2(E): Spinal Cord Disease Flashcards
What does degenerative disc disease refer to
Group of disorders including:
- Disc protrusion
- Disc herniation
- Disc sequestration
What is disc protrusion
Where nucleus pulpous presses on annulus fibrosis
What is disc prolapse (herniation)
Tear in annulus fibrosis leading to protrusion nucleus pulposus that can compress spinal nerve
What is disc sequestration
Extrusion nucleus pulposus and seperation fragment, that enters spinal canal, may compress spinal cord
What age group does IV disc prolapse most commonly occur
30-50
In which gender does IV disc prolapse occur
Male
What are the most common sites of disc prolapse
L5/S1
L4/L5
What is classical history of disc prolapse
Individual strains back (eg. lifting) then has back pain which is worse on coughing, sneezing, lifting
Describe pain in IV Disc prolapse
Lumbago - electric shock type pain
Sciatica - bilateral shooting pain down the legs
Explain sensory and motor symptoms in IV Disc Prolapse
Pareasthesia of the nerve root affected (Nerve root affected tends to be one under disc that has prolapsed)
Muscle weakness
Loss deep tendon reflexes
What worsens pain in disc prolapse
Coughing
Sneezing
What improves pain in disc prolapse
Short walks
Change in position
What deficit will be present in L4-L5 disc prolapse
L5 radioculopathy
What sensation is impaired in L4-L5 disc prolapse
Dorsum Foot
What movement is lost in L4-L5 disc prolapse
Toe Extension
What test is positive in L5 radiculopathy
Sciatic stretch test
What sensation is impaired in L5-S1 disc prolapse
Dorsum Foot
Back of calf
What motor deficits are there in L5-S1 prolapse
Calf-pain
Weak plantar flexion
What test is positive in S1 radiculopathy
Sciatic stretch test
What investigaiton is ordered for possible disc prolapse
MRI Spine
If caudal equine present in disc prolapse what is done
Refer to neurosurgery
If no cauda equina in IV disc prolapse, what is done
- Analgesia
- Rest, Early Mobilisation
- Physiotherapy
What is cauda equina syndrome
Compression cauda equina
What spinal level does the cauda equina start
L1-L2
Give 5 causes of cauda equina syndrome
- Disc Prolapse
- Traumatic
- Malignancy
- Infection (Pott’s Disease, Discitis)
- Ankylosing spondylitis (Due to chronic inflammation)
- Iatrogenic
What are three groups of cauda equina
- cauda equina syndrome with retention (CESR)
- cauda equina syndrome incomplete (CESI)
- cauda equina syndrome suspected (CESS)
How does cauda equina syndrome with retention (CESR) present
- Back pain
- LL weakness
- Bilateral loss reflexes
- Saddle anaesthesia
- Loss anal tone
- Loss badder control
Incomplete How does cauda equina syndrome
Same as CESR, except there is altered urinary sensation - opposed to loss of bladder control. This can cause painful then painless retention
How does cauda equina syndrome suspected present
- Back pain
- LL pain
- Variable neurological symptoms
Will cauda equina present with UMN or LMN signs and symptoms
LMN
What are symptoms of cauda equina
- Back pain
- Bilateral sciatica
- LL weakness
- LL parasthesia
- Saddle anaesthesia
- Impotence
- Bowel and bladder dysfunction
What are signs of cauda equina
- Loss anal tone
- Urinary retention: palpable bladder
- Hypo-reflexia
What examination is required in cauda equina
PR Exam: assess anal tone
What imaging is ordered in cauda equina
Bladder USS
Whole-spine MRI (Gold-standard)
How is cauda equina managed
Neurosurgical review:
Dexamethasone
Spinal decompression
What is spinal cord compression
Compression of spinal cord
What is the most common cause of spinal cord compression
Metastatic spinal cord compression
What cancers cause metastatic spinal cord compression
BLTKETCHUP
Breast Lung Thyroid Kidney Prostate
Aside from metastatic spinal cord compression, what else can cause spinal cord compression
- Infection (abscess)
- Traumatic - vertebral fracture, facet joint dislocation
- Neoplastic - myeloma
Why is disc herniation a rare cause of spinal cord compression
As disc herniation typically occurs in lumbar region which causes cauda equina, opposed to spinal cord compression
In general, what increases risk of spinal cord compression
Factors that cause stenosis of the spinal canal - these can be degenerative or inflammatory
What inflammatory conditions predispose to spinal cord compression
RA, Ankylosing spondylitis
What degenerative conditions predispose to spinal cord stenosis
Osteophyte (OA)
Ligamentum Flavum Hypertrophy
Is spinal cord compression UMN or LMN lesion and explain why
LMN at the level of the lesion - due to compression of anterior horn cells
UMN below the lesion - due to compression of descending corticospinal tract
What is often first stage of spinal cord compression
Back pain
When is back pain worse in spinal cord compression
Coughing
Sneezing
Lying Down
Explain sensation and proprioception
Sensation and proprioception impaired
Explain reflexes at level of the lesion
Hypo-reflexia
Explain reflexes at levels below the lesion
Hyper-reflexia
What other features will be present in spinal cord compression
Myoclonus
Upgoing babinski reflex
What are late symptoms of spinal cord compression
Autonomic symptoms: bowel or urinary incontinence/retention = carry a poor prognosis
How is spinal cord injury divided
Complete SCI
Incomplete SCI
Define complete SCI
No preservation of sensory motor function more than 3 nerve roots below level of the lesion
Why is it defined as 3 nerve roots below the lesion?
