Spinal Cord Disorders

Question 1

How is spinal compression caused?

Answer 1

Lesions in vertebral column, eg:
•Prolapsed vertebral disc
•Vertebral metastases
•Epidural abcess

Or the meninges:
•Meningioma
•Meningeal metastasis

Producing physical pressure upon the spinal cord.
Most common causes are trauma and vertebral metastases.

Question 2

What is myelopathy?

Answer 2

Spinal cord damage

Question 3

How would somebody with a spinal cord compression present?

Answer 3

Presentation can be acute or insidious depending on underlying mechanism.

Pain and evidence of local nerve root damage at level of the lesion are often features.

Question 4

How should you manage a patient with spinal nerve compression?

Answer 4

Urgent surgical decompression of the cord usually required.

Bony metastases causing compression may be treated with radiotherapy.

Early treatment maximises neurological recovery.

Question 5

How does cauda equine syndrome occur?

Answer 5

A compressive lesion is located below the end of the spinal cord.

Rather than causing spinal cord compression multiple limbo sacral nerve roots are compressed.

Question 6

What features would cauda equine syndrome present with?

Answer 6

Severe lower back pain
Leg weakness
Numbness of buttocks and perineum (saddle area)
Urinary retention.

On examination Lower motor neurone pattern of weakness with:
•Loss of reflexes
•Reduced anal sphincter tone
•Sensory disturbance in saddle distribution

Question 7

How should cauda equina syndrome be managed?

Answer 7

Urgent MRI and surgical decompression.

Question 8

What is Cervical Spondylosis?

Answer 8

Describes degenerative changes of cervical vertebrae, intervertebral joints and ligaments.

Changes may narrow vertebral canal, causing cord compression, and the nerve exit foramina, compressing cervical nerve roots.

Question 9

What would a patient with cervical Spondylosis present with?

Answer 9

Neck pain
Arm pain, tingling and weakness may occur in nerve root distribution
—most commonly C7
Features of spinal cord compression may be present.

Question 10

How would you manage a patient cervical Spondylosis?

Answer 10

In mild radiculopathy, physiotherapy and analgesia may be useful

If there is cord compression, or conservative measures are unsuccessful, decompressive surgery is required.

Question 11

How does subacute combined degeneration of the cord occur?

Answer 11

Myelopathy and peripheral neuropathy develop as a result of B12 deficiency.

Pernicious anaemia is the most common cause of B12 deficiency.
Other causes could be crohns, gastrectomy or dietary exclusion.

Question 12

What would a patient with subacute combined degeneration of the cord complain of?

Answer 12

Tingling in fingers and toes that gradually spreads proximally.
Limb weakness and gate disturbance may develop

Evidence of a peripheral sensory neuropathy in a “glove and stocking” distribution
—particularly affects proprioception, with absent ankle jerks.

Question 13

How would you test your diagnosis of subacute combined degeneration of the cord?

Answer 13

Diagnosis confirmed by low fit B12 levels and MRI may show hyper intensity in posterior part of the cord.

Question 14

How would you manage a patient with subacute combined degeneration of the cord?

Answer 14

Long term vitamin B12 supplementation

•May improve the peripheral neuropathy but has little effect on spinal cord features.

Question 15

What is syringomyelia?

Answer 15

Presence of a fluid filled cystic cavity (syrinx) within central canal of spinal cord

Question 16

What is syringobulbia?

Answer 16

Presence of a fluid filled cystic cavity (syrinx) within the brain stem.

Question 17

What is syringomyelia often associate with?

Answer 17

Arnold-Chiari malformation

=a developmental abnormality in which cerebellar tonsils extend through the foramen magnum.

Question 18

How would a patient with syringomyelia present?

What age?

Answer 18

Patients usually present aged 20-40 years.

Upper limb pain and tingling made worse by coughing

Loss of pain and temperature sensation due to selective impairment of the spinothalamic tracts. in upper limbs and trunk leads to risk of painless burns.

Relative sparing of proprioception and light touch.

This dissociated sensory loss typically has a cape distribution.

Other features include lower motor neuron weakness in the arms and spastic paraparesis.

Question 19

What happens when syringomyelia extends to the brainstem?

Answer 19

Indiv may develop Horner’s syndrome, bulbar palsy, tongue wasting and fasciculation.

Question 20

How would you diagnose and manage a patient with syringomyelia/syringobulbia?

Answer 20

Diagnosis confirmed by MRI

Management usually conservative, surgical treatment of syrinx is sometimes undertaken.

Question 21

What is transverse myelitis?

Answer 21

Describes acute inflammation of the spinal cord.

Question 22

What would a patient with transverse myelitis develop?

Answer 22

Paraplegia or tetraplegia overal several days
bowel and bladder dysfunction.
Sensory loss below level of lesion.

Question 23

Under what conditions could Transverse myelitis develop?

Answer 23

May be isolated event but also occurs in MS, viral infections, or systemic inflammatory conditions.

Question 24

How would you diagnose and manage Transverse myelitis?

Answer 24

MRI spine is required to exclude cord compression.
Treatment depends on underlying cause.

High dose steroids may reduce inflammation.

Prognosis is variable.

Question 25

Describe what happens in anterior spinal artery occlusion.

Answer 25

The ant. spinal artery provides the blood supply to most of the spinal cord.
Occlusion leads to a spinal stroke with sudden paraplegia, urinary retention and loss of spinothalamic sensation.

Relative sparing of dorsal column sensation (light touch, proprioception and vibration) occurs as this is supplied by the posterior spinal artery.

Question 26

What factors can lead to anterior spinal artery occlusion?

Answer 26

Anterior spinal artery occlusion is associated with vascular risk factors, atrial fibrillation and vasculitis.
May also occur during aortic surgery.

Question 27

How would you diagnose and manage anterior spinal artery occlusion?

Answer 27

MRI excludes cord compression and may show evidence of an infarct.

Neurological recovery is usually limited.