Nontraumatic Disorders of the Spinal Cord

Question 1

Spinal cord syndromes

Answer 1

Question 2

Causes of posterior cord syndrome

Answer 2

• Multiple sclerosis or demyelination
• Cervical spondylotic myelopathy
• Spinal cord tumors
• Atlantoaxial subluxation
• Friedreich ataxia
• Subacute combined degeneration

Question 3

Causes of myelitis

Answer 3

Question 4

Acute idiopathic transverse myelitis treatment

Answer 4

For patients with acute idiopathic TM, we suggest high-dose intravenous glucocorticoid treatment

For patients with acute TM complicated by motor impairment, we suggest additional treatment with plasma exchange
Our preferred regimen is five treatments, every other day for 10 days

Question 5

Evaluation of suspected transverse myelitis

Answer 5

https://www.uptodate.com/contents/image?imageKey=NEURO%2F88920&topicKey=NEURO%2F14088&search=myelitis&rank=2~150&source=see_link

Question 6

Diagnostic criteria for transverse myelitis

Answer 6

https://www.uptodate.com/contents/image?imageKey=NEURO%2F88914&topicKey=NEURO%2F14088&search=myelitis&rank=2~150&source=see_link

Question 7

Potential medical work-up for suspected acute transverse myelitis

Answer 7

https://www.uptodate.com/contents/image?imageKey=NEURO%2F65585&topicKey=NEURO%2F14088&search=myelitis&rank=2~150&source=see_link

Question 8

Elsberg syndrome

Answer 8

acute lumbosacral radiculitis featuring cauda equina syndrome with myelitis

Acute urinary retention with loss of sacral sensation due to lumbosacral radiculitis secondary to severe primary HSV infection.
This complication is transient but usually requires catheterization until clinical improvement ensues

Question 9

Causes of acute flaccid paralysis

Answer 9

https://www.uptodate.com/contents/image?imageKey=NEURO%2F71165&topicKey=NEURO%2F126102&search=myelitis&rank=3~150&source=see_link

Question 10

Spinal epidural abscess pathogenesis and most common pathogen

Answer 10

can occur from direct spread (vertebral osteomyelitis, local surgical or anesthetic procedures) or hematogenous spread from a distant infection (bacterial endocarditis, genitourinary infection)

approximately one-third of patients with SEA have no identifiable source for the infection

Staphylococcus aureus causes more than 50% of cases

Question 11

classic diagnostic triad for spinal epidual abscess and treatment

Answer 11

The classic diagnostic triad for SEA consists of fever, back pain, and neurologic deficits.

** However, only a small proportion of patients have all three components at presentation

Treatment may include fluoroscopic or ultrasound guided, drainage, and any necessary stabilization of the spine.
Systemic antibiotics are given for up to 2 months

Question 12

Spinal epidural abscess imaging

Answer 12

Abscesses visualized by MRI usually demonstrate fluid-equivalent signal intensity on T2-weighted images with rim enhancement and a hypointense center

Question 13

Syringomyelia etiology

Answer 13

Syringomyelia most commonly occurs in the setting of the Chiari malformation type I

Other causes of syringomyelia are:
●Other congenital malformations (eg, Klippel-Feil syndrome, and tethered spinal cord)
●Postinfectious
●Postinflammatory (transverse myelitis and multiple sclerosis)
●Spinal neoplasms (especially ependymoma and hemangioblastoma)
●Post-traumatic

Question 14

Syringomyelia diagnosis and management

Answer 14

The syrinx follows CSF signal characteristics on all MRI sequences:

T1: hypointense
T2: hyperintense, although there may be hypointense regions representing flow or pulsation artifact

Surgical decompression with fenestration and/or shunt placement is recommended for patients with neurologic deterioration or intractable central pain

Question 15

Syringomyelia clinical findings

Answer 15

A symptomatic central cord lesion typically encroaches on the medial aspect of the CSTs or on the anterior horn gray matter, producing weakness that is more prominent in the arms than the legs.
Fibers mediating the deep tendon reflexes are interrupted as they pass from the dorsal to the ventral horn, thus causing tendon reflex loss at the level of the spinal cord lesion.
There are usually no bladder symptoms, but urinary retention may occur.

Loss of pain and temperature sensation in the distribution of one or several adjacent dermatomes at the site of the spinal cord lesion is caused by disruption of crossing spinothalamic fibers in the ventral commissure!!
Dermatomes above and below the level of the lesion have relatively normal pain and temperature sensation, creating the so-called “suspended sensory level.”
Vibration and proprioception are often spared.

Syringobulbia causes dysphagia, nystagmus, pharyngeal and palatal weakness, asymmetric weakness and atrophy of the tongue, and sensory loss in the distribution of the trigeminal nerve

Question 16

Spinal cord arteriovenous shunts clinical findings and diagnosis

Answer 16

The most common initial symptoms are radicular pain, sensory disturbance, leg weakness, and bladder dysfunction.

