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MD2 Neuro > Spinal Cord Compression > Flashcards

Spinal Cord Compression Flashcards

1
Q

Why is prompt Dx of spinal cord compression essential?

A

Rapidly evolving spinal cord compression (hours to days) is a NEUROSURGICAL EMERGENCY which should be managed as soon as possible to avoid permanent neurological disability

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2
Q

Recognise the appearance of extradural, intradural/extramedullary and intramedullary lesions which may compress the spinal cord and cauda equina. Which is the most common?

A
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3
Q

What are the 5 most common categories of causes of spinal cord compression?

A

Tumour (primary or metastatic)

Degenerative

Infection

Haematoma

Developmental

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4
Q

List 3 degenerative causes of spinal cord compression

A

Disc prolapse

OP

Spondylosis

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5
Q

What anatomical features are possible sites of infection which may cause spinal cord compression?

A

Vertebral body

Disc space

Extradural

Intradural

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6
Q

Give 3 causes of spinal haematoma which may result in spinal cord compression

A

Spontaneous

Trauma

AVM

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7
Q

List 3 developmental abnormalities which may result in spinal cord compression

A

Syrinx

AVM

Arachnoid cyst

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8
Q

What is a syrinx?

A

Syringomyelia is the formation of a fluid-filled cyst (syrinx) within the spinal cord

As the cyst grows, it may compress the spinal cord

Causes include trauma, infection and congenital brain defects

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9
Q

What is an arachnoid cyst?

A

Cerebrospinal fluid-filled sacs covered by arachnoid cells and collagen that are located between the brain or spinal cord and the arachnoid membrane

Primary arachnoid cysts are present at birth and are the result of developmental abnormalities; secondary arachnoid cysts are not as common as primary cysts and develop as a result of head injury, meningitis, or tumors, or as a complication of brain surgery

Majority form in the middle cranial fossa (spinal cord cysts are less common)

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10
Q

Give 3 examples of extradural causes of spinal cord and cauda equina compression

A

Metastatic tumour

Abscess

Degenerative spinal disease

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11
Q

Give 3 examples of intradural/extramedullary causes of spinal cord and cauda equina compression

A

Meningioma

Schwannoma

Myxopapillary ependymoma

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12
Q

Give 2 examples of intramedullary causes of spinal cord and cauda equina compression

A

Glioma (astrocytoma or ependymoma)

Syrinx

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13
Q

Overview of meningioma (what is it, presentation, Dx, Ix, Mx)

A

Predominantly benign tumour of the meninges occurring at both cranial and spinal sites; they are occasionally atypical or malignant in nature

Sx: produces symptoms from local mass effect due to compression of neural structures or may present with seizure

Dx: diagnosis confirmed by the characteristic appearance on MRI with and without contrast enhancement

Ix: asymptomatic lesions may be followed up with serial observation

Mx: treatment of symptomatic meningioma is usually surgical resection, although, in some cases, local radiotherapy is used as primary treatment

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14
Q

What is schwanomma?

A

A schwannoma is a benign nerve sheath tumour composed of Schwann cells, which normally produce the insulating myelin sheath covering peripheral nerves

Less than 1% become malignant, degenerating into a form of cancer known as neurofibrosarcoma

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15
Q

What is myxopapillary ependymoma?

A

Thought to arise from the ependymal glia of the filum terminale or conus medullaris (at the end of the spinal cord); histologically, they contain papillary elements in a myxoid background, admixed with ependymoma-like cells

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16
Q

What is an ependymoma?

A

Ependymomas arise from ependymal cells lining the central canal or cell rests along the filum; they are the most common spinal cord tumour overall

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17
Q

What is an astrocytoma?

A

Astrocytomas (both intracranial and spinal) arise from astrocytic glial cells; spinal cord astrocytomas generally have a lower histologic grade than astrocytomas in the brain

They are the second most common spinal cord tumour overall

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18
Q

If a patient presents with LL neurological disturbance but UL is normal, what does this suggest about the location and level of the lesion?

