Diseases of Spinal Cord Flashcards
Motor signs of cord/root pathology
UMN - no wasting, increased tone, increased reflexes, extensor plantar. Pyramidal pattern of weakness
LMN (root) - reduced tone, absent reflexes, flexor platar, weakness
Sensory signs of cord pathology
Myelopathy - sensory level
Hemicord lesion - Brown Sequard syndrome
- ipsilateral; reduced vibration, reduced joint position sense, weakness
- contralateral - reduced pain, reduced temperature
Sensory signs of root pathology
Radiculopathy –> dermatomal sensory loss
Autonomic signs of cord/root pathology
Bladder/bowel involvement
Signs of C5 cord lesion
Wasting of C5 innervated muscle Increased tone in legs more than arms Reduced reflexes in biceps, increased all lower reflexes Power reduced in C5 innervated muscles Pyramidal pattern below Sensory level
Extrinsic Causes of myelopathy or radiculopathy
Surgical
- Tumour: extradural, intradural, extramedullary, intramedullary
- Vascular abnormlities - haemorrhage, AVVM, dural fistula
- Degenerative
- Trauma
Intrinsic causes of myelopathy or radiculopathy
Congenital/genetic
- Friedrich’s ataxia, spinocerebellar ataxias, hereditary paraparesis
Acquired
-Inflammation - Demyelination;MS, Autoimmune (Ab mediated), Sarcoid
Vascular - Ischaemic v Haemorrhage
-Infective - Viral; Herpes, EBV, CMV, measles, HIV
- Bacterial; TB, borrelia, syphylis, brucella
- Other; schistosomiasis
-Metabolic - B12 deficiency
-Malignant/infiltrative
Idiopathic
Causes of spinal cord ischaemia
Atheromatous disease Thromboembolic disease Arterial dissection Systemic hypotension Thrombotic haematological disease Hyperviscosity syndromes Vasculitis Venous occlusion Endovascular procedures Decompression sickenss Meningovascular syphylis
Spinal cord stroke - presentaion
Vascular risk factors
Onset may be sudden or several hours
Pain - back pain/radicular, visceral referred pain
Weakness - usually paraparesis than quadriparesis (vulnerability of thoracic cord to flow-related ischaemia)
Numbness and paraesthesia
Urinary symptoms - Retnetion followed by bladder and bowel incontinence as aspinal shock settles
Spinal cord stroke on examination
Usually anterior, rarely posterior spinal artery - dorsal columns spared
Occlusion of central sulcal artery - partial Brown Sequard
Mid thoracic
May be spinal shock
Treatment of spinal cord stroke
Maintain adequate BP Reverse hypovolaemia/arrhythmia Antiplatelet therapy OT and physio Manage vascular risk factors
Prognosis for spinal cord stroke
Return of function depends on parenchymal damage
Chance of major recovery low if motor recovery poor within first 24 hours
Pain may be persistent and contribute to disability
20% mortality
Demyelinating myelitis affects which part of the CNS?
White matter
What is required for B12 absorption from the gut?
Intrinsic factor- secreted by gut parietal cells
How is B12 absorption prevented in pernicious anaemia?
Autoimmune - antibodies to intrinsic factor
How does B12 deficiency affect the nervous system?
