Spinal Cord Disease Flashcards
How does cord compression present?
Chronic and Subacute Compression present as Spastic Paraparesis/Tetraparesis, Radicular Pain at Level of Compression and Sensory Loss below level of compression
Features of radicular pain
characteristically worse on coughing/straining (Raised ICP); Numbness starts
distally and rises to level of compression; Usually 2-3 Dermatome levels below level of Anatomical compression; Urinary Retention and Constipation might develop
How to approach acute spinal cord compression
Acute Spinal Cord Compression is a Medical Emergency; MRI Spine; CXR might show Primary
Tumour or Infection; Surgical exploration might be necessary
What happens if decompression is delayed
Cord Damage becomes irreversible; Good prognosis if Benign Tumours or Haematomas removed early
When can radiotherapy be used?
Radiotherapy for Cord Malignancy or Compression due to Inoperable Malignant Vertebral Body Disease causing Cord Compression
Causes of Spinal Cord Compression: Disc/Vertebral
– (Central Cervical Disc, Thoracic Disc Protrusion);
Compression due to Cervical Spondylotic Myelopathy is the commonest cause of Spastic Paraparesis in the Elderly
Causes of Spinal Cord Compression: trauma
Patients with back trauma need to be immobilised
before assessment
Causes of Spinal Cord Compression: Spinal cord tumour
Extramedullary Tumours e.g. Meningiomas and Neurofibromas can cause Cord Compression; Gradually
worsens over time; Vertebral Body Destruction by Bony Metastases (e.g. Prostate, Breast) is a common cause as well
o Intramedullary Tumours (e.g. Ependymomas) are less common; Progress slowly;
Sensory disturbances like Syringomyelia might develop
o Spinal Epidural Abscesses would present in a similar manner
Causes of Spinal Cord Compression: TB
Spinal TB commonest cause where TB is common; Destruction of Vertebral
Bodies, Disc Spaces, Local Spread of Infection
o Cord Compression and Paraparesis leading to Paralysis = Pott’s Paraplegia
Causes of Spinal Cord Compression: Epidural haemorrhage and Haematoma
Rare complication of Anticoagulation, Bleeding
disorders, Trauma, can occur following LP if clotting is abnormal
o Rapidly progressive Cord/Cauda Equina Lesion can develop
Inflammatory Lesions of the Spinal Cord: MS
- Myelopathy evolves over days, often partial recovery follows in weeks/months
- Can be seen on MRI with Gadolinium Contrast; Cord Swelling and Oedema
- Multiple Sclerosis is the commonest cause of Spastic Paraparesis in young adults; 1-2 Spinal Segments affected; Part or Entirety of Cord is affected
• Infection – VZV, EBV, HIV, HTLV1/2 (Tropical Spastic Paraparesis), MTb, Syphilis, Lyme disease,
Schistosomiasis or Para infectious Autoimmune Process E.g. Post Viral, Immunisation
• Neuromyelitis Optica (NMO = Devic’s Disease) – AQP4 Autoantibodies leading to Astrocyte
damage in Spinal Cord and Optic Nerves leading to Long Cord Lesions (≥3 Segments) and
Optic Nerve Demyelination
Inflammatory Lesions of the Spinal Cord: Inflammatory disorders
• Systemic Inflammatory disorders – SLE, Sjögren’s, Sarcoidosis
Inflammatory Lesions of the Spinal Cord: Infection
VZV, EBV, HIV, HTLV1/2 (Tropical Spastic Paraparesis), MTb, Syphilis, Lyme disease,
Schistosomiasis or Para infectious Autoimmune Process E.g. Post Viral, Immunisation
Neuromyelitis Optica
(NMO = Devic’s Disease) – AQP4 Autoantibodies leading to Astrocyte damage in Spinal Cord and Optic Nerves leading to Long Cord Lesions (≥3 Segments) and
