Spinal Cord Disease and Acute Bilateral Limb Weakness Flashcards
What tract does joint position and vibration?
Dorsal column
What tract does pain and temperature?
Spinothalamic
What tract does movement?
Corticospinal
What is myelopathy?
Any neurological deficit that is caused by a lesion in the spinal cord itself
What is myelitis?
Inflammation of the spinal cord
What is cervical spondylytic myelopathy (CSM)?
Myelopathy caused by arthritic changes (spondylolysis) of the cervical spine, which results in narrowing of the spinal canal (spinal stenosis) ultimately causing compression of the spinal cord
What is a spinal cord stroke?
Occlusion of the blood vessels supplying the spinal cord or within the spinal cord itself
What are causes of a spinal cord infarction?
- Atherosclerosis
- Thromboembolic disease - AF, MI
- Aortic dissection
- Systemic hypotension
- Thrombotic haematological disease
- Hyperviscisity syndrome
- Vasculitis
- Endovascular procedures
- Decompression sickness
What symptoms are seen in spinal cord ischaemia?
Sudden onset/several hours
-
Sensation
- Sudden onset Back pain with circumerencial tightness
- Numbness/paraesthesia (below lesion)
-
Motor
- Weakness
-
Autonomic
- Urinary/faecal incontinence - retetnion followed by bladder and bowel incontiencen as spinal shock settles
What spinal artery is most commonly implicated in spinal cord ischaemia (anterior or posterior)?
Anterior more commonly than posterior, as sections have poor collateral supply (especially 2nd - 4th thoracic segments)
What is the most common cause of spinal cord ischaemia?
Extravertebral feeder artery occulsion or ortic occlusion/dissection/clamping during surgery
- Atheromatous disease
- Thromboembolic disease - sub-acute endocarditis, AF, MI
- Aortic disssection
- Systemic hypotension
If the anterior spinal cord artery was affected, what signs might you find in someone with spinal cord infarction?
Anterior cord syndrome
- Complete motor paralysis below level of lesion - corticospinal tract
- Loss of pain + temp sensation at + below the level of lesion - spinothalamic tract
- Retained proprioception, light touch and vibratory sensation - intact dorsal columns
-
Autonomic dysfunction
- Hypotension (either orthostatic or frank hypotension)
- Sexual dysfunction
- Bowel and bladder dysfunction
- Areflexia, flaccid internal and external anal sphincter, urinary retention and intestinal obstruction - infarcted anterior horn - like a LMN injury
What are features of a central cord syndrome that can occur in trauma, syrinx or cervical spondylosis?
- Paresis more severe in upper extremities than in lower/sacral region
- Loss of pain and temperature sensation in a capelike distribution over the upper neck, shoulders, and upper trunk
- Light touch, position, and vibratory sensation relatively preserved
How would you investigate suspected spinal cord infarction?
CT/MRI
How would you manage someone with spinal cord infarction?
- Supportive
- Risk reduction - optimise BP, bed rest, reverese hypovolaemia, vascular risk
- OT/PT input
If someone had occlusion of their central sulcal spinal artery, what spinal cord syndrome may present?
Brown-Sequard syndrome
Prognosis of ischaemic myelopathy
Unless major recovery in 24 hours chance of major recovery is low
What is transverse myelitis?
Acute inflammation of gray and white matter in one or more adjacent spinal cord segments, usually thoracic
What are causes of transverse myelitis?
- Idiopathic
- MS
-
Viral/bacterial infection
- Lyme
- Syphilis
- Autoimmune
- Malignancy
- Post vaccination
What are viral causes of transverse myelitis?
- VZV
- HSV
- CMV
- EBV
- Influenza
- Echovirus
- HIV
- Hep A
- Rubella
What are autoimmune causes of transverse myelitis?
- SLE
- Sjogren’s
- Sarcoidosis
What is transverse myelitis most commonly due to?
MS
What can transverse myelitis occur with in Devics syndrome?
Optic neuritis - Form of MS
What are symptoms of transverse myelitis?
