The document discusses the spinal cord and compressive disorders that can affect it. It begins with the basics of spinal cord anatomy and concepts for determining the level of a spinal cord lesion. It then covers special patterns of spinal cord diseases like Brown-Sequard Syndrome. The majority of the document focuses on the different causes of compressive myelopathy, distinguishing between intramedullary and extramedullary lesions, as well as intradural and extradural causes. Common extradural compressive disorders discussed include intervertebral disc prolapse, spinal epidural abscess, and spinal tumors.

1. SPINAL CORD
&
ITS COMPRESSIVE DISORDERS
SHRUTHI.S.JAYARAJ
53rd, Calicut Medical College
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2. • Basics of spinal cord
• Determining the level of lesion
• Special pattern of spinal cord diseases
• Compressive disorders of spinal cord
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3. SPINAL CORD
• Most important content of the vertebral
canal
• Extension : medulla,upper border of C1 till
lower border of L1 /upper border of L2
(termination is variable)
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4. •
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Normal spine has a cervical and lumbar
lordosis and thoracic kyphosis
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5. • Cervical enlargement : C3 to T2
• Lumbar enlargement : L1 to S3
• Lowest conical part : conus medullaris
( S3,S4,S5)
• Conus continuous as a fibrous cordfilum terminale - extend to coccyx
• Lower end of central canal expand to
form terminal ventricle- conus
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6. oncept of spinal segments
• Length of spinal cord giving origin to
rootlets of one spinal nerve
• 31 spinal segments
• C-8
• T - 12
• L- 5
• S- 5
• C- 1
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7. • During embryological dvpt, growth of the cord lags behind
that of vertebral column
• Lower spinal nerves have to taka an increasingly downward
course to enter the corresponding intervertebral foraminabundle of nerves- cauda equina
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8. • Important for localising lesions causing spinal cord compression
• For eg, sensory loss below umbilicus – T10 – involvement of
cord adjacent to 7th or 8th thoracic vertebral body
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9. • MENINGES
• Dura,Arachnoid – second
sacral vertebra
• Ligamentum denticulatumto the inner aspect of dura
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12. Determining the level of lesion
SENSORY !
MOTOR !
SPHINCTER
!
1. The presence of a horizontal level below which sensory
,motor and autonomic function is impaired is a hallmark of
spinal cord disease.
2. Sensory loss below a particular level is due to damage to
spinothalamic tract on the opposite side one or two
segments higher in case of a unilateral lesion.
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13. • 2nd order neurons ascend for for one or two levels as they
cross anterior to the central canal to join the opposite STT
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14. • Sensory symptoms include numbness, tingling ,pins and
needles, dermal hypersensitivity, burning sensation, altered
temperature sensation and tight band like sensation.
• A complete cord syndrome- loss of all sensory modalities
below the level of lesion.
• Partial syndromes produce variable findings
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15. • Posterior column – loss of joint sense,vibration,tactile
discrimination,with positive romberg’s and ataxic gait
(sensory ataxia)
• STT – Contralateral loss of pain & temperature sensation
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16. SENSORY LEVEL
• Zone of hyperaesthesia (dorsal column) :level of lesion is
just below it
• Girdle like sensation exaggerated by cough and sneezingdorsal column
• Involvement of specific dermatomes
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17. 3. At the level of lesion –
LMN signs – focal muscle wasting, fasciculations, hypo- or
areflexia due to involvement of AHCs
Radicular pain or dermatomal sensory loss d/t
involvement of sensory roots
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18. 4. Interruption of motor tracts (pyramidal /extrapyramidal)
UMN signs below the level of lesion
if corticospinal tract – pyramidal pattern of weakness – greater in
the antigravity muscles – paraplegia in extension
if extrapyramidal tracts - progravity muscles are affected more –
paraplegia in flexion – may be associated with ‘mass reflex’
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19. Mass reflex
• Spontaneous urination, defaecation, sweating on
scratching skin on the medial aspect of thigh
• a/w reflex ejaculation and erection on squeezing glans
penis
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21. 5.The lesions that transect the motor tracts cause
paraplegia or quadriplegia with heightened DTRs ,babinski
sign and eventual spasticity ( Upper motor neuron
syndrome)
6. If Acute compressive lesion
(traumatic/vascular/inflammatory) : stage of neuronal
shock prior to the stage of spasticity
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22. 7. Transverse damage to the cord produces
autonomic disturbances -absent sweating below the
implicated cord level and bowel, bladder, sexual dysfunction
8. Most common sphincter disturbances resulting from spinal
cord diseases are urgency,frequency, urge incontinence.