A

No cervical spine involvement

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19
Q

What is the most common cause of cauda equina syndrome?

A

Acute disc prolapse

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20
Q

How might spinal cord compression present differently to cauda equina?

A

Spinal cord compression can present with UMN signs

In cauda equina syndrome, all signs are consistent with a LMN lesion

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21
Q

What are the two major presenting features of spinal cord compression and cauda equina syndrome? What factors can affect the presentation?

A

Presentation: pain and neurological deficit

Modified depending on: site of compression, speed of onset, involvement of adjacent nerve roots, cause, and involvement of blood supply of the spinal cord

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22
Q

Mr Verdi, 73, visited his GP complaining of difficulty walking

He could not describe the symptom very well, but thought his legs had been generally weak and stiff; he also noted some trouble with fine movements of his hands

What are these symptoms suggestive of?

A

Weak and stiff: may suggest UMN lesion

Involvement of hands: suggests cervical spine

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23
Q

Mr Verdi, 73, presents with difficulty walking

Previously well, PHx: OA of knees, occasional low back pain, more recently some neck pain, no surgery, no cancers

Symptoms have been progressively worsening over many months or maybe even years

Walking has been “shuffling” and he feels unable to continue for long distances; he has had a number of falls and feels unsteady

His hands feel numb and he has had trouble with buttoning his shirt and turning the pages of the newspaper

His bladder and bowel function have been normal

O/E: moderate restriction of neck movements due to mild pain and stiffness, shuffling stiff gait, UL power relatively normal but depressed reflexes, light touch sensation in hands diffusely reduced with no clear dermatomal distribution, LL power only mildly reduced but tone elevated and very brisk reflexes, Babinski’s sign positive, light touch sensation in LLs normal but proprioception and vibration reduced

What picture is this?

What anatomical level is the lesion

DDx?

What should Mr Verdi’s GP do next? Ix and Mx?

A

Mixed picture: UL has LMN pattern, LL has UMN pattern with spastic paraparesis

Hx and Ex suggest a slowly progressive compressive lesion of the cervical spinal cord (a classic “cervical myelopathy”)

In an older patient with neck pain, slow Sx onset, no fever and no Hx of cancer, this is most likely due to degenerative cervical canal stenosis

Main DDx: spinal tumour (primary or metastatic), spinal infection, inflammatory or neurodegeneraive diseases (MS, MND, syringomyelia/syrinx, subacute combined degeneration of the spinal cord)

Ix: baseline bloods, CT scan of cervical spine

Mx: neurosurg referral (who will most likely order an MRI of the cervical spine)

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24
Q

Mr Verdi, 73, presents with difficulty walking and has signs O/E of spinal cord compression

MRI: severe cervical canal stenosis with cord signal change due to disc prolapse, spondylosis and hypertrophy of the ligamentum flavum

Is this an emergency?

A

No; has a slow progression

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25
Q

Where does degenerative spinal canal stenosis usually occur? What sites produce the most clinically significant presentations?

A

May occur anywhere along the spinal column

Most clinically significant lesions are in the cervical spine (causing cervical myelopathy due to cord compression) and in the lumbar spine (causing sciatica and neurogenic claudication due to cauda equina compression)

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26
Q

What degenerative changes can contribute to spinal canal stenosis? What factors can contribute to these degenerative changes?

A

Spondylosis with hypertrophy and osteophytes of the fact joints

Hypertrophy of ligamentum flavum

Bulging or prolapsed intervertebral discs and associated osteophytes

Contributing factors: excessive mobility, often on a background of a congenitally narrow canal

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27
Q

What is the most common cause of spinal cord compression due to degenerative spinal canal stenosis?

A

Spondylotic spinal myelopathy

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28
Q

What is the effect of surgical intervention on symptoms of a chronically evolving spinal cord compression?

A

Operation stops the progression of symptoms but does not reverse or improve current symptoms

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29
Q

What is the cause of the neurological symptoms seen in degenerative spinal cord stenosis?

