Clinical Aspects of Spinal Cord Lesions

Question 1

What are you looking for when you are reading a vignette about Sensory?

Answer 1

1. Pain/Temperature (Body or Face) –> RED
2. Proprioception/2-Point (Body or Face) –> GREEN

Question 2

How are questions going to be presented on the test?

Answer 2

• Chief Complaint
• History
• Cranial Nerves
• Spinal Dermatomes
• Sensory (Pain/Temp or Proprio/2-Point)
• Motor Strength, Reflexes, Tone after Atrophy

Question 3

Describe the 7 lesions that are involved in the spinal cord?

Answer 3

Question 4

Describe Tabes Dorsalis.

Answer 4

Tabes dorsalis is a meningovascular inflammation of the blood vessels as they pierce through the pia at the junction of the dorsal rootlets and the posterior columns.

**** Involvement of the dorsal roots in the SACRAL REGION results in Atonic Bladder (NO input or output) and Painless retention of urine!

*** Presentation: Patients complain of “lightning pains” or “rheumatic pains” from the lower limbs for the last several years. Paroxysmal lancinating pains in the lower limbs of long duration is a common feature of tabes, and is probably due to the irritation of the epicritic (type A) pain fibers in the dorsal roots. Other paresthesias may be present.

**** Ataxic Gait (Slapping of Feet)

**** Positive Romberg Test

Question 5

Where is the lesion going to occur in the spinal cord with a Thiamina (B12) Deficiency.

Answer 5

Posterior Column Lesion!

Question 6

Describe Poliomyelitits (Normal and Paralytic)

Answer 6

LOWER MOTOR NEURON PARALYSIS!!!

• Acute anterior poliomyelitis selectively involves the motor neurons of the anterior (ventral) horns and the cranial nerve motor nuclei
• The onset of this viral disease usually lasts between 2 to 4 days with symptoms, which are characteristic of any acute viral meningitis such as pyrexia (fever), headache, vomiting, neck stiffness, and pain in the back and limbs.
• Paralytic poliomyelitis may involve damage to the nucleus ambiguus, phrenic nucleus, or medial motor cell column with resultant paralysis of the pharyngeal, laryngeal, diaphragm, or intercostal muscles. The associated problems of airway obstruction and clearance and pulmonary ventilation are potentially life-threatening conditions

Question 7

Describe what will happen with Complete Transection of the Spinal Cord at Levels C5-6 vs. Levels T1-L2.

Answer 7

Quadriplegia - Between C5-6; Bilateral Paralysis of the Upper and Lower Extremities

Paraplegia - Between T1-L2; Bilateral Paralysis of Lower Extremities

Question 8

Describe the first phase that will happen after a spinal cord injury.

Answer 8

SPINAL SHOCK

Lasts for 4 Days - 6 weeks (Average = 2-3 Weeks)

• Loss of all sensations, reflex activities
• Bilateral flaccid paralysis of involved extremities
• Loss of voluntary control of a spastic urinary bladder
• Loss in sexual potency in the male
• Various visceral deficits (loss of thermoregulation (cool, dry, skin with no sweating)
• Transient Horner’s syndrome, if the lesion is above T2

Question 9

Describe the second phase that will happen after a spinal cord injury.

Answer 9

After a few weeks or months, the Second Phase is marked by the appearance of any spinal reflex activity distal to the lesion. The return of basic spinal reflexes indicates the patient’s recovery from spinal shock.

Question 10

Describe Brown-Sequard Syndrome.

Answer 10

HEMISECTION OF THE SPINAL CORD!!!!

1. Ipsilateral loss of proprioception and vibratory sensations from the body below the level of the lesion due to interruption of the posterior columns (GREEN)
2. Ipsilateral spastic paralysis below the level of the lesion due to the destruction of the descending motor tracts. (GREY)
3. Contralateral loss of pain and temperature sensations from the body 2 sensory dermatomal segments below the level of the lesion, due to the destruction of the LSTT. (RED)

EXAMPLE:
70 year old woman with a complaint that her left leg tended to “catch” when walking. One month later, she complained of a burning sensation in her right leg, and within 2 months was unable to walk. On admission she had traouble urinating due to a T8 lesion.

Question 11

Describe Syringomyelia.

Answer 11

Enlargement of the SYRINX which is located in the Spinal Cord. The etiology is unknown. Syringomyelia may occur secondary to central cord syndrome (CCS).

Results in:
1. Destruction of the anterior white commissure with a bilateral loss of pain and temperature sensations to the upper extremities (“yoke-like” anesthesia). (RED)

2. Asymmetrical (unilateral or bilateral) destruction of the lateral corticospinal tracts (UMN) results in spastic paralysis, hyperreflexia, and hypertonia of the lower extremity. (GREY)
3. The anterior horns (LMN) may be destroyed unilaterally or bilaterally, thereby resulting in a lower motor neuron paralysis [flaccid paralysis, atrophy, areflexia and atonia] of the associated upper limb musculature. (GREY)
4. Some part of the posterior columns may also be affected, and result in an ipsilateral anesthesia (proprioceptive and 2-point sensation) BELOW the level of the lesion. (GREEN)

Question 12

Describe Amyotrophic Lateral Sclerosis (ALS).

Answer 12

Death is due to bulbar paralysis, i.e., the vital respiratory centers, within an average of four years of onset.

The most common form of ALS involves a combination of following structures:

• LMN (Anterior Horn Cells, Hypoglossal Nucleus, Nucleus Ambiguus, Facial Motor Nucleus)
• UMN (Chronic, progressive degeneration of the Corticospinal Tracts)

ALS Leads to:

• LMN paresis and atrophy of the intrinsic muscles of the hands followed later by the arms and shoulder musculature.
• Patients may develop dysarthria, dysphagia and paresis of the tongue.
• Involvement of UMN (corticospinal tract) leads to spastic paralysis, hyperreflexia and a Babinski sign.
• There are NO SENSORY DEFICITS.

Question 13

Differentiate between a neurofibroma of the Conus Medullaris vs. the Cauda Equina.

Answer 13

Question 14

Clonus will present with which kind of problem?

Answer 14

UPPER MOTOR NEURON!