retention
a /c transverse lesions –retention is the rule
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23. Localising the uppermost level of a spinal cord lesion
‘segmental signs’
• Band of altered sensation (hyperalgesia/hyperpathia) at the upper end
of sensory disturbance
• Fasciculations or muscle atrophy in muscles supplied by that sement
• Absent DTR at this level
How to differenciate from focal root or peripheral nerve disorder?
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24. Uppercervical cord lesion:
Quadriplegia
Weakness of diaphragm(above
C4)
Arnold chiari - downbeating
nystagmus & cerebellar ataxia
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Lower cervical cord lesions
Atrophy and weakness of corresponding
muscles
Spastic paralysis of trunk and lower limb
Absent biceps,radial jerk
Horner’s syndrome
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25. Thoracic cord lesions
Sensory level on the trunk,
Site of midline back pain
Beevor’s sign positive – lesion at
T9,T10
Spastic paralysis of lowerlimbs
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Lumbar cord lesions
L2-L4:weakness of Flexion
and adduction of thigh
Loss of knee jerk
Spastic paralysis
below,exaggerated ankle
jerk
Extensor plantar
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26. Cauda equina and conus medullaris lesions
CONUS MEDULLARIS
CAUDA EQUINA
B/L saddle anaesthesia
asymmetric leg weakness and
sensory loss
Prominent bowel,bladder
symptoms,impotence
Relative sparing of bowel-bladder
function
Bulbocavernous ( S2-s4) and anal
reflexes (s4-s5) are absent
Variable areflexia in lower extremities
Muscle strength largely preserved
Low back and radicular pain
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27. SPECIAL PATTERNS OF SPINAL CORD DISEASES
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28. BROWN SEQUARD SYNDROME
• HEMICORD SYNDROME
• I/L corticospinal,dorsal
column,spinothalamic
tract
• I/L – weakness,loss of
joint and vibration
sense
• C/L – loss of pain,temp
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30. Central cord syndrome
• Selective damage to grey matter and crossing
spinothalamic tracts
• Syringomyelia,intrinsic tumors of spinal cord,trauma
• Dissociated anaesthesia
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31. Shoulders,lower neck,upper
trunk –cape distribution
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32. Anterior spinal artery syndrome
• Infarction d/tanterior spinal artery
occlusion
• B/L tissue destruction which spares
posterior column
• All spinal cord functions –motor,sensory
and autonomic – are lost below the lesion
• Striking exception of retained vibration and
position sense
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33. FORAMEN MAGNUM SYNDROME
• Lesions in this area interrupt decussating
pyramidal fibres destined for the
legs,which cross caudal to those of the
arms resulting in weakness of the legs
:CRURAL PARESIS
• Around the clock pattern of weakness
• Suboccipital pain spreading to neck
and shoulders
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34. COMPRESSIVE DISORDERS OF SPINAL CORD
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35. Compressive myelopathies
• Acute compressive Myelopathy / Chronic
Myelopathy
• Extramedullary / intramedullary
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36. Compressive Myelopathy
Intra medullary
Intradural
Extramedullary
Extradural
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37. •
Cord compression
Extramedullary (95 %)
Intradural
(15%)
MENINGIOMA
NEUROFIBROMA
PATCHY ARACHNOIDITIS
AV MALFORMATIONS
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Intramedullary(5%)
Extradural
(80%)
SYRINGOMYELIA
GLIOMA,EPENDYMOMA OF
CORD
NEOPLASMS
POTT’S SPINE
IVDP
EPIDURAL ABSCESS
TRAUMA
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38. Extramedullary lesions
•
•
•
•
•
•
•
Long duration of history
Root pain (+)
Vertebral body tenderness (+)
Motor involvement usually asymmetrical
Sensory level, all sensations diminished below this level
Early loss of sensation in the saddle area ( S3,S4,S5)
Autonomic involvement late
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39. Intramedullary lesions
•
•
•
•
•
•
Short duration,painless onset
early bladder involvement
Motor – usually symmetrical
Jacket sensory loss
Dissociative sensory loss
Sacral sparing
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40. EXTRADURAL EXTRAMEDULLARY CAUSES
• 1. DICS PROLAPSE :
 Cervical disc prolapse :most common
if centrally located, can cause acute or subacute cord
compression
 Thoracic disc protrusions : sub a/c or chronic cord
compression.Can cause paraparesis / brown sequard
syndrome due to asymmetrical compression
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41. • Clear cut sensory level is usual
• Neurological symptoms may fluctuate over time
• MRI demonstrate the cord compression due to disc
prolapse.