Hours to days
- Pain in the neck, back or head
- Bandlike tighness around chest/abdomen
- Weakness
- Paraesthesiae
- Numbness - feet and legs
What are signs of transverse myelitis?
Sensorimotor myelopathy (UMN lesion)
- Paraplegia - pyramidal distribution
- Loss of sensation below lesion
- Urinary retention/Faecal incontinence
- Occasional sparing of proprioception and vibration
- Babinski +
- Clonus
- Hyperreflexia
- L’Hermittes positive
What investigations might you consider doing in someone with features of transverse myelitis?
- MRI - cord swelling and oedema at affected levels
- LP - excess monocytes, increased protein, IgG elevated
- CXR
- Serology - mycoplasma, lyme
- HIV test
- ANA
- B12, folate, copper levels
- ESR
How would you manage someone with transverse myelitis?
- Treat cause
- High-dose steroids
- Consider plasma exchange
- Consider Antibiotics
- Consider Immunosuppression
What is cervical spondylosos?
Degeneration of annulus fibrosis of cervical IVDs and osteophytes causing narrowing of spinal canal and therefore potential subsequent myeopathy/radiculopathy.
What is radiculopathy?
Means disease affecting nerve roots and plexopathy, the brachial or lumbosacral plexus.
What are symptoms of cervical spondylotic myelopathy (CSM)?
-
Neck pain, radiating down arms
- Crepitus when moving neck
- Arm pain (stabbing or dull
- Paraesthesia - both hands and feet
- Spastic leg weekenss/weak clumsy hands
- Foot drop and gait abnormality.
What are signs of cervical spondylotic myelopathy?
UMN lesion - deficits may be asymmetric, nonsegmental, and aggravated by cough or Valsalva maneuvers
- Lhermittes phenomenon - neck flexion may produce tingling down spine
- Gradual spastic paresis
- Paresthesias
- Hyperreflexia
What are signs of cervical spondylotic myeloradiculopathy?
Combined UMN/LMN signs
- L’hermittes phenomenon
- UMN features below lesion level - Spastic weakness, Hyperreflexive below lesion, urinary incontinence
- Radiculopathic (LMN) features at lesion level - radicular pain, flaccid weakness, hyporeflexia, and muscle atrophy
- Ataxia - due to loss of proprioception
What are signs of cervical spondylotic radiculopathy?
LMN radiculopathic signs
- Radicular pain - shooting in nature
- Flaccid weakness
- Hyporeflexia - dull
- Eventual Muscle atrophy
- Fasciculations
What is the meaning of radicular pain?
Pain “radiated” along the dermatome(sensory distribution) of a nerve due to inflammation or other irritation of the nerve root (radiculopathy) at its connection to the spinal column
How would you investigate someone with cervical spondylotic myelopathy?
MRI/CT
How would you manage someone with cervical spondylotic myelopathy?
- Conservative management
- Firm neck collar
-
Injection therapy
- Interlaminar cervical epidural injections
- Tranforminal injections
- Consider decompressive surgery - discectomy, laminectomy, laminoplasty
What is important when trying to establish a cause of acute bilateral limb weakness?
-
Where is the lesion?
- UMN/LMN?
- Sensory level?
- Bowel/bladder control loss
-
What is the lesion?
- Sudden/rapid progressive/slow onset?
- Signs of infection?
What are symptoms of acute spinal cord compression?
- Bilateral leg weakness
- Sensory level
- Preceding back pain
- Bladder/bowel signs - late manifestation
What are signs of spinal cord compression?
- Normal findings above level of lesion
- UMN signs below lesion - pyramidal spastic paresis (e.g. legs), hyperreflexia, weakness, babinski positive, clonus
- Can have LMN signs at level of lesion - radicular pain, flaccid weakness, muscle wasting, fasciculations, hyporeflexive
- Bowel/bladder retention - overflow incontinence, painless retention
How does bladder/anal sphincter tone change in someone with spinal cord compression?
