Lec 36

MEDICINE
Neurology
Dr.Akram Al-Mahdawi
MS
Lec 2
27/12/2016

Done by : Ansam Rahumi

‫ﻣﻛﺗب اﺷور ﻟﻼﺳﺗﻧﺳﺎخ‬

• To learn some basic anatomy of spinal cord

• To have an idea about symptoms and signs of spinal cord

• How would you approach a patient with spinal cord diseases ?

• discuss a common spinal cord diseases

Cervical +1

UTh +2

LTh (7-9)
9) +3

10Th L1 cord segments

11Th L3-4

12Th L5

1st L sacral and coccygeal cord

– Motor cortex internal capsule brainstem

spinal cord

• Lower motor neuron lesion

– Anterior horn cell nerve root plexus

peripheral nerve neuromuscular junction

muscle

Basic Features of Spinal Cord Disease

– Hyperreflexia and Babinski’s

• Sensory and motor involvement that localizes to a spinal cord level

• Bowel and Bladder dysfunction common

• Remember that the spinal cord ends at about T12-L1

History
• Onset

– Acute, subacute, chronic

• Symptoms

– Pain

– Weakness

– Sensory

– Autonomic

• Past history

• Family history
Tempo of Spinal Cord Disease (read it in slides folder :)

Motor Exam
• Strength - helps to localize the lesion

– Upper cervical

• Quadriplegia with impaired respiration

– Lower cervical

• Proximal arm strength preserved

• Hand weakness and leg weakness

– Thoracic

• Paraplegia

– Can also see paraplegia with a midline lesion in the brain

• Tone

– Increased distal to the lesion

Sensory Exam
• Establish a sensory level

– Dermatomes

• Nipples: T4-5

• Umbilicus: T8-9

• Posterior columns

– Vibration

– Joint position sense (proprioception)

• Spinothalamic tracts

– Pain

– Temperature
Autonomic disturbances
• Neurogenic bladder

– Urgency, incontinence, retention

• Bowel dysfunction

– Constipation more frequent than incontinence

• With a high cord lesion, loss of blood pressure control

• Alteration in sweating

Investigation of Spinal Cord Disease

– Plain films

– Myelography

– CT scan with myelography

– MRI

• Spinal tap

– If you suspect: inflammation, MS, rupture of a vascular malformation

Etiology of Spinal Cord Disease

Traumatic Spinal Cord Disease

• MVA, sports injuries the most common

• Vic ms under 30 yrs old, male>>females

• Fx/dislocation of vertabrae most likely to occur at:

– C5,6

– T12, L1

– C1,2
Transverse myelitis
• Inflammation of the spinal cord

– Post-infectious

– Post-vaccinial

– Multiple sclerosis, NMO

• Pain at level of lesion may preceed onset of weakness/sensory change/b&b

• Spinal tap may help with diagnosis

Infections Involving the Spinal Cord

– only the anterior horn cells are infected

• Tabes dorsalis

– dorsal root ganglia and dorsal columns are involved

– tertiary syphillis

– sensory ataxia, “lightening pains”

• HIV myelopathy

– mimics B12 de ciency

• HTLV-1 myelopathy -

– tropical spastic paraparesis

Tumors
• Metastatic or primary

• Extramedullary

– Extradural - most common

• Bony - breast, prostate

– Intradural - very rare

• Meninges - meningioma
• Nerve root - schwannoma

– Intramedullary - very rare

• Metastatic

• Primary - astrocytoma or ependymoma

Multiple Sclerosis
• Demyelination is the underlying pathology

• Cord disease can be presenting feature of MS or occur at any time during the course of
the disease

• Lesion can be at any level of the cord

– Patchy

– Transverse

• NMO(Devic’s syndrome)

– Transverse myelitis with optic neuritis

Vascular Diseases of the Spinal Cord

– Anterior spinal artery infarct

• from atherosclerosis, during surgery in which the aorta is clamped, dissecting aortic
aneurysm

– less often, chronic meningitis or following trauma

• posterior columns preserved (JPS, vib)

• weakness (CST) and pain/temperature loss (spinothalamic tracts)