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42. •
•
•
•
Treatment :
immobilising in a cervical collar
If highly symptomatic – surgical decompression
Complication of cervical disc surgery – irreversible
paraplegia due to cord infarction
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43. 2. Spinal epidural abscess
clinical triad : Midline dorsal pain (Over spine / Radicular)
Fever (WBC,ESR,CRP elevation)
Progressive limb weakness
Prompt recognition to prevent permanent sequelae
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44. • Abscess expand – venous congestion and thrombosis –
further cord damage
• Rapid progression once the features of myelopathy
develops
• a/w impaired immune status, IV drug abuse,skin and tissue
infections
(furunculosis,pharyngeal/dental abscess/bacterial endocarditis,pott’s spine,)
local causes :epidural anaesthesia, LP ,decubitus ulcer ,vertebral osteotomies
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45. • S.aureus, Streptococcus, anaerobes, gram neg bacilli, fungi
• MRI ,sometimes LP
• Treatment :
Surgical evacuation, decompressive laminectomy , long
term antibiotics
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46. TUMORS AND COMPRESSIVE MYELOPATHY
Metastasis - epidural
Thracic is common;
 Lumbar & Sacral – Prostate and ovarian
Breast > Lung > Prostate > Kidney > Lymphoma
 old age pt :Vertebral pain with a/c onset of
neurological deficit
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47. MRI – hypointense lesion in
T1; does not cross the
adjacent disc space
Bone scan may be useful to
detect the all other
metastasis
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48. PAIN !!
Recent onset,particularly thoracic
(aching,localised,sharp,radiating quality)
Typically worsens with movement, coughing,
sneezing and
Characteristically awakens the patient at night
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49.  Management:
-Glucocorticoid – upto 40mg/d Dexamethasone
-RT – 3000cGy in 15 daily fractions
Newer : IMRT (INTENSITY MODUALTED RT)
-Surgery- laminectomy or vertebral resection
(IF neuro signs worsen even with RT)
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50.  Prognosis:
•
Ambulatory pt – good response with RT
•
Fixed motor deficit once established
<12hr good response
>12hr chance to improve
>48hr no improvement
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51. POTT`S DISEASE
Common in paediatric and adolescent group
Incidence Reduced with pasteurisation – bovine bacillus
THORACIC cord – most common
Infective process begins in the vertebral body and spreads
to adjacent bodies leading to their collapse and angulation of
spine
Conservative treatment with anti tuberculous chemotherapy
if severe- surgical decompression
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53. NEUROFIBROMA:
• arises near posterior root
• May or may not be a/w generalised NF
• Can occur at any level of spinal cord
• Equally in both sexes
MENINGIOMA:
• Benign -thoracic cord level
more common in females
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54. REFERENCE
• Brain’s book of neurology
• Harrison’s Principles of internal medicine, 18th
E
• Neuroanatomy,inderbir singh,8th edition
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