Diseases of the Spinal Cord
Prof Akram Al.Mahdawi CABM,MRCP,FRCP,FACP.FAANObjective
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 ? Come across a common spinal cord diseasesUpper vs. Lower Motor Neuron
Upper motor neuron lesion Motor cortex internal capsule brainstem spinal cord Lower motor neuron lesion Anterior horn cell nerve root plexus peripheral nerve neuromuscular junction muscleBasic Features of Spinal Cord Disease
UMN findings below the lesionHyperreflexia and Babinski’sSensory and motor involvement that localizes to a spinal cord levelBowel and Bladder dysfunction commonRemember that the spinal cord ends at about T12-L1History
Onset Acute, subacute, chronic Symptoms Pain Weakness Sensory Autonomic Past history Family historyTempo of Spinal Cord Disease
Motor Exam
Upper cervical Quadriplegia with impaired respiration Lower cervical Proximal arm strength preserved Hand weakness and leg weakness Thoracic Paraplegia Tone --Increased distal to the lesionSensory Exam
Establish a sensory level Dermatomes Nipples: T4-5 Umbilicus: T8-9 Posterior columns Vibration Joint position sense (proprioception) Spinothalamic tracts Pain TemperatureAutonomic 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 sweatingClassical spinal cord syndromes
Anterior spinal artery infarct Brown Sequard syndrome Syringomyelia Conus medullaris/caude equina lesionsBrown Sequard Syndrome
Cord hemisection 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 lesionSyringomyelia
Fluid filled cavitation in the center of the cord 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. ater - 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 malformationConus Medullaris vs. Cauda Equina Lesion
Finding Conus CE Motor Symmetric Asymmetric Sensory loss Saddle Saddle Pain Uncommon Common Reflexes Increased Decreased Bowel/bladder Common UncommonInvestigation of Spinal Cord Disease
Radiographic exams Plain films Myelography CT scan with myelography MRI Spinal tap If you suspect: inflammation, MS, rupture of a vascular malformationTumors
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 ependymomaB12 Deficiency
Subacute combined degeneration of the cord B12 deficiency malabsorption of B12 secondary to pernicious anemia or surgery insufficient dietary intake - vegan Posterior columns and CST involvement with a superimposed peripheral neuropathyTransverse myelitis
Inflammation of the spinal cord Post-infectious Post-vaccinial Multiple sclerosis Pain at level of lesion may preceed onset of weakness/sensory change/b&b disturbanceInfections Involving the Spinal Cord
Polioonly the anterior horn cells are infectedTabes dorsalisdorsal root ganglia and dorsal columns are involvedtertiary syphillissensory ataxia, “lightening pains”HIV myelopathymimics B12 deficiencyHTLV-1 myelopathy - tropical spastic paraparesisMultiple Sclerosis
Demyelination is the underlying pathologyCord disease can be presenting feature of MS or occur at any time during the course of the diseaseLesion can be at any level of the cordPatchyTransverseDevic’s syndrome or myelitis opticaTransverse myelitis with optic neuritis