Initially starts as hesitency and frequency, and progresses to painless retention due to spastic tone of sphincters due to UMN lesion, coupled with weakness of detrusor muscle. Any incontinence that occurs is due to overflow incontinence
Faecal incontinence occurs due to loss of autonomic bowel function, leading to overflow incontinence
What are causes of spinal cord compression?
-
Vertebral body neoplasm
- Secondary malignancy in spine (bone) - breast, bronchus, brostate, byroid, bidney
- Myeloma
-
Disc and vertebral lesions
- Disc prolpase
- Trauma
- Chronic degenrative disease - osteoarthritis osteophytes
-
Inflammation/infection
- Epidural abscess
- TB (pott’s paraplegia)
- Cervical disc prolapse
-
Other
- Haematoma (epidural haemorhage - patients on warfarin)
- Intrinsic cord tumour
- Atlanto-axial subluxation (RA)
- Paget’s
- Bone cyst
If someone presented with features of spinal cord compression, what might you consider as part of your differential diangosis?
- Transverse myelitis
- MS
- Cord vasculitis
- Spinal artery thrombosis/aneurysm
- Trauma
- Guillain-Barre syndrome
What investigations would you want to do if you suspected spinal cord compression?
- MRI Neck/Thorax - region targeted based on clinical findings
- Biopsy - nature of mass
- CXR - degenerative bone disease, destruction of vertebrae by infection or neoplasm
- Bloods - FBC, ESR, B12, syphillis serology, U+E’s, LFT’s, PSA, Serum electrophoresis
How would you manage someone with spinal cord compression?
- Dexamethasone - 16 mg/24 hrs
- Surgical decompressive laminectomy +/- radiotherapy
- Epidural abscess - decompression and antibiotics
What is cauda equina syndrome?
Syndrome that occurs due to compression of the cauda equina
What can cause cauda equina syndrome?
- Tumour
- LD prolapse
- Spinal stenosis
- Traumatic injury
- Epidural Abscess
- Spinal surgery
- Spinal Manipulation
- Spinal epidural infection
Commonly at L4/L5 and L5/S1
What are symptoms of cauda equina syndrome?
-
Sensory
- Back pain and sciatica
- Numbness
- Saddle anaesthaesia
-
Motor
- Leg paresis - Asymmetrical, atrophic, areflexive paralysis
-
Autonomic
- Bladder/bowel dysfunction
- Urinary retention
If there was damage of S2-S5, what motor deficit would there be?
Sphincter deficit
(ie distal to L1)
If there was damage at the level of S2-S5, what sensory deficit would be present?
Perianal and saddle (perineum, external genitalia)
If you suspect someone has cauda equina syndrome, how should you investigate?
Clinical Diagnosis, followed by emergency imaging - MRI
If there was damage at the S2-S5 level, what reflex would be affected?
Bulbocavernous reflex
If you have confirmed someone has cauda equina, what is the next step to take in their management?
IMMEDIATE SURGICAL DECOMPRESSION - Within 48h
What are signs of cauda equina syndrome?
LMN lesion - asymmetrical, atrophic, areflexive paralysis of legs
- Areflexia
- Flaccid/atonic paralysis
- Sensory loss in root distribution
- Saddle anaesthesia
- Urinary/faecal incontinence
- Decreased anal tone
- Sexual dysfunction
- Loss of bulbocavernous reflex - men
How would you differentiate spinal cord compression from cauda equina?
One had UMN signs (cord compression), other has LMN signs (cauda equina)
If you suspected cauda equina syndrome, what investigations would you want to do?
- Immediate PR exam
- Urgent MRI
How would conus medullaris syndrome differ from cauda equina syndrome?
Conus medullaris syndrome has mixed picture of UMN and LMN signs - early urinary retention + constipation and decreased anal tone, sacral sensory distrubance, leg weakness, ED, pain is mild
What are extradural causes of cord neoplasms?
Bony Metastases - Breast, Bronchus, Byroid, Bidney, Brostate
What are extramedullary causes of spinal cord neoplasms?
- Meningioma
- Neurofibroma
- Ependymoma
What are intramedullary causes of spinal cord neoplasms?