A

Direct pressure on neural structures

Ischaemia of the neural structures

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30
Q

What pathological changes occur in the spinal cord due to compression and ischaemia of the neural structures?

A

Degeneration and loss of nerve cells

Spinal cord cavitation

Glial cell proliferation

Demyelination

Wallerian degeneration of tracts above and below the level of compression

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31
Q

Principles of Mx of degenerative canal stenosis

A

Conservative Mx indicated for: mild, non-progressive disease, the very elderly (although common to treat patients into their 80s), or those unfit for Sx due to comorbidities

Sx treatment indicated for moderate, severe or progressive disease to halt further disability (presenting neurological deficits may be irreversible)

32
Q

What is the risk with conservative Mx of degenerative canal stenosis?

A

Risk of sudden, irreversible worsening with even minor trauma

33
Q

What type of Sx may be indicated for degenerative spinal canal stenosis?

A

Surgical removal of the compression lesion(s): may involve a posterior or anterior approach

Spinal fusion may be necessary for pre-existing instability or extensive destructive surgery

34
Q

Name spinal surgeries and specify whether they utilise a posterior or anterior approach

A

Laminectomy

Discectomy

Vertebrectomy

35
Q

How is the type of surgery and the approach planned when operating on a degenerative spinal cord stenosis?

A

Dependent on:

Severity of compression

Number of vertebral levels involved

Whether compression is largely anterior or posterior

36
Q

Mr Verdi underwent an anterior cervical discectomy and fusion to remove the disc prolapse and fuse the spine at C3/C4, the level of most significant compression and where there was mild instability with movement

He may require a laminectomy from a posterior approach in the future to decompress the rest of the cervical canal

What does the arrow in his post-op XR show?

A

Plate and anchoring screws across the disc space which contains a “cage” for fusion

37
Q

Mr Singh, 39, presents with pain and a neurological deficit; he has progressively worsening back and leg pain and recently has noticed difficulty initiating urination

Presents at ED in severe distress, having been unable to pass urine for 8/24

What is the most common cause of this type of presentation? What is its pathophysiology? Why is the PNS affected but not the SNS?

Mx priorities?

What are some “red flags” for back pain?

A

Most common cause: acute disc prolapse, due to compression of the PNS inside the spinal canal (causes retention due to prevention of ureteric sphincter relaxation)

SNS is outside the spinal cord

Mx priorities: urinary catheter!

Red flags: progressively worsening, not related to position or movement, worse at night/waking from sleep, radiation down back of legs, Hx of fever/cancer/LOW/DM/drug use

38
Q

Mr Singh, 39, presents with pain and a neurological deficit

Has had back pain for over a year but never before that

Pain is progressively worsening, diffuse low back pain with a deep, boring quality, and is not related to position or movement but is worse at night

There is radiation of the pain down the back of the legs

No Hx of trauma, fever, cancer, LOW, DM, drug use

O/E: normal neurological examination apart from previously enlarged bladder

What does Mr Singh need next?

A

Symptoms of cauda equina compression, requiring urgent r/v by neurosurgery and an MRI scan of the thoraco-lumbar spine, as well as some routine bloods to look for signs of infection, inflammation, etc

39
Q

This is Mr Singh’s thoraco-lumbar MRI

What does it show?

A

Well-defined intradural, extramedullary lesion that enhances with contrast and is compressing the cauda equina

40
Q

What % of spinal cord tumours are benign?

A

90%

41
Q

DDx for an intradural, extramedullary, well-defined lesion in a young patient

A

Meningioma (usually young woman)

Schwannoma

Dermoid or epidermoid cyst

Metastasis (rare)

42
Q

What is the effect of surgery on symptoms in a patient presenting acutely with cauda equina syndrome due to a compressive lesion?

A

Surgical removal of the lesion should result in a return to normal function

43
Q

What is the most common early feature of cauda equina syndrome?

A

Pain (usually before neurological deficit)

44
Q

What is the mechanism of pain in cauda equina syndrome?

