Spinal cord disorders

1. SUBJECT SEMINAR
APPROACH TO SPINAL CORD LESIONS
GUIDE- Dr KALINGA B Sir
STUDENT- Dr SATISH PATIL

2. DEFINITION
Insult to spinal cord resulting in change in the
normal motor,sensory or autonomic function. This
change either temporary or permanent.

3. ANATOMY
Spinal cord lies within protective covering of vertebral column.
Begins just below foramen magnum of skull
Ends opposite 2nd lumbar vertebra
Below L2 continue as leash of nerve roots known as cauda equina.
Prolongation of Pia matter forms Filum terminale

6. Relation of spinal nerve roots to vertebrae
Spinal cord level Corresponding vertebral body
Upper cervical Same as cord level
Lower cervical One level higher
Upper thoracic Two levels higher
Lower thoracic 2 – 3 levels higher
Lumbar T10 – T12
Sacral T12 – L1

8. Markers for sensory level
T4 Nipple
T10 Umbilicus
T12 Pubic symphysis

10. Conus medullaris
• Conical structure
• Continuous with filum terminale

11. Cauda equina
• Sheath of nerve root from lumbar and
caudal segments in subarachnoid
space enlargement.
• Horse tail appearance

12. Filum terminale
• 20 cm long
• Below the level of conus medullaris
only piamater is continued as a
fibrous cord.

13. Reflex arc
 Involuntary response to a stimulus.
 Where sensory and motor nerves arise from cord
Sensory fibers enter posterior
Synapse in the grey matter
Motor fibers leave anterior

15. Spinal cord – blood supply
• Anterior spinal artery
Supplies ventral 2/3 of SC (anterior and lateral column)
One in number
• Posterior spinal artery
Supplies dorsal 1/3 of SC (posterior column)
Two in number

17. Radicular arteries
Upper half of cervical cord- no
Lower cervical & first two thoracic- 4
Mid thoracic- 1
Lower thoracic to coccygeal- arterial radicularis magna

19. Myelopathy – approach
Symptoms
• Limb weakness
• Loss of pain and temperature
• Loss of joint, position and vibration
• Sharp shooting back pain (aggravated by cough)
• Bowel and bladder incontinence

20. Approach to patient
History
Onset
1.Sudden – trauma – Fracture dislocation of vertebrae
infection – Epidural abscess
vascular- Thrombosis of ASA , hematomyelia ,
Transverse myelitis , multiple sclerosis
2.Gradual – Neoplastic – meningioma , ependymoma , glioma,
astrocytoma

21. Sensory: 1.sacral sparing - intramedullary lesion)
2.radicular(root) pain- extramedullary lesion
3.poorly localised burning pain- intramedullary lesion
Motor –limb involvement symmetrical or sequential
-weakness more in proximal muscles ( difficulty in getting from
sitting posture , climbing stairs , buckling of knees)
- weakness is progressive or static
H/O diurnal variation of weakness or fatiguability suggests – NMD(myesthenia
gravis)
H/O presence of stiffness or scissoring of limbs while walking, involuntary
movements ( flexor spasms –UMN lesion)

22. Sphincter disturbances
- urgency,hesitancy – UMN type of bladder
- Painful retention with overflow incontinence – LMN etiology
- Early bladder involvement – intramedullary lesion

23. Associated symptoms
 Fever – infective causes
 Seizures, delayed milestones
 Associated specific symptoms – vit B12 deficiency
History about
 Preceding illness
 Trauma
 Prior vaccination

24. Examination
General physical examination
o Lymph node ( TB, lymphoma, malignancy)
o Temperature ( TB, acute transverse myelitis)
o Skin ( café au lait spots in neurofibroma, trophic changes)
Higher mental function
o Affected in cerebral and degenerative diseases
o Staccato speech in multiple sclerosis
o Dysarthria in ALS and syringomyelia

25. Cranial nerve examination
• Affected in brain stem lesions
• Optic atrophy – friedrich ataxia , multiple sclerosis
• Nystagmus in multiple sclerosis
• Pupillary changes in neurosyphilis
• Difficulty on swallowing – ALS
Tone and DTR
• Increased in UMN
• Decreased in LMN
Sensory examination
Proper examination of skull and spine

26. Paraplegia
• Pyramidal (UMN ) lesion – spastic paraplegia
• Lower motor neuron ( LMN ) lesion – flaccid paraplegia

27. Spastic paraplegia
• Weakness of muscle along with increased tone
• Occurs due to UMN disease
Increased tone
Exagerated DTR
Plantar extension
Further devided;
-Paraplegia in extension
-Paraplegia in flexion

