Spinal Cord Disorders Flashcards
What is the most useful sign to determine longitudinal localization?
spinal sensory level
The spinal cord how how many segments? How are they classified?
31 Total
8 cervical
12 thoracic
5 lumbar
5 sacral
1 coccygeal
What is “around the clock” phenomenon? Why does this happen?
- with cervicomedullary lesions, the pattern of weakness is as follows:
- ipsilateral arm → ipsilateral leg → contralateral leg → contralateral arm
the pattern of decussation is that upper extremity fibers decussate rostral to lower extremities
What is the clinical presentation of a patient with a cervicomedullary lesion?
- Pattern of weakness: ipsilateral arm → ipsilateral leg → contralateral leg → contralateral arm
- +/- occipital or neck pain
- If CSF is obstructed → (+) ICP → downbeat nystagmus & papilledema
Symptoms with a SC lesion at C3 or above?
death (w/o ventilation) d/t phrenic nerve disconnect
above C4: “onion skin” pattern facial numbness from spinal trigeminal nucleus involvement
Symptoms with a SC lesion at C4-C5?
diaphragmatic weakness
above C4: “onion skin” pattern facial numbness from spinal trigeminal nucleus involvement
Symptoms with a SC lesion at C5-C6?
quadripelegia
Symptoms with a SC lesion at C7-T1?
proximal arm power spared
hand/leg plegia
Symptoms with a SC lesion at T1-T8?
Paraplegia
inability to control trunk/sit independently
bowel/bladder dysfunction
+ T7 & above → autonomic dysreflexia/neurogeneic shock
Symptoms with a SC lesion at T9-T12?
paraplegia
bowel/bladder dysfunction
trunk stability is preserved
Symptoms with a SC lesion below L1?
Paraplegia
bowel/bladder dysfunction
can sit independently
cauda equina syndrome
Symptoms with a SC lesion below L4?
paraplegia
can sit independently
bowel/bladder dysfunction
hip flexors are spared
Symptoms with a sacral SC lesion?
must be bilateral to impact bladder, bowel & sexual function
How do SC lesions impact reflexes at the level of the lesion, above the lesion, & below the lesion?
- at lesion: decreased
- above: normal
- below: increased
Describe the reflexes you would expect to see in a patient with a lesion in C5-C6?
decreased biceps & brachioradialis
increased triceps
L4 & S1 increased
Describe the reflexes you would expect to see in a patient with a lesion in C7?
decreased triceps
normal biceps & brachioradialis
L4 & S1 increased
Describe the reflexes you would expect to see in a patient with a lesion in L1?
increased patellar & ankle reflexes
Describe the reflexes you would expect to see in a patient with a lesion in L2-L4?
decreased patellar reflex
increased ankle reflex
Describe the reflexes you would expect to see in a patient with a lesion in L5?
normal patellar
increased ankle
Describe the reflexes you would expect to see in a patient with a lesion in C5-C6?
abolished ankle reflexes
normal patellar reflex
What is the clinical picture of a patient with conus medularis syndrome?
bilateral “saddle” sensory loss
mild bilateral lumbosacral LMN weakness
flaccid bladder dysfunction (early)
What is the clinical picture of a patient with cauda equina syndrome?
radicular pain
asymmetric sensory loss
marked asymmetric lumbosacral LMN weakness
flaccid bladder dysfunction (late)
absent patellar/ankel reflexes
What are the common causes of conus medullaris syndrome?
lumbar disease, trauma, epidural metastasis/abscess L1 or L2, CMV in AIDS, schistostomiasis, HSV type 2
What are the common causes of conus cauda equina?
lumbar disc disease, trauma, epidural metastasis/abscess L3 or lower, CMV in AIDS, schistostomiasis, neoplasm
lumbar disc disease, trauma, epidural metastasis/abscess L3 or lower, CMV in AIDS, schistostomiasis, neoplasm
The posterior columns of the spinal cord mediate what senses?
proprioception
vibration
discriminative touch (fine touch)
The spinothalamic tracts of the spinal cord mediate what senses?
pain
temperature
non-discriminative touch (crude touch)
pressure
The corticospinal tracts of the spinal cord mediate what senses?
lateral corticospinal: contralateral muscles
anterior corticospinal: contralateral axial & girdle muscles
What are the symptoms seen in a complete cord transection? If the transection is S4/S5?
- sensory loss to all modalities 1-2 segments below the level of inquiry
- flaccid paralysis w/ autonomic dysfunction
- spasticity, hyperreflexia below the lesion w/ time
- S4/S5
- inability to contract anal sphincter voluntarily or feel pinprick/touch aroudn anus
What is likely the cause of acute onset complete cord transection?
trauma
What is likely the cause of onset within hours of complete cord transection?
transverse myelitis (MS, neuromyelitis optica, Lupus, Sjogren’s neurosarcoidosis, etc.)