A

Due to:

Involvement of pain sensitive structures including bone and muscle

Compression of nerve roots and spinal cord

45
Q

What “pain patterns” can be produced by cauda equina syndrome due to compression of nerve roots and the spinal cord?

A

Diffuse, dull, burning

Sciatica in LLs

Brachalgia in ULs

“Girdle” pain radiating around chest wall

46
Q

What is the typical pattern of progressive weakness seen with a cervical or thoracic lesion?

A

Progressive spastic paraparesis with UMN weakness, little or no wasting, increased tone and reflexes, and a positive Babinski’s reflex; will eventually lead to paraplegia

In a cervical lesion the ULs will be involved and the pattern depends on the level of compression: often LMN/nerve root compression at the level of the compression with wasting and depressed reflexes

47
Q

What sensory level corresponds to the level of the nipples?

A

T4

48
Q

What sensory level corresponds to the level of the xiphisternum?

A

T7

49
Q

What sensory level corresponds to the level of the umbilicus?

A

T10

50
Q

What pattern of sensory disturbance will be seen in a cervical compression?

A

Sensory disturbance in the appropriate dermatomal pattern

51
Q

What are the features of Brown-Sequard syndrome and what is the cause?

A

Contralateral impairment of pain and temperature

Ipsilateral weakness and impairment of proprioception, vibtration and light touch

Due to a laterally placed mass

52
Q

What pattern of sensory disturbance is seen in intrinsic lesions of the central spinal cord and syringomyelia?

A

Cape-like loss of pain and temperature sensation

53
Q

What pattern of sensory disturbance is seen in lesions of the cauda equina and conus medullaris?

A

Saddle anaesthesia

54
Q

What compressive syndromes will cause sphincter disturbance and what symptoms will result?

A

Occurs with compression in any region, but paricularly with conus medullaris and cauda equina

Sx: difficulty initiating urination (usually 1st symptom), followed by urinary retention or incontinence, and subsequent constipation and faecal incontinence

55
Q

Mrs Abdullah, 61, was treated for breast cancer 3 years ago with a lumpectomy and subsequent local RT and chemotherapy

Has had regular FU and has no known recurrent local or metastatic disease

Presents to her GP with 1/52 of severe back pain and difficulty getting up from a chair this morning (proximal weakness)

Pain is mid-thoracic and radiates around to her anterior chest; it is severe in all postures

O/E: spastic paraparesis, normal ULs, sensory level at T4, bladder painlessly enlarged

Ix?

A

CT scan of thoracic spine

56
Q

Mrs Abdullah, 61, was treated for breast cancer 3 years ago with a lumpectomy and subsequent local RT and chemotherapy

Presents to her GP with 1/52 of severe back pain and difficulty getting up from a chair this morning (proximal weakness)

What does this CT scan of her thoracic spine show?

A

Destructive lesion at T4; vertebral body is replaced by tumour and collapsed, and there is tumour projecting into the spinal canal with spinal cord compression

57
Q

6 common causative cancers for a malignant spinal cord compression

A

Lung

Breast

Prostate

Kidney

Lymphoma

Myeloma

58
Q

What level of the spinal column is most commonly affected by malignant lesions?

A

Thoracic

59
Q

Principles of Mx for malignant spinal cord compression

A

Urgent Ix and Mx to avoid severe permanent disability

Commence dexamethasone to shrink the tumour in the short term

Prompt decision with regards to treatment modality (palliation/symptom control only, radiotherapy, surgery)

60
Q

What are the indications for palliation/symptom control as treatment of choice for malignant spinal cord compression?

A

If death from primary cancer imminent or if deficit has been present for more than a few days and is fixed

61
Q

What are the indications for radiotherapy as treatment of choice for malignant spinal cord compression?

A

In radiosensitive tumours and only if neurological deficit is mild and non-progressive, without significant neural compression on imaging

After surgical decompression (because tumour resection is generally incomplete)

62
Q

What are the indications for surgery as treatment of choice for malignant spinal cord compression?

