SPINAL CORD COMPRESSION SYNDROMES
LECTURE
PROF MUSTAPHA ADEKUNLE
.
LECTURE AIMS AND
OBJECTIVES
Review basic anatomy of the spinal cord
Neuronal organization in the spinal cord
Relate anatomy of spinal cord to clinical
manifestation of various diseases
Understand the various spinal cord syndromes
General principles of managing spinal cord lesions
ANATOMY OF THE SPINAL CORD
Extends from the level of foramen magnum, or
upper border of the atlas to the lower border of the
1st lumbar vertebra.
Cervical enlargement
From C3 to T2 spinal levels
Lumbar enlargement
From L1 to S3 spinal levels
Conus medullaris
Terminates as filum terminale, a fine thread of pia.
ANATOMY 2
Usually considered segmental level of neuraxis
31 pairs of nerves, 8 cervical, 12,
thoracic, 5 lumbar, 5 sacral, 1
coccygeal
The lumbar and sacral roots congregate around
the filum terminale as cauda equina
Discrepancy between the cord segments and the
level of spinous processes of the vertebra
SPINE-CORD CORRELATION
Vertebral body Cord segment
C1 to C4 C1 to C4
C5 to C7 add 1
T1 to T6 add 2
T7 to T9 add 3
T10 L1 L2
T11 L3 L4
T12 /L1 L5 S1-5 Co
Owolabi MO
THE ADULT SPINAL CORD
ANATOMY
• Spinal cord terminates
at L1-L2
• Covered by 3 connective
tissue: Dura, Pia &
Arachnoid
• Dural sac ends at S2
• Terminology
– Conus medullaris: most
distal bulbous part
– Filum termiale: tapering
part of conus medullaris
(mostly fibrous tissue)
– Cauda equina: distal
collection of nerve roots
CROSS SECTION OF THE SPINAL
CORD
CROSS SECTION SHOWING
SPINAL NERVES
CORTICOSPINAL TRACT
SOMAESTHETIC PATHWAY
CEREBROSPINAL FLUID
Cerebrospinal fluid is
produced by choroid
plexus located within
floor of 3rd &4th
ventricles
Exits from the 4th
ventricle through 3
foramina into the
subarachnoid space.
Reabsorbed into blood
through arachnoid villi
on the surface of
brain
GRAY MATTER OF SPINAL
CORD
Cell bodies of neurons which receive
afferent information from spinal nerves
and send it toward the brain
Cell bodies of neurons which
receive efferent information
from the brain and send it to
smooth myocytes, cardiac
myocytes, and glands
(autonomic motor innervation)
Cell bodies of neurons which receive
efferent information from the brain and
send it to skeletal myocytes (somatic
motor innervation)
WHITE MATTER
Carries afferent
information into dorsal
horn of gray matter
Carries efferent
information away
from ventral horn of
gray matter
ARTERIAL SUPPLY OF THE CORD
Intraspinal Arteries
Anterior spinal artery
Supply the ventral gray and white matter, except the
dorsal horns and dorsal white matter
Posterior spinal arteries
Supply the dorsal horns and dorsal white matter
Extraspinal Arteries
Radicular arteries
SPINAL CORD FUNCTION
Transmits neural signals and contains neural
circuits that control reflexes
Three major functions:
Motor
Sensory
Reflex
Autonomic function
CLINICAL FEATURES
Important relay centre for reflex arcs
Control of muscles, sensation and
sphincters
Depend on extra or intradural, extra or
intramedullary
Presence and timing of pain onset
useful in determining location
Sphincteric disturbance also useful in
localization
CLINICAL FEATURES
Presence of sensory level
Distal weakness; may be spastic or
flaccid
Sphincteric dysfunction
Back pain
Incomplete cord syndromes
HISTORY
Onset
Deficits
Motor
Sensory
Progression
Time to maximum disability
Changes in deficits
Sphincter dysfunction
Autonomic changes
Preceding illness
Systemic complaints
CLINICAL FEATURES
Extramedullary and Intramedullary
compressive lesion should be
distinguished
Pain
Radicular
Lancinating, dermatomal, worsened by cough or
straining. Usually from extramedullary lesions.
Vertebral
Aching pain localised to a point on the involved
spine. Common in neoplastic and inflammatory
extradural lesions.
Central
Deep, ill-defined pain. Common with
intramedullary lesions.
UMN AND LMN SIGNS
UMN: preserved muscle bulk or atrophy of
disuse, no fibrillation/ fasciculation,
hypertonia, brisk DTR, extensor plantar
response, absent abdominal reflex
LMN: wasting, fibrillation/fasciculation,
hypotonia, hyporeflexia, flexor plantar
response
Inverted supinator jerk : C5/C6 lesion
CLINICAL FEATURES
Motor disturbances
Lower motor neurone signs
Upper motor neurone signs
These occur late with intramedullary lesions but
early with extramedullary lesion.
