Diseases of the Spinal Cord and Nerve Roots Flashcards
Presentation of UMN signs
No wasting
Increased tone
Increased reflexes
Pyramidal pattern of weakness
What is the pyramidal pattern of weakness in UMN lesion?
Flexors stronger than extensors
What does UMN stand for?
Upper motor neurone
What does LMN stand for?
Lower motor neurone
Presentation of LMN signs
Decreased tone Decreased reflexes Plantar flexor Weakness Muscle wasting
What does a hemicord sensory lesion lead to?
Brown-sequard syndrome
What does a radiculopathy lead to?
Dermatomal sensory loss
What are the types of sensory signs?
Myelopathy
Hemicord lesion
Radiculopathy
If there was a C5 cord lesion, what possible signs may be present?
Wasting of C5 innervated muscles Increased tone in LL > UL Reflexes - decreased in biceps - increased all lower reflexes Sensory level
Extrinsic causes of myelopathy / radiculopathy
Tumour Hemorrhage AVM, dural fistula Degenerative (spine) Trauma
Causes of myelopathy
Inflammation - Demyelination (MS) - autoimmune (antibody mediated e.g. aquaporin 4, lupus) - sarcoid Vascular - ischaemic vs haemorrhage Infective - viral (HSV/HZV, - bacterial (TB, lyme, syphillis, brucella) - schistosomiasis Metabolic - B12 deficiency Malignant / infiltrative Congenital / genetic - friedrichs ataxia, spinocerebellar ataxias Idiopathic
What is ischaemic myelopathy?
Spinal stroke/infarction
What foodstuffs is abundant in B12?
Meat
Fish
Animal by products
Legumes
Absorption of B12 from the gut requires what? Where is this produced from?
Intrinsic factor (a binding protein) Produced by gastric parietal cells
What is pernicious anaemia?
Autoimmune condition in which antibodies to intrinsic factor prevent vit B12 absorption
What is vit B12 deficiency a complication of?
Total gastrectomy
Crohn’s
Tape worms
What of the nervous system does Vit B12 affect?
Myelopathy (L'hermittes) Peripheral neuropathy Brain Eye/optic nerves Brainstem Cerebellum
Presentation of B12 deficient myelopathy
Paraesthesia hands and feet, areflexia First UMN sign extensor plantars Degeneration of corticospinal tracts - paraplegia Degeneration of dorsal colums = sensory ataxia Painless retention of urine
Investigations of B12 deficient myelopathy
FBC
Blood film
B12
Treatment of B12 deficient myelopathy
Intramuscular B12 injection
Causes of spinal cord ischaemia
Atheromatous disease (aortic aneurysm) Thromboembolic disease (endocarditis, AF) Arterial dissection (aortic) Systemic hypotension Thrombotic haematological disease Hyper viscosity syndromes Vasculitis Venous occlusion Endovascular procedures Decompression sickness Meningovascular syphillis
Presentation spinal cord stroke
Ischaemic pain
- back / radicular
- visceral referred pain
- radiates around where intercostal nerves would be
Weakness
- usually paraperesis rather than quadraparesis
Numbness and paraesthesia
Urinary syndromes
- retention
- followed by bladder and bowel incontinence as spinal shock settles
Acute stages of UMN in spinal shock - floppiness
What risk factors may someone who presents with a spinal cord stroke have?
Vascular risk factors
What artery is usually affected in spinal cord stroke?
Anterior spinal artery
Occlusion of what artery can present as partial brown sequard syndrome?
Occlusion of central sulcal artery
Investigations of spinal cord stroke
MRI
Treatment of spinal cord stroke
OT and physio
Manageme vascular risk factors
Reduce risk of recurrence
How to reduce the risk of recurrence of spinal stroke?
Maintain adequate BP
Reverse hypovolaemia/arrythmia
Antiplatelet therapy
What does the return of function depend on in spinal cord stroke?
The degree of parenchymal damage
What is a good prognostic indicator of recovery in spinal cord stroke?
Significant motor recovery within 24 hours
Mortality of spinal cord stroke
20%
What is demyelinating myeltiis a common cause of?
Medical spinal cord disease
What is MS characterised by?
Pathological lesions of inflammation and demyelination leading to temporary neuronal dysfunction
What does MS affect?
White matter of the CNS
Treatment of MS
Supportive
Methylprednisolone
What are the vertebral ligaments?
Anterior longitudinal Posterior longitudinal Ligamentum flavum Interspinal ligament Supraspinous ligament
Where does the spinal cord extend from and to?
C1 - L2
What dermatome is C6?
Thumb
What dermatome is C7?
Middle finger
What dermatome is C8?
Pinky
C5 myotome
Elbow flexors
C6 myotome
Wrist extensor
C7 myotome
Elbow extensors
C8 myotome
Finger extensors
T1 myotome
Intrinsic hand muscles
L2 myotome
Hip flexors
L3 myotome
Knee extensors
L4 myotome
Ankle dorsiflexors
L5 myotome
Long toe extensors
S1 myotome
Ankle plantar flexors
Signs of UMN lesion
Weakness PRESENT Atrophy ABSENT Reflexes INCREASED Tone INCREASED Fasiculations ABSENT Babinski PRESENT
Signs of LMN Lesions
Weakness PRESENT Atrophy PRESENT Reflexes DECREASED Tone DECREASED Fasiculations PRESENT Babinski ABSENT
What is classed as an UMN and LMN lesion?