- Glioma
- Ependymoa
- Haemangioblastoma
- Lipoma
- AV malformation
- Teratoma
What are causes of unilateral foot drop?
- DM
- Common peroneal nerve palsy
- Stroke
- Prolapsed disc
- MS
What are causes of weak legs with no sensory loss?
- MND
- Polio
- Parasagittal meningioma
What are causes of chronic spastic paraparesis?
- MS
- Cord primary/mets
- MND
- Syrinx
- Subacute combined degeneration of the spinal cord
- Hereditary spastic paraparesis
- Taboparesis
- Histiocytosis
- Schistosomiasis
What are causes of chronic flaccid paraparesis of the legs?
- Peripheral neuropathy
- Myopathy
If someone had absent knee jerks and extensor plantars, what might your differential diangosis be?
Combined UMN and LMN signs, so:
- Combined cervical/lumbar disc disease
- Conus medullaris lesion
- MND
- Myeloradiculopathy
- Freidrich’s Ataxia
- Subacute combined degeneration of the cord
- Taboparesis
What is a spastic gait?
https://www.youtube.com/watch?v=b11ZumD1Vbs
Caused by UMN lesion - Stiff, circumduction of legs +/- scuffing of the toe of the shoes
What is an extrapyramidal gait?
https://www.youtube.com/watch?v=b11ZumD1Vbs
“Parkinsonian shuffle”
Flexed posture, shuffling feet, slow to start, postural instability
What is an apraxic gait?
https://www.youtube.com/watch?v=F2-X8JpoWAw
Pathognomic “gluing to the floor” on attempting walking or a wide-based unsteady gait with a tendency to fall - novice on an ice-rink
What is an ataxic gait?
https://www.youtube.com/watch?v=Mr8RkG5OP18
Wide based, cannot walk heel to toe - falls often
What is a myopathic gait?
https://www.youtube.com/watch?v=yY-gH68wLwo
Waddling gait, cannot climb steps or stand from sitting due to hip girdle weakness
What are causes of an ataxic gait?
- Cerebellar lesions - MS, Posterior fossa lesion, alcohol, phenytoin toxicity
- Proprioception loss - Sensory neuropathy, decreased B12
What is the pathophysiology of cervical spodylotic myelopathy?
Osteophyte formation on adjacent vertebrae leads to narrowing of the spinal cord and intervertebral foramen. as neck flexes and extends, the cord is dragged over these protruding bony spurs anteriorly and indented by a thickened ligamentum flavum posteriorly
If someone with known cervical radiculopathy developed UMN signs below the level of the lesion, what might this suggest?
Spinal cord compression
What motor, sensory, reflex and pain features might you expect to see in someone with radiculopathy of C5 nerve root?
- Motor - weak deltoid/supraspinatus
- Sensory - numb from outer aspect shoulder down to elbow
- Reflex - Decreased biceps jerk and supinator
- Pain - neck/shoulder radiating down front of arm to elbow
What motor, sensory, reflex and pain features might you expect to see in someone with radiculopathy of C6 nerve root?
- Motor - weak biceps/brachioradialis
- Sensory - numb from outer aspect elbow down to thumb and index finger
- Reflex - Decreased supinator jerk
- Pain - shoulder radiating down arm below elbow
What motor, sensory, reflex and pain features might yo expect to see in someone with radiculopathy of C7 nerve root?
- Motor - weak triceps/finger extension
- Sensory - numb middle finger
- Reflex - Decreased triceps jerk
- Pain - Pain in upper arm and dorsal forearm
What motor, sensory, and pain features might yo expect to see in someone with radiculopathy of C8 nerve root?
- Motor - weak finger flexors and small muscles of hand
- Sensory - numb 5th and ring finger
- Pain - Pain in upper arm and medial forearm
What are features of an epidural abscess?
Deficits progress over hours to days.
- Begin with local or radicular back pain
- Percussion tenderness - pain may be worsened by recumbency
- Fever
- Features of Spinal cord compression may develop
What is the most common causative organism of an epidural abscess?
