Lecture 23: Spinal Cord Disease

Question 1

Define Myelopathy vs Radiculopathy?

Answer 1

Myelopathy: Neurological deficit due to compression of the spinal cord

Radiculopathy: Pinching of nerve roots as they exit the spinal cord or cross the IV disc

Question 2

How could a myelopathy affecting UMNs appear?

Answer 2

• Spasticity
• Hyperreflexia & Plantar Extension
• Pyramidal pattern of weakness
  Weakness in lower limb flexors and upper limb extensors

Question 3

How could a myelopathy affecting LMNs appear?

Answer 3

• Decreased Tone
• Hyporeflexia
• Weakness & Wasting

Question 4

How could a myelopathy affect sensation?

Answer 4

Can trigger a sensory level:
- If theres a lesion at T4 cutting off the sensory fibres youll get abnormal sensation below T4

A hemicord lesion causes Brown-Sequard Syndrome

Question 5

What is Brown-Sequard Syndrome?

Answer 5

Tell tale sensory sign of a hemicord lesion

• Lose Contralateral pain & temp (Spinothalamic)
• Lose Ipisilateral muscle strength, vibration, proprioception & mechanoreception (CST/Dorsal Column)

Question 6

How would a radiculopathy (root lesion) present?

Answer 6

With sensory and motor features isolated to that spinal nerve
Hence its important to know your dermatomes/myotomes

Question 7

What kind of ANS symptoms can come from spinal cord disease?

Answer 7

Bowel & Bladder problems

Sexual Dysfunction

Question 8

How would a lesion at C5 pressing on the cord & nerve root present?

Answer 8

Cord

• UMN signs below C5
• Possible Sensory level at C5

Root:

• Numbness in C5 dermatome
• Weakness in C5 muscles (Deltoids/biceps)
• Hyporeflexia in Biceps reflex (C5 LMN is compressed)

Question 9

How do we categorise the causes of spinal cord lesions>?

Answer 9

Into intrinsic causes which are non-compressive and largely medical

Into Extrinsic causes which are compressive and largely surgical

Question 10

Layers in which a spinal cord lesions be located

Answer 10

Extradural
Intradural & Extramedullary
Intramedullary (These are intrinisic spinal cord lesions)

Question 11

What are the causes of intrinsic (Non-compressive) spinal cord lesiosn?

Answer 11

Congenital/genetic:

• Hereditary paraparesis
• Spinocerebellar ataxias

Aquired:

• Inflammatory: MS & sarcoid
• Autoimmune: Lupus

Infection:

• Viral: Herpes, EBV CMV, Measles, HIV, HTLV-1
• Bacterial: TB, Borrelia (Lyme), Syphillis, brucella, schistosomiasis

Metabolic:
B12 deficiency

Malignant:

Vascular:
ischaemic or haemorrhagic

Idiopathic

Question 12

Whats another name for Ischaemic Myelopathies?

Answer 12

Spinal Stroke

Question 13

And what causes Ischaemic Myelopathies?

Answer 13

Literally anything that can damage your arteries incl:

• Atheromatous disease
• Thromboemboli from Endocarditis or AF
• Hypotension
• Vasculitis
• Venous Occlusion
• Air emboli (A possible presentation of decompression sickness)

Question 14

How would ischaemic myelopathy present?

Answer 14

• First they will probably have vascular risk factors
• The onset will be sudden or over several hours
• Radicular Back Pain and/or visceral referred pain
• Weakness
• Numbness/Paraaesthesia
• Urinary retention in spinal shock and incontinence after

Question 15

What does radicular pain mean?

Answer 15

Pain radiating down a dermatome due to irritation of the nerve root, a radiculopathy

Question 16

What kind of weakness is more common in ischaemic myelopathy?

Answer 16

Paraparesis (partial paralysis of lower limbs) rather than quadraparesis because the thoracic cord is the mostly likely area to be damaged

Question 17

How would you investigate a suspected Spinal Stroke?

Answer 17

History & examination

Sagittal MRI

Question 18

How would we treat Ischaemic Myelopathy

Answer 18

• Manage the vascular problem which caused the spinal stroke
• OT & Physio

Question 19

Describe the presentation of an MS myelopathy?

Answer 19

• More likely partial than transverse
• May well be their first presentation, look for history of neuro or opthalmological episodes
• Slower onset than ischaemic, subacute i.e. ~1week

Question 20

How do we treat MS?

Answer 20

• Supportive
• Symptomatic
• Disease Modifying to reduce attack incidence
• Methylprednisalone to reduce attack severity

Question 21

How does a B12 deficiency trigger a spinal cord lesion?

Answer 21

It causes the spinal cord to slowly degenerate over time

Question 22

What care the common causes for a B12 deficiency?

Answer 22

• Dietary Failure e.g. Vegan
• Loss of ileum to surgery or disease (e.g. Crohn’s)
• Loss of intrinsic factor such as pernicious anaemia where antibodies attack intrinsic factor

Question 23

How does a B12 deficiency present?

Answer 23

• Brain, brainstem and cerebellar issues
• Eye/optic nerve issues
• Peripheral neurpathy
• Myelopathy:
  # L’hermitte’s sign, a sudden electric shock down the spine when you flex you neck forward (indicates C cord pathology)
  # Paraesthesia & Areflexia
  # UMN signs
  # Progessive degeneration of the CST (Paraplegia) and Dorsal Column (Sensory Ataxia)
  # Painless urine retention (ANS neurons lost)

Question 24

How do we investigate and treat for a B12 deficiency?

Answer 24

• FBC
• Blood Film
• B12 blood test

Treatment:
Intramuscular B12

Question 25

Recovery and prognosis for Myelopathy

Answer 25

• Poor recovery unless there is motor recovery in first 24 hrs (35-40% have minimal recovery)
• Persistent pain & disability
• 20% mortality