CC2: spinal cord disorders

Question 1

What is myelopathy?

Answer 1

-Disease or damage to spinal cord causing any neurologic deficit
-Major cause of disability

Question 2

What are some symtoms of myelopathy?

Answer 2

-motor deficits and primary sensory deficits and distrubances that localize a spinal cord level
1.weakness, ataxia (usually bilateral)

-signs of autonomic dysfunction
1. bladder/bowel disturbance
2. orthostatic hypotension, sexual dysfunction

Question 3

Where does decussation of spinothalamic fibers occur?

Answer 3

spinal cord (contralateral pinprick pain/temperature deficit

Question 4

Where does decussation of dorsal colu,ms/medial lemniscus fibers occur?

Answer 4

medulla (Ipsilateral propioception/vibration deficit)

Question 5

where is the lower motor neuron located?

Answer 5

anterior horn cells

Question 6

where is the upper motor neuron located?

Answer 6

lateral corticospinal tract

Question 7

Findings of lower motor neuron?

Answer 7

Hyporeflexia, decreased tone, fasciculations (fine twitching of muscles), atrophy

Question 8

Findings of upper motor neuron?

Answer 8

Hyperreflexia, spasticity, Babinski reflex(corticospinal tract lesion sign

Question 9

which reflexes are affected with spinal cord lesions?

Answer 9

-abdominal cutaneous reflexes
-cremasteric reflex
-anal wink
-bulbocavernous reflex

Question 10

What is the transverse cord lesion?

Answer 10

-all sensory /motor pathways partially or completely interrupted [trauma tumors, myelitis)

Question 11

What is hemicord lesions: brown-sequard syndrome?

Answer 11

Damage to lat. corticospinal tract: ipsilateral upper motor neuron deficits below level of lesion

Damage to anterior horn cells: ipsilateral lower motor neuron deficits at level of lesion

Damage to posterior columns: ipsilateral loss of position and vibration sense

Damage to anterolateral (spinothalamic) system- contral. loss of pain and temperature sensation

Question 12

What is central cord syndome?

Answer 12

-If small lesions, spinothalamic fibers crossing affected:
bilateral regions of suspended sensory loss in pain and temperature- may be asymmetric!

-If large lesions, anterior horn cells, corticospinal tract, posterior columns also affected:
1. lower motor neuron deficits at level of lesion
2. upper motor neuron deficit below level of lesion
3. Loss of propioception and vibration below the level

Question 13

What is posterior cord syndrome?

Answer 13

Lesion of posterior column: loss of propioception and vibration below level

With large lesion, may affect lat. corticospinal tract: upper motor neuron deficits
(syphillis or vit 12 defficiency

Question 14

What is anterior cord syndrome?

Answer 14

Damage to anterolateral (spinothalamic) system: decreased pain and temperature below lesion

Damage to anterior horn cells: lower motor neuron deficits at level of lesion

If large, damage to corticospinal tract: upper motor neuron deficits below level of lesion

Question 15

What is cervical spondylotic myelopathy?

Answer 15

Spinal stenosis and compression of spinal cord resulting from age-related degenerative changes of the spine

surgery to decompress the spinal cord

Question 16

What is the initial phase of trauma of spinal cord?

Answer 16

due to injury, spinal shock flaccid paralysis, los of DTRs

Question 17

explain anterior spinal artery infarct

Answer 17

most commonly caused by insufficiencies within aorta
aneurysms, dissections, surgery, atherosclerosis…

-bilateral loss of motor fx, pain/temperature sensation/-relative sparing of proprioception and vibratory senses below the level of the lesion
- acute stage with spinal shock

Treatment:
-hypothermia, CSFdrainage, revascularization of Artery of Adamkiewicz under investigation when affected
-ASA

Prevention: identification of Artery of Adamkiewicz prior to thoracoabdominal aortic repairs

Question 18

explain vitamin b12 deficiency

Answer 18

Myelopathy causing ataxia from affected dorsal columns and weakness from affected lateral corticospinal tract- subacute combined degeneration
-often not a result of poor diet, a result of poor absorption often occurring with age
-Treatment: vitamin B12 replacement

Question 19

exaplain neurosyphilis tabes dorsalis

Answer 19

Chronic slowly progressive myelopathy causing ataxia from affected dorsal columns accompanied by pain from affected dorsal nerve roots

Treatment: Penicillin G

Question 20

explain inflammatory myelitis

Answer 20

-Can be idiopathic or secondary to multiple sclerosis, neuromyelitis optica, connective tissue diseases, or sarcoidosis
-Acute or subacute myelopathy
Tx: steroids, immunosuppressant drugs

Question 21

What is metastatic myelopathy?

Answer 21

metastatic spread to epidural space most common

metastatic spread to vertebral bodies

80% of patients treated after they loose ambulation will remain nonambulatory, 80% of patients treated before loosing ambulation will remain ambulatory for the rest of their lives.
Tx: Radiation and/or sugery

Question 22

What is spina bifida myelomeningocele?

