spinal cord Flashcards
low back pain: how common is this complaint and causes
-84% of adults at some point
-lumbar strain
-degenerative ds- arthritis -> bony spurs: pain + inflammation
-discogenic pain (herniated disc)
-facet joint pain: arthritis
-spondylosis
-anterolishtesis- bone slips forward
-spinal stenosis
lumbar strain: what sx, workup, and tx
-Non-specific low back pain
-Not related to underlying serious disorder
-Often self resolves in 3 weeks
workup:
-Imaging NOT recommended if back pain unless lasting >4 weeks or if there is presence of red flags
-Labs not required
management: Non-pharm management is 1st line
-HEAT
-NO BED REST!- muscles get weaker -> more pain
-ACTIVITY MODIFICATION
-pharm tx: NSAIDs short-term
What is NOT needed in lumbar strain?
-Early PT
-Injections
-Advanced imaging early in the course of lumbar strain
-Opioids
reassure pt
spinal stenosis (neuroclaudication): definition, causes
Definition: Narrowing of canal causes compression on nerve roots
-MC >50yo
- neurogenic claudication sx
Causes:
-Congenital narrowing
-Osteoarthritis
-CENTRAL Disc herniation*
-Trauma
-Vertebral body fractures
-Fragility in osteoporosis
-Degenerative changes
-Disc height loss
-Bone spur growth (osteophytes)
-Facet bone overgrowth
-Ligamentum flavum thickening
-Degenerative spondylolisthesis
spinal stenosis neuroclaudication: sx
-Symptoms ofneurogenic claudication!:
-Pain/cramping in one/both legs when standing or walking for long periods
-Back pain +/- radiation to butt or legs
-Numbness, weakness, or tinglingunilaterally or bilaterally
-can be asymmetrical
-Shopping cart sign:
-Worse with extension* (prolonged standing)- narrows the spinal canal
-Improved with flexion* (bending forward)
-Severe: Urinary incontinence, difficulty walking (Cauda Equina syndrome)
spinal stenosis neuroclaudication: Dx and tx
PE: Typically NORMAL
-MRI will show spinal stenosis and cause (spondylolisthesis, mass, etc)
TX:
- NSAIDs
- PT
- Weight loss
- bracing
- epidural injection of steroids
-Surgical tx: decompression laminectomy
diff dx of neuropathic and vascular claudication
-vascular depends on moving -> muscle
cauda equina and conus medullaris syndrome
-Spinal cord terminates at the conus medullaris between L1-L2
-The most distal bulbous part of the spinal cord is called the conus medullaris.
-Below this lies the nerves that make up the cauda equina
what is cauda equina syndrome
-Characteristic pattern of neuromuscular and urogenital symptoms resulting from the simultaneous compression of multiple lumbosacral nerve roots below the level of the conus medullaris.
-LMN lesion.
-Compression of the nerves may be IRREVERSIBLE thus it is a neurosurgical emergency!!
Stat imaging, medication, and surgery is needed!
- Bilateral leg pain and BLADDER AND BOWEL CHANGES**
causes of cauda equina syndrome
-Lumbar stenosis (multilevel)
-Spinal trauma including fractures
-Herniated nucleus pulposus (HNP) - 90% of lumbar disk herniations occur either at L4-L5 or L5-S1.
-Neoplasm: metastases, astrocytoma, neurofibroma, and meningioma
-20% of all spinal tumors affect this area
-Spinal infection/abscess: TB, HSV, meningitis, meningovascular syphilis, CMV, schistosomiasis
cauda equina presentation
-Low back pain & Sciatica (97%)
-Lower extremity weakness, paresthesia’s
-Severe neuropathic pain
-Saddle or perineum anesthesia (92%)
-Bladder dysfunction (92%)- retention FIRST -> overflow incontinence
-Bowel dysfunction (72%): late sign
-Sexual dysfunction (impotence in men)
-Areflexic paraplegia, atrophy – late signs
- usually BILATERAL LEG PAIN
- saddle anesthesia: numbness
cauda equina syndrome evaluation - risk factors and PE
Risk factors:
-Malignancy history
-Recent trauma
-IV drug use - abscess
-Anticoagulation - bleed
-Spinal instrumentation
PE:
-Motor or sensory deficits in the legs
-Usually bilateral leg pain*
-Can be unilateral or asymmetrical
-LMN signs in chronic cord compression: areflexia, hypotonia, atrophy
-Saddle anesthesia - where you sit on a horse -> numb
-↓ or absent rectal tone -> everyone gets a rectal exam
-Abdomen = large bladder (retention)
cauda equina syndrome imaging and management
-STAT MRI cord-compression series = gold standard!
-CT myelogram if unable to obtain MRI (metal implants)
-Consider post-void residual (>100cc generally neurologic)
Management: Neurosurgical emergency!!!
-Technically a clinical diagnosis -> STAT consultation… call the surgeon!!!
-(even before MRI if high suspicion)
-Decompression within 24 hrs window*
conus medullaris syndrome (dont memorize the diff between this and cauda equina)
-Lesions at vertebral level L2 often affect the conus medullaris.
-Early and prominent sphincter dysfunction with flaccid paralysis of the bladder and rectum, impotence, and saddle (S3-S5) anesthesia.
-Causes include disc herniation, spinal fracture, and tumors
-May have some upper motor neuron (UMN) signs and present with increased tone and reflexes (UMN) and bilateral signs.
