, headache, and
malaise are early symptoms, followed by rapidly
progressive paraparesis, sensory disturbances in
the legs, and urinary and fecal retention;
• Spinal epidural abscess is a neurologic
emergency that requires prompt diagnosis and
treatment (surgery and antibiotics).

32. Spinal Epidural Abscess - MRI

33. Chronic Adhesive Arachnoiditis
• This inflammatory disorder is usually idiopathic
but can follow subarachnoid hemorrhage;
meningitis; intrathecal administration of
penicillin, radiologic contrast materials, and
certain forms of spinal anesthetic; trauma; and
surgery.

34. Chronic Adhesive Arachnoiditis -
Diagnosis & treatment
• The usual initial complaint is of constant radicular pain, but
in other cases there is lower motor neuron weakness
because of the involvement of anterior nerve roots.
Eventually, a spastic ataxic paraparesis with sphincter
involvement develops;
• CSF protein is elevated, and the cell count may be increased;
• Treatment with steroids or nonsteroidal anti-inflammatory
analgesics may be helpful;
• Surgery may be indicated in cases with localized spinal cord
involvement.

35. Chronic Adhesive Arachnoiditis - MRI

36. Vascular Myelopathies - Spinal Cord
Infarction
• This rare event occurs most commonly in the
territory of the anterior spinal artery;

37. Spinal Cord Infarction - Clinical
Implications
• The typical clinical presentation is with the acute
onset of a flaccid, areflexic paraparesis that, as
spinal shock wears off after a few days or weeks,
evolves into a spastic paraparesis with brisk
tendon reflexes and extensor plantar responses.
• In addition, there is dissociated sensory
impairment—pain and temperature appreciation
are lost, but there is sparing of vibration and
position sense because the posterior columns are
supplied by the posterior spinal arteries.

38. Spinal Cord Infarction - MRI

39. Hematomyelia
• Hemorrhage into the spinal cord is rare; it is
caused by trauma, a vascular anomaly, a
bleeding disorder, or anticoagulant therapy;
• A severe cord syndrome develops acutely and
is usually associated with blood in the CSF.

40. Hematomyelia

41. Arteriovenous Malformation (AVM)
• This may present with spinal subarachnoid hemorrhage or
with myelopathy;
• Most of these lesions involve the lower part of the cord.
Symptoms include motor and sensory disturbances in the
legs and disorders of sphincter function. Pain in the legs or
back is often conspicuous;
• On examination, there may be an upper motor neuron,
lower motor neuron, or mixed deficit in the legs, and
sensory deficits are usually extensive but occasionally
radicular; the signs indicate an extensive lesion in the
longitudinal axis of the cord.

42. Arteriovenous Malformation (AVM) - MRI
T2W cervical segment T2W thoracic segment with
arteriography

43. Spinal Cord Tumors
A spinal tumor is an abnormal growth of tissue found in the spinal column.
Tumors can be divided into two groups:
• intramedullary (10%) and extramedullary (90%);
Ependymomas are the most common type of intramedullary tumor, and the
various types of gliomas make up the remainder;
Extramedullary tumors can be either extradural or intradural in location;
Among the primary extramedullary tumors, neurofibromas and meningiomas
are relatively common and are benign; they can be intra- or extradural;
Carcinomatous metastases (especially from bronchus, breast, or prostate),
lymphomatous or leukemic deposits, and myeloma are usually extradural.

44. Spinal cord Tumors
• A primary tumor is one that originated in the area in the area in which it
is found.
• Primary spinal tumors fall into a distinct category because their timely
diagnosis and the immediate institution of treatment have an enormous
impact on the patient's overall prognosis and hope for a cure.
• Neoplastic disease can present with back pain that is indistinguishable
from back pain resulting from more benign causes.
• Therefore, the physician caring for patients complaining of back pain is
faced with the challenges of distinguishing benign causes from those
that can be neurologically or systemically devastating and prescribing
the appropriate treatment.

45. Clinical presentation
• The most common clinical presentation associated with
all spine tumors is back pain that causes the patient to
seek medical attention.
• Back pain is the most frequent symptom for patients
with either benign or malignant neoplasms of the spine.
• Neurologic deficits secondary to compression of the
spinal cord or nerve roots also can be part of the
presentation.

46. Clinical presentation
• The degree of neurologic compromise can range from slight
weakness or an abnormal reflex to complete paraplegia,
depending on the degree of encroachment.
• The loss of bowel or bladder continence can occur from
neurologic compression or can be secondary to a local mass
effect from a tumor in the sacrococcygeal region of the spine,
as occurs in chordomas.
• Systemic or constitutional symptoms tend to be more
common with malignant or metastatic disease than with
benign lesions.

47. Metastatisc Spinal tumors
• When a tumor spreads to the spine from cancer elsewhere in the body, it is
called a metastatic spinal tumor (secondary tumor). These tumors may also be
referred to as spinal metastases
• The most common regions of the body for cancer cells to metastasize, or
spread to, include the kidneys, lungs, and bones. When cancer spreads to a
bone, it is typically one or more of the vertebrae because of the spine’s
extensive venous network.

48. Symptoms
Symptoms depend on the position of a tumor in the spinal cord, and
they often come to prominence by pressing the spinal nerves.
This can cause,
• Back pain
• Neck pain
• Numbness
• Tingling
• Weakness in the arms or legs.
• Clumsiness
• Difficulty walking
Tumors in the lower part of the spinal cord may cause loss of bladder
and bowel control (incontinence).

49. Diagnosis of Spinal tumor
Diagnosis of spinal tumor
• MRI of the spine with contrast is the investigation
of choice for a patient suspected with a spinal
tumor.

50. Spinal Cord Tumors - MRI
Spinal ependymoma
T2W image
Spinal hemangioblastoma
T1W contrast+

53. Spinal Cord Tumors - MRI
Spinal Shvanoma T2W
axial image
Spinal Shvanoma T1W
sagittal contrast+

54. Spinal Cord Tumors - MRI