What is likely the cause of onset within days to weeks of complete cord transection?
transverse myelitis, paraneoplastic necrotizing myelopathy (anti-Hu, CRMP-5, anti-amphiphysin)
What is likely the cause of late onset of complete cord transection?
radiation-induced myelopathy
What is the major difference between spinal shock & neurogenic shock?
spinal shock: acute onset
neurogenic shock: delayed onset (hours-days)
What is the cause & presentation of a patient with spinal shock?
- d/t acute cervical spinal cord injury - acute onset
- below level of injury
- deceased/absent reflexes
- loss of sensation
- flaccid paralysis below injury
- transiend <48 hrs
- look for loss of bulbocavernous reflex & anal wink
What is the cause & presentation of a patient with neurogenic shock?
- d/t injury T6 & above
- delayed on set (hours - days)
- distributive d/t sympathectomy unopposed vagal function
- hypotension - vasodilation
- bradycardia
- hypothermia - unable to regulate temperature
- lasts 1-3 weeks
What is the bulbocavernous reflex?
pressure to glans penis or clitoris → anal contraction
Autonomic dysreflexia can be cause by lesions above what spinal level? Symptoms?
Above T6
increase sympathetics → increase vasoconstriction → increase blood pressure; relay inhibition via carotid & aortic baroreceptors is disrupted by trauma
- >20% increase in HR
- flushing
- piloerection
- headache
- visual changes
- at risk for malignant hypertension
What are the possible triggers for autonomic dysreflexia?
bladder distension & fecal impaction
What deficits are seen in patients with hemicord syndrome?
- Posterior columns
- ipsilateral vibration & position sensation below level
- Corticospinal tract
- ipsilateral UPM weakness below the level
- if anterior horn → LMN weakness at level of lesion
- Spinothalamic
- contralateral pain & temp 1-2 segments below the lesion
- damage to descending autonomic fibers
- ipsilateral Horner (if C8-T1)
- loss of sweat below the lesion
- NO bladder dysfuncyion
Most common causes hemicord syndrome?
penetrating trauma
knife, gunshot, metastases
What deficits are seen in patients with central cord syndrome?
- Spinothalamic tract
- bilateral loss pain & temp - cape/vest pattern
- may involve anterior horn cells → LMN weakness
- may involve corticospinal tract & anterolatera tracts → UMN weakness + descending loss temp & sensation below lesion
What is syringomyelia?
enlargement of central canal of spinal cord
Cervical hyperextension injury may involve formation of fluid in the central spinal canal called what?
syrinx
What is “man in a barrel syndrome”?
acute tramua → swelling w/ quadriplegia → as swelling decreases have proximal weakness of arms & legs
also, in cases cerebral hypoperfusion d/t watershed stroke
What are the symptoms in a patient with extramedullary compression?
ascending contralateral pain/temp & sensory loss
UMN signs usually occur early
What are the common causes of extramedullary compression?
- Spinal Stenosis
- mild (effacement CSF)
- moderate (contact/displacement of spinal cord)
- severs (compression of neural structures)
- vere severe (compression spinal cord / myelomalacia)
- tuberculosis
- spinal tumors
- breast, lung, melanoma, lymphoma
What deficits are seen in patients with posterior cord syndrome?
- impaired vibration & proprioception → sensory ataxia w/ “stomping gait”
- dorsal root involvement
- reflexes absent (esp legs)
- strength preserved
- may see Lhermitte sign: electric shock sensation on passive neck flexion
What are the major causes of posterior cord syndrome?
cervical spondylotic myelopathy, neurosyphilis, radiation
Repeated trauma to the feet can result in what condition?
Charcot arthropathy
osteoclastic resorption leading to neuropathic joints
What is the acronym associated with posterior cord syndrome?
- D - dorsal column degeneration
- O - orthopedic pain (charcot joints)
- R - reflexes decreased/absent
- S - shooting pain
- A - Argyll-Robertson pupils (accommodate but do not react)
- L - locomotor ataxia
- I - impaired proprioception
- S - syphilis (tertiary)
What deficits are seen in patients with posterolateral cord syndrome?
- impaired vibration, proprioception, UMN
- spastic/ataxic gain; reflexes may be increased or decreased
- may have bladder spasticity from descending autonomic involvement
- temp/pain generally spared
What are the main causes of posteolateral syndrome?
vitamin B12 or copper deficiency, HIV, NO / zinc toxicity, vertebral disease
What is the other name for posterolateral cord syndrome?
subacute combined degeneration
