SPINAL CORD LESIONS Flashcards
What suggests the lesion is in the spinal cord rather than other parts of the nervous system?
Mixed UMN and LMN signs
There may be a sensory level at the level of the lesion
There may be sphincter involvement e.g. urinary retention and constipation or incontinence with cauda equina syndrome
Can cause autonomic dysrefleia if the lesion is above the level of T6
Clinical signs are often bilateral and commonly asymmetrical
If all 4 limbs are affected, where is the lesion likely to be?
Cervical
If only the lower limbs are affected, where is the lesion likely to be?
Thoracic
If the diaphragm has been affected and there are respiratory issues, where is the lesion likely to be?
Above C3
Surgical sieve for spinal cord pathology?
Vascular: spinal artery occlusion, aortic dissection, arrhythmias
Infection: polio, HIV, syphilis, TB
Trauma
Autoimmune: MS, Neuromyelitis optica, sarcoidosis
Metabolic: B12 deficiency, copper deficiency
neoplastic: malignant compression of the spinal cord
Degenerative: degenerative disc disease
Genetics: Spinocerebellar ataxia or hereditary spastic paraplegia
Complete vs incomplete spinal cord syndrome?
A complete cord syndrome is characterised by a complete loss of function (motor/sensory) below the level of the lesion.
An incomplete cord syndrome is characterised by variable neurological function below the level of the injury depending on the area of the cord that is affected.
How does a complete spinal cord lesion present?
Below the level of the lesion, complete loss of motor and sensory function B/L
Loss of autonomic function - if T6 or above then bradycardia and hypotension, if below T6 then faecal and urinary incontinence
Autonomic dysreflexia if lesion is T6 or above
What most commonly causes a complete spinal cord lesion?
Trauma
What region of the spinal cord does Brown-Sequard syndrome affect?
Hemicord sydome - affects 1 lateral half of the spinal cord
Most commonly occurs in the cervical region
Which spinal cord tracts does Brown-Sequard syndrome affect?
All on the side of the lesion…
-DCML
-Descending autonomic fibres
-Corticospinal tract
-Spinothalamic tract
-Anterior gray horn
What causes Brown-Sequard syndrome?
Most commonly trauma - Severe penetrating traumas e.g. stab wounds or GSW
RTA
Very large tumours, disc disease or MS
How does Brown-Sequard syndrome present?
Ipsilateral UMN signs below the level of the lesion (corticospinal)
Ipsilateral LMN signs at the level of the lesion (anterior grey horn)
Contralateral pain and temperature loss 1-2 segments below the level of the lesion (spinothalamic)
Ipsilateral proprioception and vibration loss below the level of the lesion (DCMl)
Horner’s syndrome if lesion above T1. Or faecal/urinary incontinence if lesion lower down (descending autonomic fibres)
What can cause central cord syndrome?
Hypertension injuries of the neck e.g. RTA or falls in the elderly
Intramedullary tumours
Syringomyelia
What is a syringomyelia?
A fluid-filled cyst (syrinx) forms within the spinal cord
Its primarily a problem with CSF flow and is commonly associated with the chiari malformation
What region of the spinal cord does central cord syndrome affect?
Usually affects the cervical region
What spinal tracts are affected by central cord syndrome?
Lateral corticospinal tracts
Anterior grey horn
Descending autonomic fibres
Anterior white commisure
Why is central cord syndrome likely to affect upper extremities more than the lower extremities?
Due to the somatotropic arrangement of the lateral corticospinal tract - upper limbs are more medially located in the spinal cord
How does central cord syndrome present?
B/L UMN signs below the level of the lesion and Upper extremity weakness> lower extremity weakness (both lateral corticospinal tracts affected)
Bilateral LMN signs at the level of the lesion (anterior grey horn)
Horners syndrome (descending autonomic fibres - dependant on where lesion is)
Bilateral pain and temperature loss at the level of the lesion that is often presents as ‘cape sign’ due to cervical+thoracic region being most commonly affected (anterior white commissure)
Neck pain commonly due to hyperextension injury in trauma
Anterior white commissure function?
a collection of nerve fibers that cross the midline of the spinal cord and transmit information from or to the contralateral side of the brain. It is present throughout the length of the spinal cord and lies behind the anterior median fissure
Spinopthalamic fibres cross here
anterior grey horns function?