Myelopathy - L'hermitte's Peripheral neuropathy Brain Eye/optic nerve Brainstem Cerebellum
Signs of B12 deficient myelopathy
Paraesthesia of hands and feet, areflexia
Extensor plantars
Degen of corticospinal tract - paraplegia
Degen of dorsal columns - sensory ataxia
Painless retention of urine
Invesitgation of B12 deficient myelopathy
FBC, blood film, B12
Treatment for B12 deficient myelopathy
Intramuscular B12
Vertebra, number in each region
Cervical - 7 Thoracic - 12 Lumbar - 5 Sacral -3 Coccyx-4
Spinal cord extends from which spinal levels
C1 to L2
Spinal cord progresses to…
Conus medularis
Cauda equina
What is the transition point between UMN and LMN
Anterior horn
C5 innervates…
Elbow flexors
C6 innervates
Wrist extensors
C7 innervates
Elbow extensors
C8 innervates
Finger extensors
T1 innervates
Intrinsic hand muscles
L2 innervates
Hip flexors
L3 innervates
Knee extensors
L4 innervates
Anke dorsiflexors
L5 myotome
Long toe extensors
S1 myotome
Ankle plantar flexors
Signs of C5 spinal cord lesion
Weakness in shoulder and below Sensory level at C5 Increased tone in legs Brisk reflexes Babinski positive
Myelopathy - UMN - neurological deficit due to compression of spinal cord
L4 Nerve root lesion sign
Pain down ipsilateral leg
Numbness in L4 dermatome
Weakness in abkle dorsiflexion
Reduced knee jerk
Radiculopathy - compression of nerve root leading to dermatomal and myotomal deficits
5 Causes of surgical spine
Degenerative Tumour Infection Trauma Congenital
History for surgical spine
Pain
Onset - speed
PMH
Investigation for surgical spine
Blood
Xray
CT
MRI
What is a disc prolapse?
Acute herniation of intervertebral disc causing compression of spinal roots or spinal cord
Onset of pain in disc prolapse
Acute
Group of patients disc prolapse is common in
Younger
Central cervical disc prolapse causes which condition
Cervial myelopathy
Lateral cervical disc prolapse causes which condition
Cervical radiculopathy
Central lumbar disc prolapse causes which condition
Cauda equina syndrome
Lateral lumbar disc prolapse causes which condition
Lumbar radiculopathy
Is disc prolapse common in thoracic spine?
No
less mobile
Symptoms of disc prolapse
Acute pain down leg/arm
Numbness and weakness in distribution of nerve involved
Investigation of disc prolapse
MRI
Treatment of disc prolapse
Rehabilitation
Nerve root injection
Lumbar/cervical discectomy
Red flags for Cauda Equina Syndrome
Bilateral Sciatica
Saddle anaesthesia
Urinary dysfunction
Investigation Cauda Equina
Emergency MRI
Treatment Cauda Equina
Emergency lumbar discectomy
3 causes of degenerative spinal issues
Disc prolapse
Ligamentum hypertrophy
Osteophyte formation
2 conditions of degenerative changes in spine
Cervical spondylosis
Lumbar spinal stenosis
Presentation of cervical spondylosis
Can present with myelopathy or radiculopathy or both
Speed of onset varies months to years
Management of cervical spondylosis
Conservative if no/mild myelopathy
Surgery if progressive
Presentation of lumbar spinal stenosis
Pain down both legs - spinal claudication
Worse on walking/standing - relieve by sitting or bending forwards
Management of lumbar spinal stenosis
Lumbar laminectomy
3 types of spinal tumours
Extradural
Intradural
Intramedullary
Examples of extradural spinal tumours
Metastases (breast, lung, prostate) Primary bone (chondroma, osteroblastoma)
Examples of intradural spinal tumours
Meningioma, Neurofibroma, Lipoma
Examples of intramedullary spina tumour
Astrocytoma
Ependymoma
Teratoma
Haemangioblastoma
Malignant cord compression symptoms
Pain
Weakness
Sphincter disturbance
Investigation of malignant cord compression
Urgent MRI
- known cancer and develops back pain
Management of malignant cord compression
Cord decompression and radiotherapy
Two conditions arising from spinal infection
Epidural abscess
Osteomyelitis
Triad for urgent MRI
Back pain
Pyrexia
Focal neurology
Risk factors for Epidural abscess
IVDU
diabetes
Chronic renal failure
Alcoholism
Organisms common to epidural abscess
S.aureus
Streptococci
E.coli
Treatment for epidural abscess
Urgent surgical decompression
Long term IV antibiotics
Risk factors for Osteomyelitis
IV drug abuse Diabetes Chronic renal failure Alcoholism AIDS
Management of osteomyelitis
Antibiotics
Surgery if evidence of neurology
Contraindications to CT
Minor head trauma
Seizure
Contraindications to MRI
Cardiac pacemaker, cochlear implants Metallic implants - aneurysm clip, heart valve Claustrophobia Pregnancy Tattoos