Optic Nerve Demyelination
How to treat inflammatory lesions of the spinal cord
High-dose Steroids, Immunosuppression; Antimicrobial therapy for specific infections
Vascular Disorders of the Spinal Cord: ASA Occlusion
Acute Paraplegia, Loss of Spinothalamic Sensation
due to Infarction of the Anterior 2/3rds of the Spinal Cord
o Aortic Atherosclerosis, Dissection, Trauma, Cross Clamping in Surgery, Vasculitis, Emboli, Thrombotic disorders and Severe Hypotension
o Occlusion of the Artery of Adamkiewicz (= Great Radicular Artery, supplies Thoracic ASA) leads to Watershed Infarction typically at T8
Vascular Disorders of the Spinal Cord: AVM
Rare, difficult to diagnose but potential curable; Acquired or Congenital (True AVMs)
o Dural AV Fistulas (Acquired) – Occur in Middle-aged Men; Formed due to connection
between Artery and Vein in Dural Nerve Root Sleeve
o Oedema and Congestion at and below affected level; Gradually Progressive
Myelopathy often with Back Pain; MRI shows Cord Swelling, may show enlarged
Arterialised veins
Hereditary Spastic Paraparesis
– Severe Genetic disorders might present with UMN
syndrome resembling Myelopathy; Spasticity and Stiffness > Weakness
o 28 Genes associated with HSP; Muscle Relaxants (e.g. Baclofen) can improve gait
o Adrenoleucodystrophy – Slowly progressive Spastic Paraparesis
Vitamin B12 deficiency
Subacute Degeneration of the Spinal Cord; Abuse of Nitric Oxide can precipitate Functional Deficiency even with normal Serum B12
Other disorders of the spinal cord
- Motor Neurone Disease – Spastic Paraparesis before LMN signs develop
- Paraneoplastic Disorders, Radiotherapy, Copper Deficiency, Liver Failure and Toxins
Management of Paraplegic Patients: Bladder
Does not empty resulting in Urinary Retention; Intermittent Self-Catheterisation or
develop Reflex Bladder Emptying helped by abdominal pressure
o Early treatment of UTI essential; Reflux Nephropathy results in CKD
Management of Paraplegic Patients: Bowel
Constipation and Impaction must be avoided; Manual Evacuation is necessary; Reflex
emptying develops later
Management of Paraplegic Patients: Skin
Pressure Ulcer Prophylaxis
Management of Paraplegic Patients: Physio and Rehab
Wheelchairs, Psychological, Practical needs etc
Syringomyelia
Syrinx – Fluid-filled Cavity within Spinal Cord; Syringobulbia –
Cavity in the brainstem
Associated with Arnold-Chiari Malformation; Pulsatile waves
of CSF transmitted to fragile tissues of the Spinal Cord
causing Secondary Cavity formation
Syrinx formation might also follow Spinal Cord Trauma; Also by Intrinsic Cord Tumours
Consequences of Syringomyelia
Expanding Cavity in cord gradually destroys Spinothalamic Neurons, Anterior Horn cells, Lateral Corticospinal Tracts; In the Medulla it will affect Lower
CN Nuclei
Management of syringomyelia
MRI demonstrates cavity/Herniation in Arnold-Chiari Malformation; Surgical Decompression
of Foramen Magnum causes Syrinx to collapse
Presentation of Syringomyelia
- Arnold-Chiari Malformation typically presents 20-30yrs; Upper Limb Pain exacerbating by Coughing/Exacerbation is typical
- Spinothalamic Sensory Loss (Painless Upper Limb Burns, Trophic Changes) and Paraparesis
- Suspended Area of Dissociated Sensory Loss (Dorsal Columns Modalities preserved)
- Loss of Upper Limb Reflexes, Muscle Wasting; Spastic Paraparesis might initially be mild
- Brainstem – Tongue Atrophy, Fasciculation, Bulbar Palsies, Horner’s Syndrome, Impaired Facial Sensation