– Artery of Adamkiewicz at T10-11

– Watershed area

• upper thoracic

• Arteriovenous malformation (AVM) and venous angiomas

– Both occur in primarily the thoracic cord

– Can cause recurrent symptoms

– If they bleed

• Associated with pain and bloody CSF

– Notoriously difficult to diagnose

• Hematoma - trauma, occasionally tumor

B12 De ciency
• Subacute combined degeneration of the cord

• B12 de ciency

– malabsorp on of B12 secondary to pernicious anemia or surgery

– insufficient dietary intake - vegan

• Posterior columns and CST involvement with a superimposed peripheral neuropathy

Other Disease of the Spinal Cord

– Usually autosomal dominant

• Infectious process of the vertabrae

– TB, bacterial

• Herniated disc with cord compression

– Most herniated discs are lateral and only compress a nerve root

• Degenerative disease of the vertabrae

– Cervical spondylosis with a myelopathy

– Spinal stenosis

Classical spinal cord syndromes

• Brown Sequard syndrome

• Syringomyelia
• Conus medullaris/caude equina lesions

Complete

• All tracts are interrupted at the site of the lesion causing pyramidal, sensory and
autonomic dysfunction below the level of the lesion.

• Clinically pinprick most useful in localizing.

• Causes:

• Trauma,Tumour,(metastatic

Brown Sequard Syndrome

• Trauma or tumor

• Dissociated sensory loss

– loss of pain and temperature contralateral to lesion, one or 2 levels below

• crossing of spinothalamic tracts 1-2 segments above where they enter

– loss of vibration/proprioception ipsilateral to the lesion

• these pathways cross at the level of the brainstem

• Weakness and UMN findings ipsilateral to lesion

• 1. Ipsilateral pyramidal weakness

• 2. Ipsilateral dorsal column loss (propriocep on)

• 3. Contralateral spinothalamic loss (pain, temperature)

• causes

• MS

• Cord compression

Anterior cord syndrome

1. Areflexia, -flaccid paraparesis

• 2. Sphincter disturbance

• 3. Pain and temperature loss with dorsal column (propriocep on and light touch)
preservation

• causes

• Anterior spinal artery occlusion

• Cervical cord most common site

– Loss of pain and temperature related to the crossing fibers occurs early

• cape like sensory loss

– Weakness of muscles in arms with atrophy and hyporeflexia.

– Later - CST involvement with brisk reflexes in the legs, spasticity, and weakness

• May occur as a late sequelae to trauma

• Can see in association with Arnold Chiari malformation

Central cord syndrome

1. Early suspended (cape-like) pain and temp loss with preservation of dorsal columns

• 2. Forward extension = pyramidal weakness

• 3. Lateral extension = ipsilateral Horner’s

• causes

• Syrinx

• Intramedullary

• cord tumor
Anterior horn cell syndrome

• 1. Diffuse weakness, atrophy, and fasciculation's

• 2. Reduced tone

• 3. Sensory symptoms absent

• Spinal muscular atrophy

syndromes

Combined anterior horn cell+ pyramidal tract syndrome

• 1. LMN signs (fasciculations, atrophy, weakness ± pseudobulbar)

• 2. UMN signs ( planters up, spas city ±bulbar)

• 3. Preserva on of sphincters

• Amyotrophic lateral sclerosis

• (ALS)----MND
Posterolateral column syndrome

• 1. Dorsal column loss (proprioception, vibration)

• 2. UMN signs ( increase re exes, extensor plantars, weakness)

• 3. Preserva on of pain and temperature

• Subacute combined

degeneration of the spinal cord (B12 de cency)

• 1. Dorsal column loss (propriocep on, vibration)

• 2. ± Lancina ng pains (o en lower limb)

• 3. ± Lhermi e’s sign

• Tabes dorsalis

Conus Medullaris vs. Cauda Equina Lesion

Motor Symmetric Asymmetric

Sensory loss Saddle Saddle

Pain Uncommon Common

Reflexes Increased Decreased

Bowel/bladder Common Uncommon

Thank u 