Sensory disturbances
Paresthesiaes
Sensory level to pain and temperature
Dissociated sensory loss and sacral sparing
are features of intramedullary lesions
SLR,Lasegue’s, Shober’s
CLINICAL FEATURES
Sphincter disturbances
Urinary and fecal incontinence or retention
Early loss of sphincter control and saddle anesthesia in
conus medularis and cauda equina lesions
Autonomic disturbances
Horner syndrome
Vasomotor or sudomotor abnormalities do not distinguish
intramedullary from extramedullary lesions
SPINAL CORD SYNDROMES
Bone level, motor level, reflex level, sensory
level
Transverse/Transection, hemisection
Extradural, intradural, intramedullary
(saddle sparing)
Anterior, Posterior, Central, Lateral
Foramen magnum ( around the clock)
Conus medullaris, (saddle anesthesia)
Cauda equina (saddle an, relative sphincter
sparing)
INTRAMEDULLARY VS
EXTRAMEDULLARY
Intramedullary Extramedullary
Poorly localized burning pain Prominent radicular pain
“sacral sparing” Early sacral sensory loss
Corticospinal tract signs Early spastic weakness in legs
appear later
Usually rapid progression Usually slow progression
(usually malignant lesion) (usually benign lesion)
CONUS MEDULLARIS VS.
CAUDA EQUINA LESION
Findings CONUS CAUDA
MEDULLA EQUINA
Motor Symmetric Asymmetric
Sensory loss Saddle Saddle
Pain Uncommon Common
Reflexes Increased Decreased
Bowel/bladder Common Uncommon
Brown-Sequard Syndrome Syringomyelia
Owolabi MO
TRANSVERSE SPINAL CORD SYNDROME
Allmotor and sensory functions below
the level of lesion are impaired
Motor disturbances
Paraplegia or tetraplegia
Lower motor neurone signs at the level of
the lesion
Paresis, atrophy, fasciculations, areflexia
Upper motor neurone signs below the level
of the lesion
Hypertonia, extensor plantar reflex, absent
abdominal reflexes
TRANSVERSE SPINAL CORD
SYNDROME
Sensory disturbances
Allsensory modalities, discriminatory and non-
descriminatory touch, position sense, vibration,
temperature, and pain are lost below the level of
the lesion
Band-like radicular pain or segmental
paraesthesiae
Localised pain over the vertebral spinous process
TRANSVERSE SPINAL CORD
SYNDROME
Autonomic disturbances
Sphincters
Urgency of micturition
Urinary retention, urinary incontinence
Constipation
Note Sphincteric disturbances results from
bilateral lesions
Anhidrosis
Trophicskin changes
Sexual dysfunction
Impotence
ETIOLOGY OF COMPRESSIVE
TRANSVERSE CORD LESIONS
Trauma
Infection (Acute, TB, Brucella, Fungal,
Schisto, Norcardia)
Neoplasms ( primary, secondariries,
lymphoma, multiple myeloma)
Abscesses
Degenerative disc disorders
Vascular (angioma, AVM)
HEMISECTION OF THE SPINAL CORD
Usually due to extramedullary lesion
Contralateral Signs
Loss of pain and temperature sensation
Due to interruption of the crossed spinothalamic tract
Ipsilateral signs at the level of the lesion
Lower motor neurone signs
Due to damage to anterior horn cells
Ipsilateral signs below the level of the
lesion
Loss of proprioceptive sensation
Due to interruption of posterior column
Spastic weakness
Due to interruption of corticospinal tracts
Brown-Sequard Syndrome
CENTRAL CORD LESIONS
Etiology
Syringomyelia, Hydromyelia, Hematomyelia
Intramedullary tumors
Early Signs
Suspended thermoanesthesia and analgesia
Dissociated sensory loss, preserved proprioception
and discriminative touch
Late signs, which follow extension of the lesion
Segmental atrophy, paresis and areflexia
Kyphoscoliosis following weakness of paraspinal
muscles
Loss of position and vibration sense
Loss of sensation below lesion with sacral sparing
POSTERIOR CORD SYNDROME
Signs
Impaired vibration and kinesthetic sense
Impaired two point discrimination
Stereoanesthesia
Impaired graphesthesia, tactile localisation
Sensoryataxia which is worse in the dark and
Romberg sign
CERVICAL SPONDYLOSIS WITH
MYELOPATHY
Most common form of myelopathy
Degenerative disease of the spine usually at
mid and lower cervical spine vertebrae
Narrowing of spinal canal and vertebral foramina
Progressive injury of the spinal cord and spinal
roots
PATHOLOGY