Answer 22

The most severe type of spina bifida- portion of the neural tube fails to develop or close properly in babies, causing defects in the spinal cord and in the bones of the spine.

Limb deformities , weakness, sensory disturbances , bowel and bladder problems, hydrocephalus

Treatment- surgery

Question 23

3 important nerve roots in the arm?

Answer 23

C5, C6, C7 (most common in radiculopathies)

Question 24

3 important nerve roots in the leg

Answer 24

L4, L5 (most common), S1 (most common)

Question 25

What is a radiculopathy?

Answer 25

Sensory or motor dysfunction caused by a spinal nerve root lesion
a type of neuropathy
most commonly caused by disc herniation (C6,C7, L5, S1 most common)
Other causes: degenerative disease of vertebra/ligaments of spine, diabetes, metastasis, Guillain- Barre syndrome, herpes zoster

Question 26

what are some signs and symptoms of radiculopathy?

Answer 26

-Burning, tingling pain that radiates or shoots down a limb in dermatome of affected nerve root
-Sensation may be diminished in dermatome of affected nerve root
-Loss of reflexes, and motor strength in radicular distribution(following dermatome)
-If chronic, atrophy and fasciculations (fine twitching of muscle)

Question 27

How can radiculopathies be evaluated?

Answer 27

-Straight leg raising test may be helpful in diagnosis of mechanical nerve root compression in lumbosacral region
1. reproduction pain and abnormal sensation (paresthesias)
-Flexing or turning head toward affected side for cervical root compression
1. reproduction of pain and abnormal sensation (paresthesias)
-Percussion of spine
Imaging, nerve conduction studies, labs

Question 28

how can we treat radiculopathies?

Answer 28

Treatment:
NSAIDS or oral steroids for inflammatory process

General pain management and for neuropathic pain- antiepileptic drugs, tricyclic antidepressants

physical therapy

nerve root block injections- i.e., epidural steroid injections

surgical option to decompress root for persistent or progressive pain and disability from compressive etiologies
Discectomy
Artificial disc replacement
Laminectomy
Spinal fusion

Radiation if bone metastasis
For infectious causes- Acyclovir for Herpes Zoster,Gancyclovir for CMV

Question 29

which is the most common cause of rediculopathies?

Answer 29

herniated discs, in c6, c7, l5, s1

Question 30

what is cervical herniated discs?

Answer 30

constricted by posterior longitudinal ligament to herniate laterally toward nerve root.

nerve root invovled usually corresponds tot he lower if the adjacent two vertebrae

Question 31

what is lumbosacral herniated discs?

Answer 31

-posterolateral herniations more common
-nerve root invovled usually corresponds to the lower of the adjacent two vertebrae

Question 32

What is spondylosis?

Answer 32

another cause of radiculopathies; Degenerative disc disease leads to bone over bone trauma leading to formation of osteophytes that may compress nerve roots

Question 33

how deos herpes zozster relate to radiculopathies?

Answer 33

Reactivation of varicella zoster virus
persists for life in the sensory ganglia after initial systemic infection (chickenpox)

Dermatomal rash (shingles) associated with severe radiating pain
Most common in thoracic region

About 1/5 develop a chronic postherpetic neuralgia

Prevention with vaccine- Shingrix Treatment: acyclovir, NSAIDS, narcotics, calamine, tricyclic antidepressant and antiepileptic drugs

Question 34

How is diabetic radiculopathy?

Answer 34

-One type of rare diabetic neuropathy
-Usually involves the thoracic region with severe pain and dysesthesias along chest and abdominal wall, sometimes weakness of abdominal wall confused with hernia, and sometimes weight loss
-Usually good prognosis with good recovery within a yr.

Question 35

explain guillain barre in radiculopathies

Answer 35

Common cause of acute flaccid paralysis
Autoimmune , causing a rapidly progressive neuropathy with a predilection for nerve roots

Often but not always preceded by a viral illness
-Campylobacter jejuni enteritis
-HIV infection

Typically presents with progressive ascending weakness , loss of deep tendon reflexes, tingling sensation of hands and feet, and pain that may be radicular
-Motor involvement generally more than sensory involvement- several variants

Question 36

What is cauda equina syndrome?

Answer 36

Impaired function of multiple nerve roots below L1-L2 spine level

-Sensory deficit S2-S5, saddle anesthesia
-Lumbosacral radicular pain
-leg weakness with decreased tone, hyporeflexia, muscle twitching
-Bladder dysfunction, decreased rectal tone, loss of erections
-loss of anal wink /bulbocavernous reflex as seen with spinal cord lesions

Causes: compressive-central disc herniation, epidural metastasis, lumbar spinal stenosis, trauma, noncompressive- sarcoidosis, cytomegalovirus

Consider a conus medullaris syndrome
-similar deficits with sacral spinal cord lesion but with Babinski sign, hyperreflexia

Neurologic emergency-