28. Paraplegia in extension Paraplegia in flexion
Cause Pyramidal lesion Pyramidal or extrapyramidal
Hypertonia More in extensors More in flexors
Position of LL Extended Flexed
Deep reflexes Exaggerated Less exagerated
Clonus Present Absent
Mass reflex Absent May be present
Bladder precipitancy Autonomic bladder

29. Causes
Cortical
Superior saggital sinus thrombosis
Thrombosis of unpaired anterior cerebral artery
Parasaggital meningioma
Multiple sclerosis
Space occupying lesion over motor area ; gliomas

30. Myelopathy – classification
Myelopathy
Compressive Non compressive
Extradural Intradural
Extramedullary Intramedullary

31. Compressive myelopathy

32. 1.Extradural
Craniovertebral anomalies
Cervical spondylosis
Trauma
Epidural abscess
Aortic aneurysm compressing vertebral column
Myeloma
metastasis

33. 2.Intradural
Extramedullary lesion Intramedullary lesion
Manifestations Stage 1: Root pain
Stage 2: brown Sequard syndrome
Stage 3: complete transection
Motor UMN- early involvement with sacral sparing
LMN- not involved
UMN- late involvement
LMN- due to AHC affection
Sensory Dissociative sensory loss
(spinothalamic lost, posterior column
spared)
ANS Not very common Early bowel and bladder involvement
Trophic changes Not very common Common due to loss of pain
Spinal deformity
Spinal tenderness
Present Absent
CSF proteins Present Absent
Examples Trauma
Tumour/mets
Aneurysm
TB/ syphilis
Neurofibroma
Meningioma
Arachnoid cyst
Pachymeningitis

34. Tumors
• Most spinal tumors are extradural – about 85%
Primary- spine
Secondary – lung, breast,prostate,kidney ,thyroid
Symptoms
-pain
-numbness
-muscle weakness ,spasticity
-loss of bowel and bladder control

35. 1.Extradural tumors
 Most common spinal tumor -85%
 Mostly metastatic
 Arise from osseous element
of spinal column.
 Primary: lung,breast,
prostate and kidney.
 Collapse of vertebrae distortion
and narrowing.
Ex ;
1. -Lymphoma
2. -Hemangioma
3. -Neuroblastoma

36. 2.Intradural extramedullary tumors
• Inside the dura but outside the spinal cord.
• Arise from dural sheath around the cord or shwann
cell sheath around the spinal root
• Can grow into retroperitoneal or retropleural through
intervertebral foramen
Ex;
Meningeoma
Neurinoma

37. 3.Intradural intramedullary tumors
• Inside the spinal cord
• Arise from glial elements
of spinal cord
• More common in children
Ex
Astrocytoma –most common
intramedullary tumor of childhood.
Ependymoma – most common
intramedullary tumor of adulthood

38. Non compressive myelopthies
1. Infections: TB/ HIV/ Lyme’s disease
2. Demyelinating disorders: Multiple sclerosis, ATM
3. Nutritional: SACD
4. Vascular: Anterior spinal artery syndrome, Leriche’s syndrome
5. Autoimmune: Lupus
6. Traumatic: Electric shock
7. Hereditary: Freidrich’s ataxia
8. Toxic: Lathyrism, flourosis

39. Pott’s disease
Infection reaches – Hematogenous spread
- Adjescent paravertebral lymph nodes
Involves two or more vertebral bodies
Most common – lower thoracic and upper lumbar vertebra
Collapsed vertebra or abscess cause compression of spinal cord leading to
paraparesis
X-ray shows decreased vertebral height collapsed vertebrae and irregular
vertebral margins

41. Acute transverse
myelitis
Gullian barre
syndrome
Lower limb > upper
limb
Progressive lower limb
Proximal>distal
Weakness Symmetrical Ascends to upper
limbs and to face
Sensory Sensory ataxia Normal
Reflexes Hyperreflexia below
the lesion
Areflexia
Bladder symptoms + -
Band like sensation
(Definite sensory level)
-

42. Friedreich’s ataxia and Sub acute combined degeneration
FRIEDREICH’S ATAXIA SACD
DRG -> Spinal cord ->
Peripheral nerves
Post column -> CST ->
Peripheral neuropathy
Reflexes Areflexia in lower limb Lost due to peripheral
neuropathy
Sensory Sensory ataxia Loss of vibration sense
Tingling and numbness
Weakness UMN type UMN type
Associated
findings
Cardiomyopathy
Optic atrophy
Vitamin B12 deficiency
Bilateral optic neuropathy
Dementia

43. Quadripares /quadriplegia
Compressive
1.Trauma
2.Tumors
- Metastatic
- Primary
3.Vertebral disease
-Disc Prolapse
-Spondylosis
-Pagets Disease
-Deformity