Fraying of annulus fibrosus
Extension of disc material in the spinal
canal
Bulging of annulus fibrosus
Osteophytes
Hypertrophied longitudinal ligaments
and ligamentum flavum
Compression of roots may lead to
degeneration in posterior columns
Compression of spinal cord may
produce demyelination or focal
necrosis
PATHOGENESIS
No clear explanation
Compression and ischemia
High mobility of lower cervical vertebrae
Diminished AP diameter of the spinal canal
Compression of spinal arteries
Trauma from sudden extreme extension
DEGENERATIVE DISEASE OF THE
SPINE
Prevalence of cervical degenerative disease
reaches 95 % at the age of 65 years
Cervical spondylosis is a non-specific
degenerative process of the spine
There is stenosis of central spinal canal and
root canals
Factors which contribute to narrowing
Degenerate disc central, or posterolateral prolapse
Osteophyte
Hypertrophy of lamina
Articular facets
Ligamentum flavum
Posterior longitudinal ligaments
DEGENERATIVE DISEASE OF THE
SPINE
There may be congenital narrowing of spinal
canal
Degenerative changes are few in the first two
decades
Changes most common at C5/C6 and C6/C7
Only a small proportion of subjects with
radiological evidence of degenerative
disease have neurological symptoms
CLINICAL PRESENTATION
Radiculopathy
Spondylotic Myelopathy
Myeloradiculopathy
RVAO, VBI
Lhermitte’s
Spurling’s
Intermittent neurogenic clausdication
CERVICAL SPONDYLOTIC
RADICULOPATHY
Referred pain in the arm from nerve root
irritation
Disc prolapse
Osteophyte
Unstable spinal segment
Pain
Centered on back of the neck
May radiate to the scapular, or anterior chest pain,
or substernally
May extend to the elbow, wrist, or fingers
Burning sensation may be present
Pain may be monoradiculopathy or
polyradiculopathy
Paresthesiae
CERVICAL SPONDYLOTIC
RADICULOPATHY
Limitation of neck motion, extension or
lateral rotation
Symptoms usually begin on waking
Symptoms worsen with Valsalva activities
Motor and reflex changes
C5/C6 disc herniation compresses C6 root
C6/C7 disc herniation compresses C7 root
INVESTIGATIONS
MRI is the investigation of choice
Cervical spine X – ray
AP, lateral, oblique views
Flexion and extension views if instability
suspected
MANAGEMENT
Spontaneous recovery is common
Analgesics/anti-inflammatories
Cervical collar speeds recovery
Surgical decompression, discectomies
CERVICAL SPONDYLOTIC MYELOPATHY
Chronic disc degeneration with
osteophytes is the most common
cause of spinal cord compression in
patients over 65 years of age
Modes of presentation
Transversecord syndrome
Brown – Séquard syndrome
Myeloradiculopathy
Numbness and paraesthesias
Usually of distal limbs, especially hands
CERVICAL SPONDYLOTIC MYELOPATHY
Cough, straining, or turning the neck
may induce electrical feelings down
the spine, Lhermitte symptom
Bladder disturbance
Fingers may feel swollen or clumsy
Weakness of small muscles of the
hand
Clumsiness
Weakness of the legs
Spasticity is more than weakness
Quadriparesis
CERVICAL SPONDYLOTIC MYELOPATHY
Muscle stretch reflexes
Loss of biceps reflex, but exaggerated triceps
reflex
Extensor plantar reflex
Sensory Changes
Impaired vibration sense, joint position sense
Romberg sign may be present
Sensory gait ataxia in some subjects
DIFFERENTIAL DIAGNOSIS
Motor neurone disease
Cervical rib
Cervical sprain
Polyneuropathies
Rheumatoid arthritis
Syringomyelia
INVESTIGATIONS
Cervical X – rays
Lossof disc height
Prominent osteophytes
MRI
Signal changes may be present within the spinal
cord
MANAGEMENT
Cervical collar to prevent repetitive cord
injury
Surgery to decompress
Discectomy
Resection of osteophytes
TREATMENT
Soft collar
Semirigid collar
Decompressive laminectomy
TB SPINE/ POTT’S DISEASES
Extradural compression
seven different types of radiological abnormalities:-
(i) disc space narrowing only
(ii) kissing lesions; half-moon
(iii) wedge collapse of vertebra;
(iv) vertebra plana;
(v) lesions localised in the vertebral body and/or its
appendages;
TB SPINE/ POTT’S DISEASE
(vi) para-spinal abscesses;
(vii) complete destruction of vertebral body.