Seventy-five percent of patients have a slowly progressive myelopathy caused by cord compression from an AVM, and 10% have a sudden onset of cord compression due to hemorrhage or spinal cord infarction.
Weakness and numbness may increase after ambulation.

MRI and magnetic resonance angiography can identify the lesions, but angiography is the gold standard

T1
* signal voids from high-velocity flow
* dilated perimedullary vessels indent/scallop the cord

T2
* signal voids from high-velocity flow
* increased cord signal due to cytotoxic edema or myelomalacia

Question 17

Spinal cord vascular supply
Which part is more vulnerable to infarctions

Answer 17

Three major vessels arising from the vertebral arteries in the neck supply the spinal cord.
There is one anterior spinal artery (ASA) and a pair of posterior spinal arteries (PSAs).
The ASA supplies the anterior two-thirds of the spinal cord.
Along its course, the ASA and PSAs are augmented by radicular arteries.

The thoracic spinal cord is particularly dependent on radicular contributions (τμηματικές μυελικές αρτηρίες) and may be the most vulnerable to infarction

The most prominent thoracic radicular artery is the artery of Adamkiewicz, also known as the artery of the lumbar enlargement.
The artery of Adamkiewicz contributes to the ASA between the T9 to T12 level in 75 percent of individuals, but may be found above and below this level

Question 18

Causes of spinal cord infarction

Answer 18

https://www.uptodate.com/contents/image?imageKey=NEURO%2F57862&topicKey=NEURO%2F1125&search=spinal%20cord%20infarct&rank=3~98&source=see_link

Question 19

classic neurologic finding in vitamin B12 deficiency

other findings

Answer 19

subacute combined degeneration of the dorsal (posterior) and lateral columns (white matter) of the spinal cord due to demyelination

areflexia, sensory ataxia, paraparesis, and extensor plantar responses!

Question 20

Cervical radiculopathy: which nerve root is most often affected

Answer 20

C7 nerve root is most often affected (60%), followed by C6 (25%)

Question 21

Lumbar radiculopathy: which nerve root is most often affected

Answer 21

L5 is the most commonly compressed
nerve root, followed closely by S1

Question 22

Approach to acute cervical radiculopathy

Answer 22

https://www.uptodate.com/contents/image?imageKey=NEURO%2F109708&topicKey=NEURO%2F5271&search=radiculopathy&rank=4~150&source=see_link

Question 23

Approach to acute lumbosacral radiculopathy

Answer 23

https://www.uptodate.com/contents/image?imageKey=NEURO%2F101562&topicKey=NEURO%2F5262&search=radiculopathy&rank=1~150&source=see_link

Question 24

Most common cause of acquired spastic paraparesis in middle and older adulthood

Answer 24

Cervical spondylotic myelopathy

Question 25

Cervical spondylotic myelopathy clinical findings

Answer 25

Patients frequently have difficulties with balance, especially spasticity, and radicular symptoms.
Bladder incontinence is uncommon, but urinary frequency is common when spasticity is present.
On examination, lower motor neuron signs are
present at the level of the lesion, and upper motor neuron signs are present below the lesion.

Question 26

Signs and symptoms differentiating between conus medullaris and cauda equina syndrome

Answer 26

Question 27

Cauda equina syndrome etiology and clinical findings

Answer 27

The cauda equina syndrome is caused by an intraspinal lesion caudal to the conus that injures two or more of the 18 nerve roots constituting the cauda equina within the lumbar spinal canal

Potential etiologies include developmental abnormalities such as neural tube defects, infectious or inflammatory conditions, or mass lesions such as tumors.

The cauda equina syndrome is typically associated with marked neurologic disability. The clinical presentation is dominated by bilateral leg weakness in multiple root distributions (L3-S1) and may be associated with perineal sensory symptoms as well as bowel, bladder, and sexual dysfunction due to involvement of the S2-4 spinal nerve roots

loss of reflexes!!

Question 28

Copper deficiency myeloneuropathy: risk factors and clinical findings

Answer 28

Gastric surgery is the most common cause of acquired copper deficiency.
Other causes include excessive zinc ingestion, dietary copper deficiency, malabsorption syndromes, and chelation therapy in Wilson disease.

Neurologic manifestations – The most common neurologic manifestation of acquired copper deficiency is that of a myeloneuropathy. Patients typically present with a subacute onset of a gait disturbance. Examination reveals long tract signs with spasticity in the legs and Babinski response, along with impaired vibration and position sense and a positive Romberg sign

Hematologic manifestations – The hematologic hallmark of copper deficiency is anemia and leukopenia; these are present in most, but not all, patients with associated neurologic deficits

Question 29

Nitrous oxide toxicity

Answer 29

Neurologic toxicity is well documented in patients who misuse N2O, and due to its effects on vitamin B12.

Neurological findings include sensorimotor polyneuropathy, ataxia, and psychosis

The clinical effects are commonly from a myelopathy involving the cervical spine similar to the subacute combined degeneration syndrome associated with pernicious anemia

Neurotoxicity is potentially reversible with vitamin B12 (cyanocobalamin) supplementation and abstinence from N2O