44. Non compressive
• Infection – bacterial osteomyelitis, spinal abscess, HIV infection
• Inflammatory – transverse myelitis, multiple sclerosis, SLE.
• Vascular – Anterior spinal artery occlusion
-Angioma
-Av malformation
• Others
-Degenerative MND
-Vit B12 deficiency

45. Spinal cord injury
1.Primary
- initial mechanism of injury
2. Secondary
Ongoing progressive damage
- Ischemia
- Hypoxia
- Microhemorrhage
- Edema

46. Statistics
National Spinal Cord Injury Database ( NSCISC)
 MVA - 38.2%%
Falls - 32.3%
Violence - 14.3%
Sports - 7.8%
Medical and surgical- 4.1%
-55% cases occur in 16- 30 years of age
- Among 81.6% are male.

47. Mechanism of injury
 Flexion
 Hyperflexion
 Compression
 Rotation

48. Flexion (hyper flexion)
• Most common because of natural protection position

50. Compression
• Cause by force from above , as hit on head
• Below as landing on butt
• Usually affects lumbar region

51. Rotation
• Most unstable
• Results in tearing of ligamentous structures that normally stabilize the
spine
• Usually results in serious neurologic deficits.

52. Classification of spinal cord injury
(Degree of injury )
1. Complete
2. Incomplete
 Central cord syndrome
 Anterior cord syndrome
 Brown sequard syndrome
 Posterior cord syndrome
 Cauda equina and conus medullaris

53. Complete
Features
- Loss of voluntary movement
of parts innervated by segment
this is irreversible.
- Spinal shock
Deficits
 Motor – spastic paralysis below level of injury
 Sensory – loss of all sensation perception
 Autonomic – vasomotor failure and spastic bladder

54. Incomplete
 Some function is present below site of injury
 More favourable prognosis overall
 Are recognizable pattern of injury, although they are rarely pure and
variations occur

55. Central cord syndrome
 Injury to center of the cord
by edema and hemorrhage
 Motor weakness and sensory loss in all extremities
 Upper extremities affected more

56. Anterior cord syndrome
 Injury to anterior cord
 Loss of voluntary motor,
pain and temperature perception below injury
 Retains posterior column function
(sensation of touch , position, vibration, motion)

57. Posterior cord syndrome
 Least frequent syndrome
 Injury to the posterior(dorsal) column
 Loss of proprioception, pain , temperature sensation.
 Motor function below the
level of lesion remain intact
 Usually good power and sensation

58. Brown – Sequard syndrome:
 Hemisection of cord
 Ipsilateral paralysis
 Ipsilateral superficial sensation,
vibration and proprioception loss.
 Contralateral loss of pain and
temperature perception.

60. Cauda equina and conus medullaris
Conus medullaris
- injury to the sacral cord (conus) and lumbar
nerve roots
Cauda equina
- injury to the lumbosacral nerve roots
RESULT - areflexic ( flaccid) bladder and bowel , flaccid lower limbs

61. Conus medullaris and cauda equina syndrome
Conus medullaris syndrome Cauda equina syndrome
Vertebral level L1-L2 L2-sacram
Spinal level Sacral cord segment and roots Lumbosacral nerve roots
Presentation Sudden and bilateral Gradual and unilateral
Radicular pain Less severe More severe
Low back pain More Less
Motor strength Symmetrical,less marked hyperreflexic distal
paresis of lower limb, fasciculation
Symmetric , more marked ,areflexic
paraplegia, atrophy more common
Reflexes Ankle jerks affected Both knee and anke jerks affected
Sensory Localised numbness to perianal
area,symmetrical and bilateral
Localised numbness at saddle area,
asymmetrical,unilateral
Sphincter dysfunction Early urinary and fecal incontinence Tend to present late

62. Syringomyelia
Cavitatory expansion of central canal of spinal cord (lower cervical)
Associated with ARNOLD CHIARI MALFORMATION TYPE 1 (75%)
Syringomyelia reaching medulla is syringobulbia

63. Clinical features
• Like an intramedullary lesion
• HALF CAPE distribution of sensory loss
Sensory loss along chest, upper arm, shoulder
• ONION PEEL PATTERN ON FACE
Loss of sensation on face
• Compression of AHC
Wasting of thenar eminence, forearm, arm
• Spastic weakness
• Horner’s syndrome (C8-T1)

65. Chiari malformation
Type 1 Herniation of cerebellear
tonsils
Associated with
syringomyelia
Type 2 (Arnold Chiari) Herniation of cerebellar
vermis
Usually accompanies by a
lumbar myelomeningocele
Type 3 Occipital encephalocele Usually with
syringomyelia,tethered
cord and hydrocephalous
Type 4 Lack of cerebellar
development
Not compatible with life

