Diseases of the spinal cord and nerve roots (clinical)

Question 1

What are the expected signs of nerve/ root pathology

Answer 1

• Motor
- Upper motor neuron
	○ Increased reflexes
	○ Increased tone
	○ Pyramidal pattern of weakness
- Lower motor neuron
	○ Decreased reflexes
	○ Decreased tone
	○ Weakness
• Sensory
	○ If the spine is damaged then the sense from below that area will vanish

Question 2

What are the medical causes of myelopathy?

Answer 2

Inflammation
- Demyelination (Multiple Sclerosis)
- Autoimmune (antibody mediated eg aquaporin 4, lupus)
- Sarcoid
Vascular: ischaemic vs haemorrhage
Infective
- Viral: herpes simplex/zoster, EBV, CMV, measles, HIV etc
- Bacterial: TB, borrelia (Lyme), syphilis, brucella
- Other: schistosomiasis
Metabolic
- B12 deficiency
Malignant / infiltrative
Congenital / genetic
- Friedreich’s ataxia, spinocerebellar ataxias
Idiopathic (~20%)

Question 3

What are the causes of spinal cord ischaemia?

Answer 3

• 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

Question 4

What is the clinical presentation of spinal cord stroke?

Answer 4

• May have vascular risk factors
• Onset may be sudden or over several hours
• Pain
  
  • Back pain/radicular
  • Visceral referred pain
• Weakness
  
  • Usually paraparesis rather than quadriparesis 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

Question 5

What is the treatment of spinal cord stroke?

Answer 5

• Reduce risk of recurrence
• Maintain adequate BP
• Reverse hypovolaemia/arrhythmia
• Antiplatelet therapy
• OT and physiotherapy
• Manage vascular risk factors

Question 6

Explain MS

Answer 6

• Characterised by pathological lesions of inflammation and demyelination leading to temporary neuronal dysfunction
• Affects the white matter of the CNS
• One or more lesions anywhere
• Treatment
  * Supportive
  * Methylprednisolone
• May have a chronic progressive myelopathy
  * 2˚ or 1˚ progressive

Question 7

Explain B12 deficiency?

Answer 7

• Paraesthesia hands and feet, areflexia
• First UMN sign extensor plantars
• Degeneration of:
  
  • Corticospinal tracts → paraplegia
  • Dorsal columns → sensory ataxia
• Painless retention of urine
• Investigations: FBC/blood film (can be N), B12
• Treatment
  
  • Intramuscular B12 (quicker the better)