UMN - anterior horn of the spinal cord or above
LMN - distal to this
What would a C6 spinal cord lesion present with?
Weakness in elbow below sensory level at C6 and in legs
Reduced sensations after C6 - starts to have weakness in their hands
Power in shoulders but probably not below that
Increased tone in legs
Brisk reflexes
Babinski +ve
UMN!!
Definition of myelopathy. Is it an UMN or LMN lesion?
Neurological deficit due to compression of the spinal cord
UMN
What would a L4 nerve root lesion present with?
Pain down ipsilateral leg Numbness in T4 dermatome Weakness in ankle dorsiflexion = myotomes 2,3,4 Reduced knee jerk LMN!!
Definition of radiculopathy. Is it an UMN or LMN lesion?
Compression of the nerve root leading to dermatomal and myotomal deficits
LMN
Definition of disc prolapse
Acute herniation of intervertebral disc causing compression of spinal roots or spinal cord
Presentation of disc prolapse
Acute onset pain
- leg / arm
Sciatica
Numbness and weakness in the distribution of the nerve root involved
Investigation of disc prolapse
MRI
Definition of sciatica
Shooting pain down the leg into the ankle
What will a disc prolapse in the cervical spine cause?
Myelopathy (UMN lesion)
What will a disc prolapse in the lumbar region cause?
UMN of L1 and LMN below it
Treatment of disc prolapse
Rehab
Nerve root injection
- steriods and anaesthetics
Lumbar/cervical disectomy
What is a discectomy?
Remove the disc
Nerve root injections give pain relief for approx. how long?
2 weeks
Types of spinal tumours
Extradural (55%)
Intradural (40%)
Intramedullary (5%)
Types of intramedullary spinal tumours
Astrocytome
Ependymoma
Teratoma
Hemangioblastoma
Types of intradural spinal tumours
Meningioma
Neurofibroma
Lipoma
Types of extradural spinal tumours
Mets - lung - breast - prostate Primary bone tumours - chondromas - oesteoblastomas - osteiud osteoma
Presentation of malignant cord compression
Pain
Weakness
Sphincter disturbance
Treatment of malignant cord compression
Surgical decompression
Radiotherapy
Cancer treatment
Examples of spinal infections
Osteomyelitis
Discitis
Epidural abscess
Where would you get osteomyeltiis of the spine?
Within the vertebral body
Where would you get discitis of the spine?
Intervertebral disc
Where would you get an epidural abscess?
Epidural space
Presentation of epidural abscess
Back pain
Pyrexia
Focal neurology
Investigations of epidural abscess
Urgent MRI
Treatment of epidural abscess
Urgent surgical decompression
Long term IV antibiotics
Causative organisms of epidural abscess
Staph aureus
Streptococcus
E coli
Risk factors for epidural abscess
IV drug abuse
DM
Chronic renal failure
Alcoholism
Risk factors for osteomyelitis of the spine
IV drug abuse DM Chronic renal failure Alcoholism AIDs
Treatment of osteomyleitis of the spine
Antibiotics
Surgery if evidence of neurology
Who is the loss of normal spinal structure seen in?
Older patients
Pathology of normal loss of spinal structure in elderly
Product of - disc prolapse - ligamentum hypertrophy - oestophyte formation Leading to - myelopathy - radiculopathy
Definition of cervical spondylosis
Umbrella term for degenerative change in cervical spine leading to spine and nerve root compression
Presentation of cervical spondylosis
Myelopathy
Radiculopathy
Speed of onset of cervical spondylosis
Months to years
Treatment of cervical spondylosis
Conservative if no / mild myelopathy
Surgery for progressive / severe
Presentation of lumbar spinal stenosis
Pain down both legs ‘spinal claudication’
Worse on walking/standing and relieved by sitting/bending forward
Treatment of lumbar spinal stenosis
Lumbar laminectomy
Is lumbar spinal stenosis an emergency?
No
What is similar to lumbar spinal stenosis that is an emergency?
Cauda equina syndrome
What is cauda equina syndrome?
Large disc prolapse in combination with clinical signs
All nerve roots are compressed
What is the triad of cauda equina syndrome?
Bilateral sciatica
Saddle anaesthesia
Urinary dysfunction
Investigations of cauda equina syndrome
Urgent MRI
Treatment of cauda equina syndrome
Emergency lumbar dissectomy
What does brown sequard syndrome result in?
LOSS of proprioception and PARALYSIS on the SAME side as the lesion
LOSS of pain and temp on the OPPOSITE SIDE of the lesion
What signs does MND result in? What does it affect?
A combination of UMN and LMN signs
Affects both upper (corticospinal) tracts and lower tracts
What signs does poliomyelitis result in? What does it affect?
