Myelopathy Flashcards
Myelopathy
Any disease that affects the spinal cord
Spinal Cord Ends at what level
L1-L2
Spinal Taps are done where?
L4-5…Far below the end of the spinal cord
Pt says back pain is in the thoracic region?
BE CONCERNED
What is the only tract that crosses in the spinal cord?
Spinothalamic…all others stay ipsilateral within the spinal cord and cross in the brain
KNOW THE spinal cord antomy slide
ok
Damage to the Corticospinal tract results in
- Hyper-reflexia
- Spasticity
- Babinski signs
- weakness
Damage to the posterior columns results in:
Loss of vibration, proprioception, pts will show a Romberg sign because of loss of proprioception
Damage to the spinothalamic tract results in
Loss of Pain, Temperature
Damage to the anterior horn cells results in:
Flaccid weakness, hypo-reflexia, fasciculations
Damage to the Dorsal Root
numbness, lancinating pain, hyporeflexia
Romberg sign is NOT A CEREBELLAR SIGN.
IT is a posterior column sign
Spinothalamic and corticospinal are organized medually to laterally
ARM , Trunk Leg
KNOW spinal cord anatomy from inside to out
Starting inside
- Parenchyma of the spinal cord itself
- Pia mater
- subarachnoid space
- arachnoid
- Subdural space
- dura
- epidural space (filled with fat)
- Bone
Epidural really means
extradural
Intradural really means
subdural
Within the subarachonoid space
leptomeningeal
Within the spinal cord parenchyma
Intramedullary
Nipple line sensory level
T4…KNOW
Umbilicus sensory level
T10…KNOW
Describe the two general kinds of bladder symptoms present in spinal cord lesions
1) In acute lesions we generally see urinary retention
2) In chronic lesions there is a small spastic bladder that doesn’t completely empty with spasms and urge incontinence
Acute and subacute myelopathies are:
EMERGENCIES
In pts with acute myelopathy
do immediate neuroradiologic testing
therapy is usually IV steroids
Approach to the pt with myelopathy
- General Exam:
Fever
Ask the pt to show you where it hurts
Check for tenderness on vertebral body - Neuro exam looking at motor, sensory, reflexes, gait
Early symptoms of an EPIDURAL LESION
- Dorsal root may be compressed which would lead to numbness, allodynia (hypersensitivity to touch)
- If the spinothalamic tract has been injured, very subtle changes in sensory symptoms are seen in the CONTRALATERAL lower extrmity
- Urinary urgency is common
- some hyper-reflexia, babinski signs and difficulty walking
As time passes, epidural lesion symptoms change how?
- Legs become weak
- Sensory symptoms worsen
- Bladder and bowel dysfunction
What is Partial Brown Sequard>
hemi-cord syndrome where you see weakness and numbness to touch on the ipsilateral side (corticospinal and medial lemniscal pathways)
and loss of pain sensation and temp on the CONTRA side because of the crossing over of spinothalamic tract
Full blown spinal cord compression
Flaccid areflexic
If this was an acute injury there is complete sensory loss at lesion level
Treatment for acute spinal cord injury
IV methyprednisolone
Cancer can affect the spinal cord at EVERY level
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Epidural myelopathy is a common complication of metastatic cancer from what locations
LUng, Breast, Prostate
If you are suspicious of a spinal cord lesion in a cancer pt…
treat with steroids first (dexamethasone), arrange for a spinal cord MRI with Gadolinium
What if the spine MRI is negative in a pt you suspect of a spinal cord lesion?
lumbar puncture
Separating mets from infection
Cancer affects the vertebral body, infection begins in the disc
The most common culprit of spinal cord infection
staph aureus….be very suspicious of IV drug abusers
Epidural abscess signs and symptoms
KNOW
Fever, pain on percussion, elevated white count, elevated ESR, Risk factors such as drug use, immunosuppression, etc…
What is osteomyelitis
infection of vertebral body…..causes weakness of the vert bodies and subsequent compression
What the hell is Pott’s disease
Osteomyelitis resulting from TB infection
Spinal meningiomas located where
Intradural, extramedullary lesion
- Classic in the thoracic spine
- Classic in middle aged women
Examples of nerve sheath tumors
Schwannoma or neurofibroma
- DUMBBELL SHAPE IS CLASSIC
- most lesions common with neurofibromatosis
Progression of a CENTRAL cord lesion (lesions that begin in the parenchyma of the cord)
- Many start right around where the spinothalamic fibers cross so that loss of pain and temp are early signs
- First sign may be pain in shoulders however
- Posterior columns are spared until late, this is called Dissociate Sensory Level where vibration and proprioception are preserved compared to pain and temp.
- Injury to dorsal root entry zone means reflex arcs are screwed up leading to hyporeflexia.
- Sacral dermatomes may be spared until the very end becuase they are the most lateral
Syrinx
Large expanding space in the spinal cord, a result of trauma or tumor
Anterior Spinal Artery syndrome
KNOW
Artery of Adamkiewicz (Great Radicular Artery)- Pts have symptoms referable to spinothalamic and corticospinal loss because these tracts are located in teh anterior 2/3 of the spinal cord but they will retain Epicritic sensation coming through the posterior columns. Yet another examples of DIssociate Sensory Level
Spinal Cord Shock
Complete Transection of SC
The big three things to look for are: FLACCIDITY, URINARY RETENTION, and COMPLETE SENSORY LEVEL
How does B12 deficiency present as a spinal cord system
Epicritic and corticospinal damage
- spastic weakness of lower extremities
- decreased vibration and position sense
- Romberg’s sign (remember that it is a medial lemniscus test)
- Ataxia
- Hyperreflexia
Treatment is IM injections of B12
HTLV-1
Human T lymphotrophic virus 1 causes spastic paraperesis
