diseases of the spinal cord pdf - Prof Akram Al.Mahdawi

Medicine

Dr. Akram

Neurology

“

Diseases of the Spinal Cord

”

Prof. Akram AI-Mahdawi

LECTURE 12

Diseases of the Spinal Cord Prof. Akram Al-Mahdawi

Diseases of the Spinal Cord

- Prof Akram Al-Mahdawi
- CABM, MRCP, FRCP, FACP& FAAN

Objectives



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 diseases

Upper vs. Lower Motor Neuron



Upper motor neuron lesion (UMNL)

Motor cortex internal capsule brainstem spinal cord



Lower motor neuron lesion (LMNL)

Anterior horn cell nerve root plexus peripheral nerve
neuromuscular junction muscle

Basic Features of Spinal Cord Disease



UMN findings below the lesion

- 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

This box was added by the students for those who don’t know what these
abbreviations mean:

CABM:

Certification of Arab Board of Medical Specialization

MRCP& FRCP: Member and Fellow of the Royal College of Physicians

FACP: Fellow of the American College of Physicians

FAAN: Fellow of the American Academy of Nursing

Diseases of the Spinal Cord Prof. Akram Al-Mahdawi

History



Onset

- Acute, subacute and chronic



Symptoms

-  Pain
-  Weakness
-  Sensory
-  Autonomic



Past history



Family history

Tempo of Spinal Cord Disease

Etiology

Acute

Subacute

Chronic

Trauma

Mass lesion

Infections

Inherited

Vascular

Autoimmune

Nutritional

This box was added by the students and it has been explained by Dr. Akram:

Before continuation you have to understand and review the spinal cord pathways (sensory and
motor): dorsal column& spinothalamic-sensory pathways- and corticospinal -motor pathway.

You can find series of 4 videos explaining these pathways on YouTube under the name of

Spinal

pathways uploaded by Handwritten Tutorials.

Or you can find a summary page from (First Aid for USMLE step 1 version 2015) uploaded in

www.muhadharaty.com

(Baghdad college of medicine 5

grade Neuromedicine

Prof. Akram Al.Mahdawi diseases of the spinal cord)

Diseases of the Spinal Cord Prof. Akram Al-Mahdawi

Motor Exam



Upper cervical

- Quadriplegia with impaired respiration



Lower cervical

- Proximal arm strength preserved
- Hand weakness and leg weakness



Thoracic

- Paraplegia

Note: 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 and retention



Bowel dysfunction

- Constipation more frequent than incontinence



With a high cord lesion, loss of blood pressure control



Alteration in sweating

Diseases of the Spinal Cord Prof. Akram Al-Mahdawi

The picture below was added by the students it is not included in the lecture:

Classical spinal cord syndromes



Anterior spinal artery infarct



Brown Sequard syndrome



Syringomyelia



Conus medullaris/caude equina lesions

Brown 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 lesion

Diseases of the Spinal Cord Prof. Akram Al-Mahdawi

Syringomyelia



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 – corticospinal tract 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

Conus Medullaris vs. Cauda Equina Lesion

Finding

Conus Medullaris

Cauda Equina

Motor

Symmetric

Asymmetric

Sensory loss

Saddle

Pain

Uncommon

Common

Reflexes

Increased

Decreased

Bowel/bladder

Common

Uncommon

Investigation of Spinal Cord Disease



Radiographic exams

-  Plain films
-  Myelography
-  CT scan with myelography
-  MRI



Spinal tap

- If you suspect: inflammation, MS and rupture of a vascular

malformation.

Diseases of the Spinal Cord Prof. Akram Al-Mahdawi

The picture below was added by the students it is not included in the lecture:

Spinal cord

Dura matter

The figure above demonstrates the different locations of spinal cord tumors, (A)
Intramedullary tumors (B) Extramedullary – Intradural tumors (C) Extramedullary –
Extradural tumors

Tumors



Metastatic or primary

- Extramedullary

 Extradural (most common)

 Bony, breast or prostate

 Intradural (very rare)

 Meninges - meningioma

 Nerve root - schwannoma

- Intramedullary (very rare)

 Metastatic

 Primary - astrocytoma or ependymoma

Diseases of the Spinal Cord Prof. Akram Al-Mahdawi

B12 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 corticospinal tract involvement with a

superimposed peripheral neuropathy

Transverse myelitis



Inflammation of the spinal cord

-  Post- infectious
-  Post- vaccinial
-  Multiple sclerosis



Pain at level of lesion may precede onset of weakness/sensory

change/bladder and bowel disturbances.