Affects ANTERIOR HORN CELLS resulting in LMN signs
What tracts does brown sequard syndrome affect?
- Lateral corticospinal tracts
- Dorsal columns
- Lateral spinothalamic tracts
What causes subacute combined degeneration of the spinal cord?
Vitamin B12 and E deficiency
What tracts does the subacute combined degeneration of the spinal cord affect?
- Lateral corticospinal tracts
- Dorsal columns
- Spinocellebellar tracts
What does subacute combined degeneration of the spine result in?
Bilateral spastic paralysis
Bilateral loss of proprioception and vibration sensation
Bilateral limb ataxia
What does friedrichs ataxia result in?
- Lateral corticospinal tracts
- Dorsal columns
- Spinocerebellar tracts
Presentation of friedrichs ataxia
Bilateral spastic paralysis
Bilateral loss of proprioception and vibration sensation
Bilateral limb ataxia
Cerebellar ataxia e.g. intention tremor
What tracts are affected in anterior spinal artery occlusion?
Lateral corticospinal tracts
Lateral spinothalamic tracts
Presentation of anterior spinal artery occlusion
Bilateral spastic paresis
Bilateral loss of pain and temp sensation
Tracts affected in synringomyelia
Ventral horns
Lateral spinothalamic tract
Presentation of synringomyelia
Flaccid paralysis (typically affecting intrinsic hand muscles) Loss of pain and temp sensation
What tracts are affected in MS?
Asymmetrical, varying spinal tracts involved
What tract is involved in neurosyphilis?
Dorsal columns
Presentation of neurosyphillis
Loss of proprioception and vibration sense
Risk factors for degenerative cervical myelopathy
Smoking (due to effects on intervertebral discs)
Genetics
Occupation (high axial loading)
Symptoms of degenerative cervical myelopathy
VERY VARIABLE Pain (neck, upper and lower limbs) Loss of motor function Loss of sensory function - numbness Loss of autonomic function (incontinence, impotence) Symptoms of carpal tunnel syndrome Hoffmans sign
What does hoffmans sign investigate for and explain it?
Degenerative cervical myelopathy
Gently flick one finger on a patients hand - +ve test is when twitching of the other fingers on the same hand in response to the flick
Investigation of degenerative cervical myelopathy
MRI spine - gold standard
Management of degenerative cervical myelopathy
Urgent referral to assessment by special spinal services
Decompressive surgery
What in degenerative cervical myelopathy confers best prognosis?
Early surgery within 6 months of diagnosis
If neuropathic pain originally doesn’t resolve with conventional treatment, what opoid can be tried?
Tramadol
What is the only nerve root that originates below a vertebrae? How does this differ from other nerve root names?
C8
The rest of the cervical spine roots derive their name from the vertebrae below them
Nerve root of ankle reflex
S1 - S2
Nerve root of knee reflex
L3 - L4
Nerve root of biceps reflex
C5 - C6
Nerve root of triceps reflex
C7 - C8
What does a high stepping gait compensate for?
Foot drop
What is bilateral foot drop meant to be due to?
Peripheral neuropathy
What is unilateral foot drop due to?
Common peroneal nerve lesion
What does the lesion of the common peroneal nerve lead to?
Weakness of dorsiflexion
Weakness of foot eversion
What indicates autonomic dysreflexia and when does this occur?
Occurs if the spinal cord injury is above the C6 level Combination of - severe HTN - flushing - sweating - no congruent response in HR
Triggers of autonomic dysreflexia
Things that cause a sympathetic spinal reflex via thoracolumbar outflow e.g.
- faecal impaction
- urinary retention
Others
Management of autonomic dysreflexia
Removal / control of stimulus
Tx life threatening HTN or bradycardia
What is subacute degeneration of the spinal cord often due to?
Vitamin B12 deficiency
What could be a warning sign for degenerative cervical myelopathy?
Progressive condition, worsening, deteroriation or new symptoms
What is thoracic outlet syndrome?
A disorder involving compression of the brachial plexus, subclavian artery or vein at the site of the thoracic outlet
Types of thoracic outlet syndrome
Can be
- neurogenic OR
- vascular
Pathology of TOS (thoracic outlet syndrome)
When neck trauma occurs in individuals with anatomical predispositions - either an acute incidence or repeated stress
Anatomical anomalies can be either
- soft tissue (70%) or
- osseous structures (30%)
Example of a well known osseous structure predisposing to TOS
Presence of a cervical rib
Examples of soft tissue anomalies predisposing to TOS
Scalene muscle hypertrophy
Anomalous bands
What is there usually a history of preceding TOS?
Neck trauma
Presentation of neurogenic TOS
Painless muscle wasting of the hands with patients complaining of hand weakness e.g. grasping
Sensory symptoms such as numbness and tingling
If autonomic nerves are involved
- cold hands
- blanching
- swelling
Presentation of vascular TOS
Subclavian vein compression leads to painful diffuse arm swelling with distended veins
Subclavian artery compression leads to painful arm claudication and in severe cases ulceration and gangrene