Dorsolumbar region is the most frequently involved with
D.11 vertebra being most often affected.
Arachnoiditis, Froin syndrome,
Queckenstedt test
myelitis
Intraspinal granuloma, vasculitis with infarction,
AntiTB for 12 months,, Spinal support, decompression
OTHER CAUSES OF NARROWING
OF SPINAL CANAL
Lumbar canal stenosis
Ankylosing spondylitis
Ossification of posterior longitudinal ligament
Paget disease
Achondroplasia
Platybasia and basilar invagination
INTRASPINAL TUMOURS
Most intraspinal tumours are benign
Effects are usually due to compression
rather than infiltration
Anatomical groups
Intramedullary
Primary
Metastasis
Extramedullary
Primary
Metastasis
INTRASPINAL TUMOURS
Primary neoplasms
Intramedullary
Astrocytomas, oligodendrogliomas, Ependymomas
lipomas, teratomas
Extramedullary
Neurofibromas, more intradural than extradural
Meningiomas, sarcomas, vascular tumours, chordomas
INTRASPINAL TUMOURS
Compression of spinal cord by tumor reduces
the CSF space arround the cord
Loculation of CSF below the lesion
Increase
protein and xanthochromia (Froin
Syndrome)
INTRASPINAL TUMOURS
Secondary neoplasms
Extramedullary
Extradural
Carcinomas, lymphoma, myeloma
Intradural
Usually lymphoma spreading to the meninges
Intramedullary
Bronchogenic carcinoma
CLINICAL FEATURES
Sensorimotor syndrome
Radicular-Spinal cord syndrome
Intramedullary syringomyelic syndrome
Foramen magnum syndrome
Conus medullaris syndrome
Cauda equina syndrome
CLINICAL FEATURES
Sensorimotor spinal cord syndrome
Asymmetric spastic weakness of the legs in
thoracolumbar lesions, or arms and legs if
lesion is in the cervical region
Sensory level
Spastic bladder
Onset is usually gradual
Progressive course, which may be rapid
or leisurely
Weakness may start in one limb and
progress to others
Brown-Séquard syndrome may be
observed
CLINICAL FEATURES
Radicular-Spinal Cord Syndrome
Radicular pain, pain in the distribution of a
sensory nerve
Radiation of knive-like or sharp stab pain is
away from the spine
Pain is worsened by cough, sneezing, and
straining
Tenderness of spinous process may be
present
Segmental sensory changes often precede
compressive spinal cord features
CLINICAL FEATURES
Intramedullary syringomyelic sydrome
Pain
Dissociated sensory loss
Amyotrophy
Early incontinence
Late corticospinal weakness
Sacral sparing
CLINICAL FEATURES
Foramen magnum syndrome
Pain
Suboccipital
Lhermitte symptoms
Quadriparesis
Neck stiffness
Atrophy of the muscles of the hands and dorsal
neck muscles
Lower cranial nerve palsies, IX – XII
Horner’s syndrome
Papilledema
Downbeat nystagmus
Cerebellar ataxia
CLINICAL FEATURES
Conus medullaris syndrome
Early disturbance of bladder and bowel control,
urine retention, constipation
Erectile impotence
Symmetrical saddle anesthesia
Pain is not common, but may occur late
CLINICAL FEATURES
Cauda equina syndrome
Earlyradicular pain in the distribution of
lumbosacral roots, usually asymmetric
Pain
May be unilateral
Worse when lying down
Flaccid paresis, glutei, posterior thigh
muscles, anterolateral leg muscles, and
foot
Assymetric saddle anesthesia
Loss of ankle jerk
Sphincter disturbance
INVESTIGATIONS
MRI myelography
CSF examination
TREATMENT
Surgery
Radiotherapy
High dose steroids
INVESTIGATIONS
CT myelography
Xray : osteoblastic/ osteolytic
MRI
Bone scan
Tumor markers
DIFFERENTIAL DIAGNOSIS
Non-compressive myelopathies
SPINAL ASTROCYTOMA
LHERMITTE’S PHENOMENON
MS
Radiation myelopathy
Cerv Spondylosis
SACDC
Cord compression synd
NEUROFIBROMA
SCHWANNOMA
SPINAL MENINGIOMA
SPONDYLOSIS
CERVICAL SPONDYLOSIS
REHABILITATION AND REINTEGRATION
Motorized wheel chair
Pneumatic mattress
DVT prophylaxis
Bladder and bowel care
Skin care
Diaphragmatic pacing
Dedicated seats, toilets, walkways
NEW HORIZONS
Stem cell
Laminin
Assistive devices
Animal studies, grafting, polylaminin
