spinal cord syndrome Flashcards
low back pain
-84% of adults at some point
-lumbar strain
-degenerative - arthritis -> bony spurs
-discogenic pain (herniated disc)
-facet joint pain
-spondylosis
-anterolishtesis- bone slips forward
-spinal stenosis
lumbar strain
-Non-specific low back pain
-Not related to underlying serious disorder
-Often self resolves in 3 weeks
-Imaging NOT recommended if back pain unless lasting >4 weeks or if there is prescence of red flags
-Labs not required
-Non-pharm management is 1st line:
-HEAT
-NO BED REST!- muscles get weaker -> more pain
-ACTIVITY MODIFICATION
-Pharmacologic:
-NSAIDs short-term
-What is NOT needed:
-Early PT
-Injections
-Advanced imaging early in the course of lumbar strain
-Opioids
spinal stenosis (neuroclaudication)
-MC >50yo
-Narrowing of canal causes -compression on nerve roots
-Congenital narrowing
-Osteoarthritis
-CENTRAL Disc herniation
-Trauma
-Vertebral body fractures
-Fragility in osteoporosis
-Degenerative changes
-Disc height loss
-Bone spur growth (osteophytes)
-Facet bone overgrowth
-Ligamentum flavum thickening
-Degenerative spondylolisthesis
spinal stenosis neuroclaudication: sx, dx, tx
-Symptoms ofneurogenic claudication!:
-Pain/cramping in one/both legs when standing or walking for long periods
-Back pain +/- radiation to butt or legs
-Numbness, weakness, or tinglingunilaterally or bilaterally
-can be asymmetrical
-Shopping cart sign:
-Worse with extension* (prolonged standing)- narrows the spinal canal
-Improved with flexion* (bending forward)
-Severe: Urinary incontinence, difficulty walking (Cauda Equina syndrome)
-Exam: Typically NORMAL
-MRI will show spinal stenosis and cause (spondylolisthesis, mass, etc)
-TX: NSAIDs, PT, Weight loss, bracing, epidural injection of steroids
-Surgical tx: decompression laminectomy
diff dx of neuropathic and vascular claudication
-vascular depends on moving -> muscle
cauda equina and conus medullaris syndrome
-Spinal cord terminates at the conus medullaris between L1-L2
-The most distal bulbous part of the spinal cord is called the conus medullaris.
-Below this lies the nerves that make up the cauda equina
-!CES (cauda equina syndrome) refers to compression of these nerves
-Can include the conus medullaris or the cauda equina distal to it
-Herniated disc, retropulsion of bone fragments, hematoma, epidural abscess, epidural hematoma, diskitis, tumor, vascular insufficiency, spinal stenosis
what is cauda equina syndrome
-Characteristic pattern of neuromuscular and urogenital symptoms resulting from the simultaneous compression of multiple lumbosacral nerve roots below the level of the conus medullaris.
-LMN lesion.
-Compression of the nerves may be irreversible thus it is a neurosurgical emergency!!
Stat imaging, medication, and surgery is needed!
-BLADDER AND BOWEL CHANGES
causes of cauda equina syndrome
-Lumbar stenosis (multilevel)
-Spinal trauma including fractures
-Herniated nucleus pulposus (HNP) - 90% of lumbar disk herniations occur either at L4-L5 or L5-S1.
-Neoplasm
-including metastases, astrocytoma, neurofibroma, and meningioma
-20% of all spinal tumors affect this area
-Spinal infection/abscess
-eg, tuberculosis, herpes simplex virus, meningitis, meningovascular syphilis, cytomegalovirus, schistosomiasis
cauda equina presentation
-Low back pain & Sciatica (97%)
-Lower extremity weakness, paresthesia’s
-Severe neuropathic pain
-Saddle or perineum anesthesia (92%)
-Bladder dysfunction (92%)- retention 1st -> incontinence
-Bowel dysfunction (72%)- retention -> incontinence
-Sexual dysfunction (impotence in men)
-Areflexic paraplegia, atrophy – late signs
cauda equina syndrome evaluation and exam
-Ask about risk factors:
-Malignancy history
-Recent trauma
-IV drug use - abscess
-Anticoagulation - bleed
-Spinal instrumentation
-Examination:
-Motor or sensory deficits in the legs
-Usually bilateral
-Can be unilateral or asymmetrical
-Lower motor neuron signs in chronic cord compression : areflexia, hypotonia, atrophy
-Saddle anesthesia - where you sit on a horse -> numb
-↓ or absent rectal tone -> everyone gets a rectal exam
-Abdomen = large bladder (retention)
cauda equina syndrome imaging and management
-STAT MRI cord-compression series = gold standard!