This contains motor neurons that affect the skeletal muscles = when there’s a lesion affecting this it causes LMN signs at the level of the lesion
What is posterior cord syndrome?
Aka dorsal cord syndrome
A rare syndrome due to injury of the posterior aspect of the spinal cord
Only affects the DCML pathways!
Clinical features of posterior cord syndrome?
Bailteral loss of fine touch, crude touch, proprioception and vibration senses below the level of the lesion
Gait ataxia
Aetiology of posterior cord syndrome?
Syphilis
Hereditary - Friedreich’s ataxia
MS
B12 deficiency causing subacute degeneration of the cord
Posterior spinal artery syndrome
Posterior spinal stenosis
What is tabes dorsalis?
Slow progressive degenerative disease of the dorsal column of the spinal cord as a result of syphilis
Causes posterior cord syndrome + Argyll-Robertson pupil, and CVD
Typical age of onset of Friedreich’s ataxia>?
10-15
Presentation of Friedreich’s ataxia?
Gait cerebellar ataxia and limb ataxia (Spinocerebellar tract)
Kyphoscoliosis
Increasing weakness (corticospinal tract)
UMN signs but absent ankle jerks/extensor plantars
Loss of proprioception and vibration sense (DCML)
Optic atrophy
HOCM
Some have DM
Which regions in the spinal cord are affected by subacute combined degeneration of the spinal cord?
DCML
Lateral corticospinal
Spinocerebellar tracts
What causes subacute combine degeneration of the spinal cord?
Vitamin B12 deficiency
Recreational NO inhalation may also result in B12 deficiency and lead to this
Presentation of subacute combined degeneration of the spinal cord?
Distal sensory loss symmetrical and affects legs more than arms + impaired proprioception and vibration sense + positive Romberg’s sign (DCML)
Muscle weakness, UMN signs in the limbs (lateral corticospinal tract)
Sensory ataxia (spinocerebellar tract)
What is spinal cord concussion?
Transient loss of spinal cord function that usually resolves within 48 hours
What is spinal stenosis? Where does it usually affect and how does it present?
When the spinal canal narrows to compress the spinal cord e.g. tumour, disk prolapse, degenerative changes
Most commonly affects the lumbar region and presents with glute + leg pain on walking or standing (spinal claudication). Classically relieved by forward flexion or sitting.
Most common cause of spinal stenosis?
Degenerative disease - cell death and loss of proteoglycans and water lead to progressive disk bulging and collapse which leads to an increased stress transfer to the posterior facet joints which accelerates cartilaginous degeneration, hypertrophy and osteophyte formation; there is associated thickening and distortion of the ligamentum flavum
All of this leads to circumferentially narrow the spinal canal and the space available for the neural elements
Diagnosis of spinal stensois?
MRI
Treatment of spinal stenosis?
Laminectomy (removal of the lamina of the vertebrae to relieve pressure from the nerves)
What is anterior cord syndrome?
Ventral cord syndrome
Damage to the anterior 2/3rds of the spinal cord
Which spinal tracts does anterior cord syndrome affect?
Corticospinal tract
Spinothalamic tract
Descending autonomic fibres
Anterior grey horn
(Everything except for the DCML!)
Clinical features of anterior cord syndrome?
Bilateral weakness and UMN symptoms below the level of the lesion (corticospinal)
B/L loss of pain and temp below the level of the lesion (spinothalamic)
B/L LMN symptoms at the level of the lesion (anterior grey horn)
Horners syndrome, or urinary/faecal incontinence dependant on where lesion is (descending autonomic fibres)
Aetiology of anterior cord syndrome
Anterior spinal artery infarction - thromboembolism, trauma, hypotension, aortic disease
Any pathology damaging anterior spinal cord- disc herniation, tumour, trauma, epidural collection
Presentation of anterior horn syndrome?
LMN signs - flaccid paralysis and areflexia
Causes of anterior horn lesions?
Viruses e.g. poliomyelitis and West Nile virus
Spinal muscular atrophy
Amytrophic lateral sclerosis
How does amytrophic lateral sclerosis present?