-In terms of the diagnosis, differentiating between cauda equina syndrome and conus medullaris syndrome doesn’t matter, as the management is the same. What’s needed is an MRI and urgent referral**
julia notes:
- CMS: around L1-L2 -> has UMN and LMN sx; faster onset
- CES: L2-S5 -> LMN lesion ONLY; more gradual onset, may have more assymetric sx
epidural abscess: definition, pathogenesis, risk factors
Definition: Infection within the epidural space of the spinal cord
-Any age, more often 50-70 yo
-Can lead to spinal cord compression / ischemia
Pathogenesis:
-Hematogenous spread - bacteremia
-Direct inoculation: surgery, trauma
-Mostly staph aureus infections- skin infection
Risk factors:
-25% have no risk factors
-Immunocompromise: DM, HIV, malignancy, chronic steroids, immunosuppressants
-Recent SSTI bacteremia
-Spinal anatomy abnormality
-Substance abuse: alcohol, IVDU!
-Presence of indwelling catheter
-Elderly
epidural abscess sx, dx, tx
Symptoms: Non specific, easily missed
-Triad: Back pain, fever, neuro signs
-Back pain 75% - Localized, midline!, with tenderness to percussion
-Fever 50%
-Neuro symptoms 33% - radiculopathy, weakness, sensory deficits, paralysis
Labs are non-specific
-Blood cultures!!*
Imaging:
-MRI with gadolinium = gold standard
Management:
-Empiric antibiotics (Vanc+Ceftriaxone)
-Urgent neurosurgery or ortho spine consult
complete spinal cord injury (SCI)
Def: Complete transection of all spinal tracts at a given level
-Total bilateral loss of motor/sensory/bowel/bladder function below the level of injury
-Some features only appear in the chronic phase (6-8 weeks)
Below the level of the lesion:
-Bilateral anesthesia
-Bilateral paralysis (spastic paralysis)*
-Hyperreflexia*
-Clonus
-Absent anal reflex
-!Positive babinski*
-Autonomic dysfunction
-Neurogenic bowel
-Erectile dysfunction
UMNs can’t send signals past the injury to control the LMNs.
- LMNs don’t get the normal signals from the brain that inhibit or control them -> LMNs = overactive + spastic muscles and stronger reflexes.
incomplete spinal cord injury (SCI)
Def: Partial transection of the spinal cord affecting select parts of the ascending or descending pathways
-Will maintain some but not all sensorimotor functions below the level of injury
types:
-Central cord syndrome: MC
-Anterior cord syndrome: worst prognosis
-Posterior cord syndrome: b12 and syphillis, rare mechanically
-Brown-Sequard syndrome
-Conus medullaris syndrome
-Cauda equina syndrome
spinal shock: def, when does this occur, sx
Definition: acute and transient loss/depression of sensorimotor functions below SCI
-Occurs immediately after any SCI
-Typically resolves within 48 hours
-cant assess actual issues until this is gone
Symptoms:
-Paralysis , anesthesia, and areflexia below the level of injury
-Cervical cord -> paraplegia or tetraplegia
-Autonomic dysfunction
-Neurogenic shock: hypotension and bradycardia
-Loss of bladder and bowel control
-
Once spinal shock resolves you can determine the true chronic injury:
-Persistent total impairment -> complete SCI
-Improving neuro function -> incomplete SCI
ASIA classification of spinal cord injury
-dont memorize
central cord syndrome
-MC incomplete cord injury
-Elderly, minor extension head injuries
-Patho: Spinal cord compression and central cord edema (UE are located “centrally” in corticospinal tract)
-hyperextension injury -> chin hits the ground
-Prognosis: Good
Sxs:
-Bilateral loss of light sensation and pain/temperature below the level of the lesion
-UE>LE bilateral hand weakness
-“Cape” distribution if in c-spine - numb, weak, tingling
anterior cord syndrome
Patho: Direct compression/flexion injury or anterior spinal artery injury*
-Sxs:
-Bilateral paralysis below the lesion
-Bilateral loss of pain/temperature
-LE>UE affected*
-(preserved proprioception/vibration)
Prognosis: Worst of all incomplete SCI*
brown-sequard syndrome
-Hemitransection of the spinal cord
-Prognosis: Good
-MOA: Usually PENETRATING trauma
Sx:
-Ipsilateral: Motor paralysis, loss of proprioception and vibration sense
-Contralateral: Loss of pain/temperature sensation 2 levels below injury
posterior cord syndrome
Causes:
-Very rare to occur mechanically
-Syphilis**
- B12 deficiency ***
- MS
- copper deficiency
- trauma with hyperextension
- extrinsic spinal cord compression
Sx:
-Bilateral loss of proprioception and vibration -> ataxia
-(Preserved motor, sensation)
imaging for SCI
MRI spine: Test of choice for SCI **
- better for spinal cord, nerve root, disc and ligamentous problems
-XR : Low sensitivity
-CT spine without IV contrast: Good for vertebral fractures/dislocations
-CTA/MRA: If suspicion of vascular injury
SCI management
-ABCDE
-requires a large trauma or elderly
-hard c spine collar
-Unstable injury -> immobilize
-Catheterize early - assume urinary retention
-call spine surgeon or trauma surgeon
-ICU / CCM / Neuro ICU admission
Expert opinion: High dose steroids -> decrease inflammation around spinal cord
distribution of paralysis
Stocking-glove: Think polyneuropathy causes
-radiculopathy -compression of distal nerve or nerve ROOT -> carpal tunnel
-hemi - stroke
-neuropathy- dorsal column findings, DM, guillan barre
causes of dorsal column issues
-tertiary syphilis
-B12 deficiency
-when you lose proprioception -> Ataxic gait