Less than 3 nerve roots could indicate nerve root pathology
Define incomplete SCI
Residual motor or sensory function in more than 3 nerve roots below the lesion
What is often spared in incomplete SCI
Sacral sparing
Give 5 examples of incomplete SCI
- Anterior Cord Syndrome
- Posterior Cord Syndrome
- Brown-Sequard Syndrome
- Central cord Syndrome
- Cauda Equina
Who classified spinal cord injury
American Spinal Injury Association (AISA)
What did AISA classify spinal cord injury into
A-E
What is AISA Grade A
Complete SCI
What is AISA Grade B
Incomplete:
Sensory, but not motor, is preserved
What is AISA Grade C
Incomplete Injury:
>50% Muscles are MRC <3
What is AISA Grade D
Incomplete Injury:
>50% Muscles are MRC >3
What is AISA Grade E
Normal: Motor and Sensory function are normal
What is the most common incomplete SCI
Central cord syndrome
What mechanism of injury causes central cord syndrome
Hyperextension in presence of osteophytes (OA)
Why is central cord syndrome more prevalent
Centre of the spinal cord is a watershed area - and is more susceptible to oedema
What are symptoms of central cord syndrome
- Cape-like sensory loss of pain and temperature
- Arm weakness > Leg weakness
Why does weakness occur in arms over legs in central cord syndrome
As coricospical tract is organised so region representing arms is more medial to that of legs
What causes anterior cord syndrome
Infarct anterior spinal artery (ASA)
Where does anterior spinal artery arise from
Vertebral artery
What typically causes anterior cord syndrome
Herniated disc
What sensory loss is present in anterior cord syndrome
Loss of pain and temperature
Why are proprioception, vibration and fine touch in tact in anterior cord syndrome
As these are transmitted by dorsal column pathway which are located in posterior cord. Spinothalamic pathway travels in anterior cord
What motor deficit is present in anterior cord syndrome
Paraplegia. Unless above C7 - then quadriplegia
What is prognosis of anterior cord syndrome
Poor prognosis. Only 10-20% recover motor function
What is Brown-Sequard syndrome
Lateral compression of spinal cord
What are ipsilateral symptoms in brown sequard syndrome and why does it happen
- Loss vibration, proprioception, fine touch
- Ipsilateral paralysis
= Due to damage to corticospinal tract and DCP which have already decussated in the medulla
What are contralateral symptoms in brown sequard syndrome and why does it happen
Loss pain, temperature and crude touch = due to damage to spinothalamic tract that decussates at the spinal cord
Why is light touch preserved in brown-sequard
As transmitted via anterior spinothalamic tract
What is posterior cord syndrome also called
Contusion Cervicalis Posterior
What causes contusion cervicalis posterior
Infarct PCA
Where does PCA arise
Posterior inferior cerebellar artery (PICA)
How does posterior cord syndrome present
- Loss sensation and burning in neck, upper arms and torso
- Mild paresis of the upper limbs
What is first-line if suspecting spinal cord compression
MRI Spine
How is spinal cord compression managed
Urgent referral neurosurgery:
- Dexamethasone
- Decompressive laminectomy
When is decompressive laminectomy used
Disease at single spinal level
What is radiotherapy used
Disease at multiple levels (Malignancy)
What is the best prognostic indicator for SCC
Mobility status
What is a complication of complete spinal cord compression
Spinal shock
What causes spinal shock
Disruption sympathetic innervation
How does spinal shock present
- Hypotension. Hypothermia
- Quadraplegia
- Respiratory Inusfficiency
- Anaesthesia below the level
How can spinal cord lesions be divided in terms of presentation
- Motor
- Motor and Sensory
- Sensory
What are two purely motor spinal cord lesions
- MND
- Poliomyelitis
How does ALS (MND) present
Combination UMN and LMN signs
How does poliomyelitis present and why
LMN signs - due to disrupting anterior horn cells
What 3 conditions cause motor and sensory disruption spine
- Friedrichs ataxia
- Syringomyelia
- Subacute combined degeneration spinal cord
What causes subacute combined degeneration of the spinal cord
Vitamin B12 deficiency
How does subacute combined degeneration of spinal cord present
CST: bilateral paraparesis
DCP: bilateral loss vibration and proprioception
SCT: bilateral ataxia and tremor
What is syringomyelia
Collection CSF in spinal cord
How does syringomyelia present
- Cape like loss pain and temperature (due to spinothalamic tracts crossing being first affected)
- Preservation proprioception, fine touch
- Spastic weakness upper limbs
What is syringomyelia associated with
Chiari malformato
What is a purely sensory condition of spinal cord
Tabes dorsalis (Syphillis)