DISEASES OF THE SPINAL CORD

Dr. Khairul P Surbakti , SpS

DISEASES OF SPINAL CORD

Related to special physiologic and anatomic
Including:
1. Complete sensory motor myelopathy
2. Combined painful radicular & transverse
cord syndromes
3. Hemicord (Brown-Squard syndromes)
4. Ventral cord syndromes, sparing posterior
column function
5. High cervical-foramen magnum syndromes
6. Central cord or syringomyelic syndromes
7. Syndrome of conus medullaris
8. Syndromes of cauda equina

1.

The syndrome of acute paraplegia due to

complete transverse lesion of the spinal cord
(Transverse myelopathy)
Trauma to the spine and Spinal cord
Clinical Effects of spinal cord injury
a. All involuntary movements in parts of the body
below the lesion is immediately and permanently
lost
b. All sensation from the lower parts is abolished
c. Reflex functions in all segments of the isolated
spinal cord are suspended
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Spinal shock
- Involves tendon as well as autonomic reflex
- Duration : 1 to 6 weeks as, but sometimes
longer
- Riddoch : spinal cord transection
- spinal shock & areflexia
- heightened reflex activity
- Less complete lesions little or no spinal
shocks
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Stage of Spinal shock or Areflexia

- Loss of motor function:
Cervical cord Tetraplegia
Thoracic cord Paraplegia
- Immediate atonic paralysis of bladder and bowel
- Gastric atony
- Loss of sensation below a level corresponding to the spinal
cord lesion
- Muscular flaccidity
- Almost complete suppression of all spinal segmental
reflex activity below the lesion

- Impaired of autonomic control in the segments below

the lesion
- Abolished of vasomotor tone, sweating, and
piloerection in the lower parts of the body temporarily
- Systemic hypotension
- The lower extremities lose heat
- The skin becomes dry and pale
- The spinchters of bladder and the rectum remain
contracted to some degree due to loss of inhibitory
influences of higher CNS centers, but detrussor of the
bladder and smooth muscle of the rectum atonic
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- Overflow incontinence
- Passive distension of the bowel
- Retention of feces
- Absence of peristaltic (paralytic ileus)
- Genital reflexes are abolished or profoundly depressed

Stage of Heightened Reflex activity

- The more familiar neurologic state that emerges
within several weeks or months after spinal injury
- Heightened flexion reflexes
- Babinski sign (+)
- The Achilles and patellar reflexes return
- Retention of urine becomes less complete
- Reflex defecation also begins

TRANSIENT CORD INJURY ( SPINAL CORD

CONCUSSION)
Transient loss of motor and /or sensory functions
of the spinal cord that recovers within minutes or hours
but sometimes persist for a day or several days

The syndromes including:

- bibrachial weakness
- quadriparesis ( occasionally hemiparesis )
- paresthesia or dysesthesias in a similar distribution to
the weakness or sensory symptom alone
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Central cord syndrome (Schneider syndrome) and

Cruciate Paralysis
- The loss of motor function is more severe in the
upper limb than lower limbs and particularly severe in
the hands
- Bladder dysfunction with urinary retention
- Sensory loss is often slight (hyperpathia over shoulder
and arms may be the only sensory abnormality
- Damage of the centrally ituated gray matter
atrophic, areflexic paralysis, segmental loss of pain,

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Causes :
- Retroflexion injury of the head and neck
- Hematomyelia
- Necrotizing myelitis
- Fibrocartilagenous embolism
- Infarction due to dissection
- Compression of the vertebral artery in the medullarycervical region

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Examination and Management of the spine injured

patient

The level of the spinal cord and vertebral lesions can

be determined from clinical findings
- Diaphragmatic paralysis : lesion of the upper three
cervical segments
- Complete paralysis of arm and legs : fractures or
dislocation C4 to C5 vertebrae

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The level of sensory loss on the trunk determined by

perception of pinprick an accurate guide to the level of the
lesion

If any movement or sensation is elicitable during te first 48 to 72

hours the prognosis is more favorable

If the spine can be examined safely inspection of

angulation/irregularity, signs of bony injury

In all cases of suspected spinal injury the immediate

concern is that the movement (especially flexion) of the cervical
spine be avoided.
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The patient should be placed supine on a firm, flat surface, keep

the head and neck immobile

A neurologic examination wit detailed recording of motor,

sensory, and spinchter function is necessary to follow the clinical
progress of SCI

Common practice to define the injury:

1. Complete : motor and sensory loss below lesion
2. Incomplete : some sensory preservation below the
zone of injury
3. Incomplete : motor and sensory sparing, but the patient
is nonfunctional
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4. Incomplete : motor and sensory sparing and the

patient is functional (stands and walks)
5. Complete functional recovery : reflex may be
abnormal
Group 2, 3, and 4 have a more favorable prognosis
for recovery than does group 1

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Radiologic examination:
- alignment of vertebrae and pedicles
- fractures of pedicle or vertebral body
- compression of spinal cord or cauda equina due to
malalignment , bone debris in the spinal canal, the
presence of tissue damage within cord

The MRI is ideally suited to display these process, but if

it is not available myelography with CT scanning is an
alternative

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Once the degree of injury to spine and cord have been

assessed Administer of metylprednisolone in high
dosage ( bolus of 30 mg/kg followed by 5.4
mg/kg every hour), beginning within 8 h of
the injury and continued for 23 h.