-CT myelogram if unable to obtain MRI (metal implants)
-Consider post-void residual (>100cc generally neurologic)
-Management
-Neurosurgical emergency!!!
-Technically a clinical diagnosis -> STAT consultation
-(even before MRI if high suspicion)
-Decompression within 24 hrs window
conus medullaris syndrome (dont memorize the diff between this and cauda equina)
-Lesions at vertebral level L2 often affect the conus medullaris.
-Early and prominent sphincter dysfunction with flaccid paralysis of the bladder and rectum, impotence, and saddle (S3-S5) anesthesia.
-Causes include disc herniation, spinal fracture, and tumors
-May have some upper motor neuron (UMN) signs and present with increased tone and reflexes (UMN) and bilateral signs.
-In terms of the diagnosis, differentiating between cauda equina syndrome and conus medullaris syndrome doesn’t matter, as the management is the same. What’s needed is an MRI and urgent referral.
epidural abscess
-Infection within the epidural space of the spinal cord
-Any age, more often 50-70 yo
-Pathogenesis:
-Hematogenous spread - bacteremia
-Direct inoculation
-Mostly staph aureus infections- skin infection
-Can lead to spinal cord compression / ischemia
-Risk factors:
-25% have no risk factors
-Immunocompromise: DM, HIV, malignancy, chronic steroids, immunosuppressants
-Recent SSTI bacteremia
-Spinal anatomy abnormality
-Substance abuse: alcohol, IVDU!
-Presence of indwelling catheter
-Elderly
epidural abscess sx, dx, tx
-Symptoms
-Non specific, easily missed
-Triad: Back pain, fever, neuro signs
-Back pain 75% - Localized, midline!, with tenderness to percussion
-Fever 50%
-Neuro symptoms 33% - radiculopathy, weakness, sensory deficits, paralysis
-Labs are non-specific
-Blood cultures!!*
-Imaging
-MRI with gadolinium = gold standard
-Management:
-Empiric antibiotics (Vanc+Ceftriaxone)
-Urgent neurosurgery or ortho spine consult
complete spinal cord injury (SCI)
-Complete transection of all spinal tracts at a given level
-Total bilateral loss of motor/sensory/bowel/bladder function below the level of injury
-Some features only appear in the chronic phase (6-8 weeks)
-Below the level of the lesion:
-Bilateral anesthesia
-Bilateral paralysis (spastic paralysis!)
-!Hyperreflexia
-Clonus
-Absent anal reflex
-!Positive babinski
-Autonomic dysfunction
-Neurogenic bowel
-Erectile dysfunction
ASIA classification of spinal cord injury
-dont memorize
central cord syndrome
-MC incomplete cord injury
-Elderly, minor extension head injuries
-Patho: Spinal cord compression and central cord edema (UE are located “centrally” in corticospinal tract)
-hyperextension injury -> chin hits the ground
-Sxs:
-Bilateral loss of light sensation and pain/temperature below the level of the lesion
-UE>LE bilateral hand weakness
-“Cape” distribution if in c-spine - numb, weak, tingling
-Prognosis: Good
anterior cord syndrome
-Patho: Direct compression/flexion injury or anterior spinal artery injury
-Sxs:
-Bilateral paralysis below the lesion
-Bilateral loss of pain/temperature
-LE>UE affected
-(preserved proprioception/vibration)
-Prognosis: Worst of all incomplete SCI
brown-sequard syndrome
-Hemitransection of the spinal cord
-MOA: Usually penetrating trauma
-Signs and symptoms:
-Ipsilateral: Motor paralysis, loss of proprioception and vibration sense
-Contralateral: Loss of pain/temperature sensation
-Prognosis: Good
posterior cord syndrome
-Very rare to occur mechanically
-Syphilis!, multipole sclerosis, copper deficiency, B12 deficiency!, trauma with hyperextension, extrinsic spinal cord compression
-ataxia!
-SXS:
-Bilateral loss of proprioception and vibration
-(Preserved motor, sensation)
distribution of paralysis
Stocking-glove: Think polyneuropathy causes
-radiculopathy -compression of distal nerve or nerve ROOT -> carpal tunnel
-hemi - stroke
-neuropathy- dorsal column findings, DM, guillan barre
