Diseases of the Spinal Cord and Nerve Roots Flashcards
What motor signs would you expect to see with an UMN pathology?
- Increased tone (spasticity)
- Increased reflexes, extensor plantar
- Pyramidal pattern of weakness
What motor signs would you expect to seen with a LMN pathology?
- Decreased tone
- Decreased reflexes, flexor plantar
- Weakness
What sensory sign would you expect to see in a myelopathy?
Sensory level
What sensory sign would you expect to see with a hemicord lesion?
Brown-Sequard syndrome
What are the features of Brown-Sequard syndrome?
Ipsilateral
-Decreased vibration
-Decreased joint position sense
Weakness
Contralateral
- Decreased pain
- Decreased temperature
What are the dorsal columns responsible for?
- Deep touch
- Joint position sense (proprioception)
- Vibration
What is the ventral corticospinal tract responsible for?
Motor
What is the ventral spinothalamic tract responsible for?
Light touch
What is the lateral spinothalamic tract responsible for?
- Pain
- Temperature
What is the lateral corticospinal tract responsible for?
Motor
What sensory sign would you expect to see in a radiculopathy?
Dermatomal sensory loss
What autonomic signs may be present with a cord/root pathology?
Bladder/bowel dysfunction
What signs would be present in a C5 cord lesion?
- Wasting of C5 innervated muscles
- Increased tone in lower limbs > more upper limbs
- Reflexes decreased in biceps, increased in all lower reflexes
- Power decreased in C5 innervated muscles, pyramidal pattern below
- Sensory level
What surgical causes of myeleopathy/radiculopathy are there?
- Tumour (extradural, intradural/extramedullary, intramedullary
- Vascular abnormalities (haemorrhage, AVM, dural fistula
- Degenerative (spine)
- Trauma
What medical causes of myelopathy are there?
- Inflammation
- Vascular (ischaemic vs haemorrhage)
- Infective
- Metabolic (B12 deficiency)
- Malignant/infiltrative
- Congenital/genetic
- Idiopathic
What inflammatory causes of myelopathy are there?
- Demyelination (Multiple sclerosis)
- Autoimmune (antibody mediated e.g. aquaporin 4, lupus)
- Sarcoid
What infective causes of myelopathy are there?
- Viral: herpes simplex/zoster, EBV, CMV, measles, HIV et.
- Bacterial: TB, borrelia (Lyme), syphilis, brucella
- Other: schistosomiasis
What congenital/genetic causes of myelopathy are there?
- Friedrich’s ataxia
- Spinocerebellar ataxias
What can cause spinal cord ischaemia?
- Atheromatous disease (aortic aneurysm)
- Thromboembolic disease (endocarditis, AF)
- Arterial dissection (aortic )
- Systemic hypotension
- Thrombotic haematological disease
- Hyperviscosity syndromes
- Vasculitis
- Venous occlusion
- Endovascular procedures
- Decompression sickness
- Meningovascular syphilis
How does a spinal cord stroke present clinically?
- Onset: sudden or over several hours
- Pain (back pain/radicular which radiates to the front, visceral referred pain)
- Weakness (usually paraperesis rather than Quadra paresis given vulnerability of thoracic cord to flow related ischaemia)
- Numbness and paraesthesia
- Urinary symptoms (retention followed by bladder and bowel incontinence as spinal shock settles)
- May have vascular risk factors
What are the general examination points of spinal cord?
- Very rarely posterior spinal artery => dorsal columns spared
- Usually anterior spinal artery
- Occlusion of a central sulcal artery can present as a partial Brown-Séquard syndrome
- Usually mid thoracic
- May be spinal shock
What investigation is key in spinal cord stroke?
MRI
What is the treatment for spinal cord stroke?
- Reduce risk of recurrence (Maintain adequate BP, reverse hypovolaemia/arrhythmia, antiplatelet therapy)
- OT and physiotherapy
- Manage vascular risk factors
What is the prognosis of spinal cord stroke?
- Return of function depends on degree of parenchymal damage
- Unless significant motor recovery in first 24 hours chance of major recovery is low
- Pain may be persistent and significantly contribute to disability
- 20% mortality, only 35-40% have more than minimal recovery
What is demyelinating myelitis usually part of?
Multiple sclerosis
What is demyelinating myelitis a common cause of?
Medical spinal cord disease
Who can demyelinating myelitis affect?
The young
What is demyelinating myelitis in MS characterised by?
- Characterised by pathological lesions of inflammation and demyelination leading to temporary neuronal dysfunction
- One or more lesions anywhere
What type of matter does demyelinating myelitis in MS affect?
Only the white matter of the CNS
What may be the initial presentation of MS?
Demyelinating myelitis
60-70% have MRI brains typical of MS
How can demyelination myelitis of MS present
- Partial or incomplete transvers myelitis
- Subacute onset (slower than ischaemia)
What may there be a history of in demyelination myelitis?
There may be a history of previous neurological or ophthalmological episodes
How is myelitis investigated in MS?
MRI
How is MS myelitis treated?
- Supportive
- Methylprednisolone
What can MS myelitis result in?
Mya have chronic progressive myelopathy (secondary or primary progressive)
What are some sources of B12?
- Abundant in meat, fish and most animal by-products
- Legumes
What does absorption of B12 form the gut require?
Intrinsic factor: a binding protein secreted by gastric parietal cells
What is pernicious anaemia?
Autoimmune condition in which antibodies to IF prevent B12 absorption
What does B12 deficiency complicate?
Complicates total gastrectomy, Crohns, tape worms
What parts of the nervous system are affected by B12 deficiency?
B12 deficiency affects most of the nervous system
- Myelopathy (L’hermitte’s)
- Peripheral neuropathy
- Brain
- Eye/optic nerves
- Brainstem
- Cerebellum
How does B12 deficiency myelopathy?
- Paraesthesia hand and feet, areflexia
- First UMN signs extensor plantars
- Painless retention of urine
- Paraplegia
- Sensory ataxia
What is there degeneration of the B12 deficiency myelopathy?
Corticospinal tracts leading to paraplegia
-Dorsal columns leading to sensory ataxia
What investigations should be carried out for B12 deficient myelopathy?
- FBC/ blood film (may be negative
- B12 levels
What is the treatment for B12 deficient myelopathy?
IM B12 (the quicker the better)
