Spinal Cord Disease

Question 1

How does cord compression present?

Answer 1

Chronic and Subacute Compression present as Spastic Paraparesis/Tetraparesis, Radicular Pain at Level of Compression and Sensory Loss below level of compression

Question 2

Features of radicular pain

Answer 2

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

Question 3

How to approach acute spinal cord compression

Answer 3

Acute Spinal Cord Compression is a Medical Emergency; MRI Spine; CXR might show Primary
Tumour or Infection; Surgical exploration might be necessary

Question 4

What happens if decompression is delayed

Answer 4

Cord Damage becomes irreversible; Good prognosis if Benign Tumours or Haematomas removed early

Question 5

When can radiotherapy be used?

Answer 5

Radiotherapy for Cord Malignancy or Compression due to Inoperable Malignant Vertebral Body Disease causing Cord Compression

Question 6

Causes of Spinal Cord Compression: Disc/Vertebral

Answer 6

– (Central Cervical Disc, Thoracic Disc Protrusion);

Compression due to Cervical Spondylotic Myelopathy is the commonest cause of Spastic Paraparesis in the Elderly

Question 7

Causes of Spinal Cord Compression: trauma

Answer 7

Patients with back trauma need to be immobilised

before assessment

Question 8

Causes of Spinal Cord Compression: Spinal cord tumour

Answer 8

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

Question 9

Causes of Spinal Cord Compression: TB

Answer 9

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

Question 10

Causes of Spinal Cord Compression: Epidural haemorrhage and Haematoma

Answer 10

Rare complication of Anticoagulation, Bleeding
disorders, Trauma, can occur following LP if clotting is abnormal
o Rapidly progressive Cord/Cauda Equina Lesion can develop

Question 11

Inflammatory Lesions of the Spinal Cord: MS

Answer 11

• 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

Question 12

Inflammatory Lesions of the Spinal Cord: Inflammatory disorders

Answer 12

• Systemic Inflammatory disorders – SLE, Sjögren’s, Sarcoidosis

Question 13

Inflammatory Lesions of the Spinal Cord: Infection

Answer 13

VZV, EBV, HIV, HTLV1/2 (Tropical Spastic Paraparesis), MTb, Syphilis, Lyme disease,
Schistosomiasis or Para infectious Autoimmune Process E.g. Post Viral, Immunisation

Question 14

Neuromyelitis Optica

Answer 14

(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

Question 15

How to treat inflammatory lesions of the spinal cord

Answer 15

High-dose Steroids, Immunosuppression; Antimicrobial therapy for specific infections

Question 16

Vascular Disorders of the Spinal Cord: ASA Occlusion

Answer 16

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

Question 17

Vascular Disorders of the Spinal Cord: AVM

Answer 17

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

Question 18

Hereditary Spastic Paraparesis

Answer 18

– 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

Question 19

Vitamin B12 deficiency

Answer 19

Subacute Degeneration of the Spinal Cord; Abuse of Nitric Oxide can precipitate Functional Deficiency even with normal Serum B12

Question 20

Other disorders of the spinal cord

Answer 20

• Motor Neurone Disease – Spastic Paraparesis before LMN signs develop
• Paraneoplastic Disorders, Radiotherapy, Copper Deficiency, Liver Failure and Toxins

Question 21

Management of Paraplegic Patients: Bladder

Answer 21

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

Question 22

Management of Paraplegic Patients: Bowel

Answer 22

Constipation and Impaction must be avoided; Manual Evacuation is necessary; Reflex
emptying develops later

Question 23

Management of Paraplegic Patients: Skin

Answer 23

Pressure Ulcer Prophylaxis

Question 24

Management of Paraplegic Patients: Physio and Rehab

Answer 24

Wheelchairs, Psychological, Practical needs etc

Question 25

Syringomyelia

Answer 25

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

Question 26

Consequences of Syringomyelia

Answer 26

Expanding Cavity in cord gradually destroys Spinothalamic Neurons, Anterior Horn cells, Lateral Corticospinal Tracts; In the Medulla it will affect Lower
CN Nuclei

Question 27

Management of syringomyelia

Answer 27

MRI demonstrates cavity/Herniation in Arnold-Chiari Malformation; Surgical Decompression
of Foramen Magnum causes Syrinx to collapse

Question 28

Presentation of Syringomyelia

Answer 28

• 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