A

If destabilisation of spine

63
Q

How is the type of surgical procedure for malignant spinal cord compression decided?

A

Number of vertebral levels involved

Whether compression is largely anterior (vertebrectomy) or posterior (laminectomy)

Whether spinal fusion is necessary (pre-existing instability or extensive destructive surgery)

64
Q

Mr WIlliams, 24, BIBA to ED with a GCS of 10; known IVDU and rapidly revived with naloxone

Immediately on awakening he complains of severe neck pain and is noted to be febrile

What are the red flags here?

A

Lowered GCS

IVDU

Severe pain

Febrile

65
Q

Mr Williams, 24, BIBA to ED with GCS of 10; known IVDU and on awakening complains of severe neck pain and is found to be febrile

Neck pain has been progressive over 2-3 days and is severe, radiating into both arms and increasing Mr Williams’ usual narcotic use

Has remained in bed for last few days until his girlfriend called in an ambulance

Has been unwell and feverish

O/E: temperature 39 degrees C, number of infected track marks and rotten teethi, holds cervical spine rigid, bilateral reduction of biceps and triceps reflex and weakness of elbow flexion and extension, increased reflexes in LLs

Ix?

A

FBE

Blood cultures

MRI of cervical spine

66
Q

Mr Williams, 24, is BIBA to ED with a GCS of 10; known IVDU and on awakening complains of severe neck pain and is found to be feverish

What does his cervical spine MRI show?

A

T1-weighted sagittal MRI with contrast (left) shows C5/C6 discitis wtih an associated epidural abscess from C5 to C7 that enhances with contrast

T2-weighted sagittal MRI (right) showing cord compression due to the abscess

67
Q

What is the common spinal region for a spinal abscess?

A

Thoraco-lumbar region

68
Q

Describe the possible pathophysiologies of spinal abscess

A

Haematogenous spread to disc or epidural space from distant infected site (skin, respiratory tract, sinuses, middle ear, teeth, genitourinary tract, endocarditis, infected prosthesis, phlebitis, IVDU, infected wound)

Direct spread from adjcent infection, including vertebral body, decubitus (pressure) ulcer, paraspinal or psoas abscess

69
Q

Should empirical Abx be given for a patient with a suspected spinal abscess? Should a LP be performed?

A

No, because it will mean that sampling during the operation will not be accurate

LP will not show any meaningful results

70
Q

What is the most common micro-organism causing spinal abscess?

A

Staph aureus (or other Staphs)

71
Q

List some common micro-organisms responsible for spinal abscess

A

Often unknown

Bacterial: staph, strept, Gram negatives, anaerobes, multiple

Mycobacterial: MTB

Fungal: aspergillus, actinomyces, nocardia, cryptococcus

Other: parasites, syphilis (rare)

72
Q

What is the clinical presentation of spinal abscess and what is the mechanism of these signs/symptoms?

A

Presents with severe local spinal pain, rapidly progressive neurological deficit, systemic features of infection

Spinal cord compression due to inflammatory swelling and pus (mostly extradural), cord ischaemia due to thrombosis of arteries and veins (may lead to rapid and irreversible neurological deterioration)

73
Q

Principles of Mx for spinal abscess

A

Emergency Ix and transfer for neurosurgical assessment

Emergency surgical decompression

Broad spectrum Abx until micro-organism isolated and sensitivities known

74
Q

What is subacute combined degeneration of spinal cord?

A

Lichtheim’s disease

Degeneration of the posterior and lateral columns of the spinal cord as a result of vitamin B12 deficiency (most common), vitamin E deficiency and copper deficiency

75
Q

How does subacute combined degeneration of the spinal cord (Lichtheim’s disease) present?

A

Gradual and uniform onset

Weakness and parasthesia of ULs, LLs and trunk

Vision changes and change of mental state

Bilateral spastic paresis may develop

Pressure, vibration and touch sense are diminished

MD2 Neuro (9 decks)

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