The picture above was added by the students it is not included in the lecture

Diseases of the Spinal Cord Prof. Akram Al-Mahdawi

Infections Involving the Spinal Cord



Polio

- Only the anterior horn cells are infected



Tabes dorsalis

-  Dorsal root ganglia and dorsal columns are involved
-  Tertiary syphilis
-  Sensory ataxia, “lightening pains”



HIV myelopathy

- Mimics B12 deficiency (Subacute combined degeneration of the

cord)



HTLV-1 myelopathy

- Tropical spastic paraparesis

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



Devic’s syndrome or myelitis optica

- Transverse myelitis with optic neuritis

Diseases of the Spinal Cord Prof. Akram Al-Mahdawi

Vascular Diseases of the Spinal Cord

 Infarcts



Anterior spinal artery

- From atherosclerosis, during surgery in which the aorta is

clamped, dissecting aortic aneurysm
 less often, chronic meningitis or following trauma

- posterior columns preserved (joint position sensation and

vibration)

- weakness (corticospinal tracts) 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



May present either acutely, sub acutely or chronically (act as a

compressive lesion)



Can cause recurrent symptoms



If they bleed:

- Associated with pain and bloody CSF



Notoriously difficult to diagnose

 Hematoma - trauma, occasionally tumor

Other Disease of the Spinal Cord



Hereditary spastic paraparesis

- Usually autosomal dominant



Infectious process of the vertebrae

- TB, bacterial



Herniated disc with cord compression

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



Degenerative disease of the vertebrae

- Cervical spondylosis with a myelopathy
- Spinal stenosis

End

Diseases of the Spinal Cord Prof. Akram Al-Mahdawi

Appendix

(added by the students not included in the lecture):

The picture above summarizes the different locations of the spinal cord lesions.

Cases

Case (1)

A 19-year-old man is brought in to the emergency department after being stabbed in the back.
He has no past medical history and takes no medications. Muscle strength is absent and tone
is decreased in the right leg. The right patellar and Achilles reflexes are absent. Babinski
sign is present on the right. There is a loss of vibratory sense and toe joint position on the
right. There is a loss of pain and temperature sensation below T12 on the left. Which of the
following will cause a loss of pain and temperature sensation on the left side, beginning at T12?

A.  Damage to left-sided lateral spinothalamic tracts at T10
B.  Damage to left-sided lateral spinothalamic tracts at T12
C.  Damage to left-sided lateral spinothalamic tracts at L1
D.  Damage to right-sided lateral spinothalamic tracts at T10
E.  Damage to right-sided lateral spinothalamic tracts at T12

Diseases of the Spinal Cord Prof. Akram Al-Mahdawi

Explanation:

The Brown-Sequard syndrome is associated with damage to the lateral spinothalamic tracts
causing contralateral loss of pain and temperature sensation beginning two levels below the
level of the lesion (remember that the spinothalamic tracts cross very early on in the
spinal cord). Therefore, a lesion of the right-sided lateral spinothalamic tracts at T10 will result in
a left-sided loss of pain and temperature sensation beginning at T12

So the answer is D

Case (2)

A 33-year-old white female comes to the office for the evaluation of weakness in her upper
extremities. She thinks she is unable to feel pain or heat, because she recently noted some
burn wounds on her fingertips, and does not know how she got them. She denies weakness in
her lower limbs, as well as any history of trauma, headache, bowel or bladder problems, neck
pain or facial pain. Examination reveals absent reflexes in her upper limbs. There is absent
pain and temperature sensation on the nape of neck, shoulders and upper arms in a 'cape'
distribution. Vibration and position sensations are preserved. Which of the following is the
most likely pathology of the patient's condition?

A.  Caudal displacement of the cerebellar tonsils and vermis
B.  Caudal displacement of the fourth ventricle
C.  Cord cavitation
D.  Focal cord enlargement
E.  Disc herniation and cord compression

Explanation:

The above patient is most likely suffering from syringomyelia. Areflexic weakness in the upper
extremities and dissociated anesthesia (loss of pain and temperature with preserved position and
vibration) in a "cape" distribution are classic findings of this condition. The pathology involves
cavitary expansion of the spinal cord, which may produce myelopathy. There is destruction of the
gray and white matter adjacent to the central canal. The most characteristic feature is the
presence of a cord cavity, which usually communicates with the central canal of the spinal cord.
The most frequent site of involvement is the lower cervical or upper thoracic region. When the
syringes occur in the upper cervical cord and extend proximally to involve the medulla oblongata,
the condition is called syringobulbia. Acquired causes of syringomyelia include trauma,
inflammatory spinal cord disorders or spinal cord tumors. Occasionally, syringomyelia is
idiopathic.

So the answer is C