LMN signs in arms and UMN signs in legs
Usually starts with progressive muscle weakness
It can cause diffiuclty with speech and swallowing
In later stages it causes respiratory issues
(Note there are never any sensory signs as only affects motor neurones!!)
What is spinal muscular atrophy?
A genetic condition seen in children
Causes hypotonia, muscle weakness, tremors, scoliosis, swallowing and breathing diffiuclties
There are 4 types and they each affect different ages.
What is poliomyelitis?
Polio
Mainly affects children under 5
An infectious disease caused by poliovirus which damages the anterior horn cells
= LMN signs and it can cause permenant paralysis
What is the terminal end of the spinal cord called?
Conus medullaris
Found between L1 and L2 vertebrae
What is the cauda equina?
The collection of nerve roots that emerge from the Lumbosacral part of the spinal cord below the L1 vertebra and descend down towards the coccyx
It gives rise to spinal nerves which provide motor and sensory innervation to the lower limbs, pelvis and perineum. Also gives rise to parasympathetic innervation to the pelvic viscera
Spinal cord blood supply?
Anterior spinal artery supplies the anterior 2/3rds
Posterior spinal artery supplies the posterior 1/3rd of the spinal cord
What causes Cauda equina syndrome?
Central disc prolapse at L4/5 or L5/S1 - most common
Tumours
Infections - abscess, discitis
Trauma
Haematoma
Why is early diagnosis of cauda equina syndrome so important?
Late diagnosis can lead to permenant nerve damage resulting in long term leg weakness and urinary/bowel incontinence
Presentation of cauda equina syndrome?
Lower back pain
Bilateral sciatic
Reduced sensation or pins-and-needles in the perianal area
Decreased anal tone -> bowel dysfunction
Urinary dysfunction - incontinence, retention
Sexual dysfunction
Investigtaions for cauda equina syndrome?
Lumbar-sacral spine MRI
Management of cauda equina syndrome?
Immediate hopsital admission and MRI scan
Surgical decompression asap
What is metastatic spinal cord compression?
This is when a metastatic lesion compresses the spinal cord. It presents similarly to cauda equina with back pain and motor & sensory signs. A key symptom is worsening back pain on coughing/straining and its often worse at night
This is an oncological emergency which requires a whole spine MRI and management asap!!
Management of metastatic spinal cord compression?
Consider immobilisation
Ensure adequate pain relief
Consider corticosteroids if no neurological sighs - 16mg oral dex
Carry out MRI within 1 week!
Tx is usually radiotherapy but surgery and chemotherapy are sometimes done
Which cancers is malignant spinal cord compression most common in?
Breast
Lung
Prostate
Lymphoma
Myeloma
What is transverse myelitis?
A rare neurological disorder causing inflammation of the spinal cord
Most commonly affects the thoracic region - causes bilateral symptoms as the disorder transverse the spinal cord
Can be autoimmune or caused by infections or cancer
Clinical presentation of transverse myelitis?
Muscle weakness, paralysis, paraesthesia, neuropathic pain, spasticity, bladder/bowel/sexual dysfunction
Presents over hours/days
Diagnosing transverse myelitis?
MRI spine
CSF to look for infection
What cause cause acute spinal cord compression?
Cancers
Trauma - vertebral fracture or facet joint dislocation
Infections resulting in abscess formation
Disc prolapse - rare cause and more likely to cause cauda equina syndrome
What pathologies can predispose a person to a narrowed cord canal and therefore increases their risk of developing acute spinal cord compression?
Inflammatory conditions such as RA or ankylosing spondylitis
Degenerative conditions e.g. ligamentum flavum hypertrophy or osteophyte formation
Clinical features of acute spinal cord compression?
Sensation and proprioception impaired below level of the lesion
Pain aggravated by strain e.g. coughing
Weakness
UMN signs below the level of the lesion (compared with cauda equina syndrome which has LMN signs)
Can be autonomic involvement e.g. bowel Incontinence or iurinary retention but this is a late stage!
Investigtaions for acute spinal cord compression?
MRI whole spine within 1 week (within a day if cord is believed to be compressed)
Routine bloods including group & save and clotting screen
What is one of the best indicators of prognosis for acute spinal cord compression?
Mobility state at time of treatment; 90% of ambulatory ot will remain mobile whereas only 1/3rd of non-ambulatory pt at presentation will regain the ability to walk