Staph aureus, followed by E. Coli
How would you manage an epidural abscess?
- Antibiotics
- Immediate drainage
Where does the spinal cord go from and to?
From C1-L1, below this it is the cauda equina
What is paraplegia?
Weakness in both legs - always cauysed by a SC lesion
What is hemiplegia?
Weakness one side of the body 0 usually due to lesion in brain
What is demyleination myelopathy?
Characterised by pathological lesion of inlammation and demyelination elding to temporary neural dysfunction - partial or complete transverse myelitis
Affects white matter
May be inital presentaiton of MS
What is pernicous anaemia?
B12 absorbed from gut using intrinsic factor which is made by gastric parietal cells.
In pernicious anaemia antibodies to intrinsive factor prevent B12 absorption
Complicates total gastectomy, Crohn’s and tape worms
What is subactue combined degeneration of the spinal cord?
Complication of vitB12 deficiency
Symptoms of sub-acute combined degeneration
Paraesthesia
Dorsal column affected (joint position and vibration) - falls, bilateral stamping, high stepping gait
Sensation may remain intact eeven in severe cases
Weakness if untreated
Signs of subacute combined degeneration
Of pernicious anaemia - “lemon tinge” of skin
Classic triad: extensor plantors (UMN), absent knee jerks (LMN), absent ankle jerks (LMN)
Ataxia
Romberg’s test - positive in posterior column dysfunction (nothing to do with cerebellar syndrome)
Investigations in subacute combined degeneration
FBC - anaemia, raised MCV
Serum B12
Parietal cell antibodies
Managment subacute combined degeneration
B12 replacement
Rapid onset parapeisis DDx
Transverse myelitis
Anterior spinal artery occlusion
MS
Insidious onset weakness
MND (no sensory deficit)
Subactue degeration of spinal cord
Non metastatic manifestation of malignancy
What is spina bifida?
Non fusion of the vertebral arches during embryonic development
What are the three types of spina bifida?
- Myelomeningocele,
- Spina bifida occulta
- Meningocele
Myelomeningocele is the most severe type with associated neurological defects that may persist in spite of anatomical closure of the defect
Up to 10% of the population may have spina bifida occulta, in this condition the skin and tissues (but not not bones) may develop over the distal cord. The site may be identifiable by a birth mark or hair patch
The incidence of the condition is reduced by use of folic acid supplements during pregnancy
Conditions associated with spina bifida
Hydrocephalus
Chiari malfomation (downward replacement of cerebellar tonsils through foramen magnum)
Aqueduct stenosis
Tethered cord
Describe presentation of brown sequard syndrom
Ipsilateral spasticity
Posterior column sensory loss
Contralteral spinothalamic loss (may be asymptomatic)
Describe presenation of central cord lsions
Early spincter disturbance and spinothalamic loss
Loss of pain and temp sensation
Wasting weakness and areflexia in affected segments
Dorsal column loss symptoms
Ataxia
Loss of proprioception and vibration sense
Symptoms/signs of anterior cord syndrome
Striking preservation of dorsal column sensation with loss of all other functions
CORTICOSPINAL TRACT
a) what does it do
b) where does it cross
c) Symptoms/signs of damage
a) voluntary motor control
b) crosses at medulla
c) Symptoms: weakness, unsteadiness, difficulty in walking
Signs: increased tone, increased reflexes, extensory plantar response
DORSAL COLUMN
a) what does it do
b) where does it cross
c) Symptoms/signs of damage
a) ipsilateral joint positon sense and vibration sense
b) crossess at medulla
c) symptoms: ataxia and clumsiness
signs: loss of pain, joint position and vibration sense
SPINOTHALAMIC TRACT
a) what does it do
b) where does it cross
c) Symptoms/signs of damage
a) Contralteral pain, light tough and temp
b) crossess at level of entry
Symptoms: Loss/altered cutaneous sensation
Signs: loss of pain and temperature sensation
Lateral column
Presentation
Sphincter disturbance