The greatest risk to the patient with spinal cord injury is

the first 10 days : gastric dilatation, ileus, shock,
infection

The mortality rate falls rapidly after 3 months

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Aftercare of patient with paraplegia :

- psychologic support
- management of bladder and bowel dirturbances
- care of skin
- prevention of pulmonary embolism
- maintenance of nutrition
- decubitus ulcers can be prevented by frequent turning
to avoid pressure necrosis
- use of special mattresses
- morning suppositories
- physical therapy
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MYELITIS
= infective and non infective inflammatory process of
the spinal cord.
If it is confined to gray matter poliomyelitis
white matter leukomyelitis
If approximately the whole cross-sectional area of the
cord is involved transverse myelitis

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The evolution of myelitic symptoms :

- Acute more or les within days
- Sub acute 2 to 6 weeks
- Chronic more than 6 weeks

CLASIFICATION OF INFLAMMATORY DISEASE

OF THE SPINAL CORD
I. Viral myelitis
A. Enteroviruses ( groups A and B Coxsackie virus,
poliomyelitis, others)
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B. Herpes zoster
C. Myelitis of AIDS
D. Epstein-Barr virus (EBV), cytomegalovirus
(CMV), herpes simplex.
E. Rabies
F. Arboviruses-flaviviruses (Japanese, West Nile,
etc.)
G. HTLV-1 (tropical spastic parapareis)
II. Myelitis secondary to bacterial, fungal, parasitic, and
primary granulomatous diseases of the meninges
and spinal cord
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A. Mycoplasma pneumoniae
B. Lyme disease
C. Pyogenic myelitis
1. Acute epidural abscess and granuloma
2. Abscess of spinal cord
D. Tuberculous myelitis
1. Pott disease with spinal cord compression
2. Tuberculous meningomyelitis
3. Tuberculoma of spinal cord

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E. Parasitic and fungal infections producing

epidural granuloma, localized meningitis, or
meningomyelitis and abscess, especially certain
form of shistosomiasis
F. Syphilitic myelitis
1. Chronic meningoradiculitis (tabes dorsalis)
2. Chronic meningomyelitis
3. Meningovascular syphilis
4. Gummatous meningitis including chronic
spinal pachymeningitis
G. Sarcoid meningitis
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III. Myelitis (myelopathy) of noninfectious

inflammatory type
A. Postinfectious and postvaccinal myelitis
B. Acute and chronic relapsing or progressive
multiple sclerosis (MS)
C. Subacute necrotizing myelitis and Devic disease
D. Myelopathy with lupus or other forms of
connective tissue disease and antipospholipid
antibody
E. Paraneoplastic myelopathy and poliomyelitis

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TUBERCULOUS SPINAL OSTEOMYELITIS

( POTT DISEASE )
- Tuberculous osteitis of the spine with kyphosis
(Pott disease) is well known in regions of endemic
tuberculosis
- Children and young adults are most often affected
- The osteomyelitis is the result of reactivation of
tuberculosis at a site previously established by
hematogenous spread

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An infectious endarteritis bone necrosis and collapse

of a thoracic or upper lumbar (
less often cervical ) vertebral body
angulated kyphotic deformity
Symptoms : fever, night sweats, elevated sedimentation
rate
In some cases : spinal deformity compresive myelopathy
Treatment :- external stabilization of the spine
- long term antituberculous medication

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TUBERCULOUS MYELITIS
- Pus or caseous granulation tissue may extrude from
infected vertebra and gives rise to an epidural
compression of the cord Pott paraplegia

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DEMYELINATIVE DISEASE
( ACUTE MULTIPLE SCLEROSIS )
- The most typical mode of clinical expression of
demyelinative myelitis is with numbness that spread
over one or both sides of the body:
from the sacral segments to the feet ant. Thighs
up over the trunk coincident with asymmetric
weakness then paralysis
- As this process becomes complete, bladder is affected
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Acute spinal MS is relatively painless and without fever

the patient usually improves with variable residual signs
Treatment :
- Corticosteroid may lead to regression of symptoms
sometimes with relapse when the
medication is discontinued.
- Plasma exchange
- IVIG

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The combination of spinal cord necrosis and

optic neuritis Neuromyelitis optica (Devics
disease)

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VASCULAR DIEASE OF THE PINAL

CORD
- In comparison with the brain , the spinal cord
is an uncommon site of vascular disease
- The spinal arteries tend not to be susceptible
to atherosclerosis and emboli rarely lodge
there.
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Vascular disorders of spinal cord :

- infarction
- dural fistula
- bleeding
- arteriovenous malformation

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INFARCTION OF THE SPINAL CORD

( MYELOMALACIA)

HEMORRHAGE OF THE SPINAL CORD

AND SPINAL CANAL (HEMATOMYELIA)

VASCULAR MALFORMATIONS OF THE

SPINAL CORD AND OVERLYING DURA

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SYRINGOMYELIA
SYRINX = PIPE OR TUBE A CHRONIC
PROGRESSIVE DEGENERATIVE OR
DEVELOPMENTAL DISORDER OF THE
SPINAL CORD
CLINICALLY : PAINLESS WEAKNESS AND
WASTING OF THE HAND AND ARMS
PATHOLOGICALLY: CAVITATION OF THE
CENTRAL PARTS OF SPINAL CORD
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USUALLY IN THE CERVICAL REGION

BUT EXTENDING UPWARD IN SOME
CASES INTO MEDULLA OBLONGATA
AND PONS ( SYRINGOBULBIA ) OR
DOWNWARD INTO THE THORACIC OR
EVEN THE LUMBAR SEGMENTS

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