67. Clinical manifestations based on the level of the lesion
1) Lesion at foramen magnum
• Around the clock weakness or ELSBERG PHENOMENON
• Cruciate hemiparesis
• Suboccipital pain with radiation to neck and shoulders
• Bilateral papilledema due to raised ICT

68. 2) Lesion at C5-C6
• Inverted supinator reflex
• Paraplegia
3) Lesion at C8-T1
• Wasting of small muscles of hand
• Horner’s syndrome
• Spastic paralysis of trunk and lower limbs

69. 4) Lesion in the mid thoracic region
• Wasting of intercoastal muscles
• Spastic paralysis of abdominal muscles and lower limbs
5) Paraplegia – lesion below T10 vs Above T10
• On flexion of neck and contraction of abdominal muscles, if the umbilicus moves
2-3 cm upwards; indicates a T10 pathology
• Upper abd reflex preserved
• Lower abd reflex lost BEEVOR’s SIGN +
• Loss of tone of lower abd muscles

70. 6) Lesion at T12-L1
• Cremasteric reflex lost
7) Lesion at L3-L4
• Wasting of quadriceps and hip adductors
• Knee jerk lost, ankle jerk present
• Extensor plantar, foot drop

71. 8) Lesion at S1-S2
• Wasting of intrinsic muscles of foot
• Knee jerk preserved, ankle jerk is lost
• Plantar reflex is lost
9) Lesion at S3-S4
• Anal and bulbocavernous reflexes are lost
• Saddle anesthesia

72. Determination of the level of the lesion
• Below the level of lesion
UMN weakness, hyperreflexia, complete sensory loss
• At the level of lesion
LMN weakness, areflexia, root pain/ dysesthesia/ paresthesia
• Above the level of lesion
Complete sparing

73. Investigation
X-ray
CT scan
MRI
Myelogram
Biopsy
Bone scan
Blood and spinal fluid studies

74. CSF analysis
Routine cell count, glucose,protein,serological tests-syphilis
Froin’s syndrome-in spinalcanal blockage
(xanthochromia and Increase in protein as a result of which fluid –
coagulate spontaneously)
slight or no increase in cells , oligoclonal bands in multiple sclerosis
IgG index, CSF culture and sensitivity ,PCR for VZV,HSV-1,HSV-2 ,EBV,
CMV ,HHV-6,HIV

75. Immune mediated disorders
ESR,ANA,RA factor,antiphospholipid antibodies ,p-ANCA
Schirmer test, salivary gland scintigraphy ,lacrimal gland biopsy –
sjogrens syndrome
Demyeilinating disease
MRI brain , CSF oligoclonal bands,neuromyelitis optica antibody (anti-
aquaporin-4)

76. • MRI –investigation of choice for cord compression
-can differentiates syringomyelia from intramedullary tumors,
transverse myelitis etc
• CT-SCAN – detecting bony abnormalities like
osteomyelitis,metastasis,myeloma,osteosclerosis
• Chest-xray- lung carcinoma to rule out possible mets, mediastinal widening in
lymphoma
• Cerebral angiography-vascular abnormality
• Fundus – papilledema in intracranial tumor. Temporal pallor in multiple
sclerosis,

77. Therapeutic interventions
• Stabilisation /immobilisation
• Traction
-Gardner- well tongs
-Halo
Casts
Splints
Collars
Braces

78. Management of spinal cord injuries
A-B-C-D-E sequance
Airway management
-Use bag-valve-mask devise initially for airway compromise

79. Breathing
 Lesions above C5 level will cause partial to complete diaphragmatic
paralysis
 Any lesion above T12 may cause some airway compromise,
 Lesions at C5 and below will allow full diaphragmatic movement, but
intercostal muscles (T1) and abdominal muscles (T12) are affected

80. Circulation
Cardiac output is affected by external or internal hemorrhage.
To determine external bleeding , turn the patient in log-roll fashion
and quickly note the site of injury
Two signs of internal bleeding from abdominal trauma are abdominal
pain and muscular rigidity.
However, these signs may be masked in a patient with sensory and
motor deficits.

81. Exposure
• Patients with spinal cord injury become poikilothermic
• Because they lose the ability to regulate core body temperature
through vasodilatation and vasoconstriction

82. Neurological/orthopedic management
• Reduction
• Fixation
• Fusion
Fixation involves stabilizing vertebral fractures with wires ,plates and
other types of hardware

83. Rehabilitation and Long- Term issues
• Mobility
• Self care
• Exercise
• Spasticity
• Contractures
-Bed mobility
-Pressure relief
-Wheel chair transfer

84. References
• Guyton and hall textbook of medical physiology
• Localisation of clinical neurology ; Paul w Brazis
• Adams and victors Principles of neurology
• Harrison’s neurology in clinical medicine