Spinal Cord Syndromes Flashcards
Myopathy
-any disease that affects the spinal cord
Spinal Cord Anatomy
- ends at L1-L2
- Spinal Taps: done b/w L4 & S1
- most back pain is lumbar
- bad things happen in thoracic area
Parts of Spinal Cord
- Corticospinal tract (hyper-reflexia, spasticity, Babinski, weakness)
- Post. Columns (loss of vibration, position sense, Romberg sign)
- Spinothalamic tract (loss of pain & temp)
- Anterior Horn Cells (flaccid weakness, hypo-reflexia fasiculations)
- Root (lancinating pain, numbness, hypo-reflexia)
- Corticospinal tract (hyper-reflexia, spasticity, Babinski, weakness)
Anatomy of Spinal Cord: Inside to Outside
- cord
- pia mater
- subarachnoid space
- subdural space
- dura
- epidural space (fat)
- bone
Leptomeningeal
-within subarachnoid space
extrdural
-epidural
intradural
subdural
Intramedullary
-within spinal cord parenchymal
Conus
- end of spinal cord
- L1/L2
Nipple Line
T4
-sensory level
Umbilicus Line
T10
-sensory level
What is common in spinal cord lesions?
- sphincter dysfunction
- micturition ultimately controlled by CNS
- bladder symptoms
-long axons from the frontal lobe of brain synapse in the thoracic & sacral areas of the spinal cord (those tracts are vulnerable to injury)
2 types of bladder symptoms that occur with spinal cord lesions?
- acute lesions - urinary retention with some overflow incontinence
- chronic lesions - small spastic bladder that does not completely empty with spasms and urge incontinence
Acute & Subacute myelopathies are?
emergencies
- recognize signs & symptoms, neuro-radiologic testing, lumbar puncture if neuro neg.
- Therapy is usually IV steroids
Chronic Myelopathy Approach to Patient
- signs & symptoms
- neurotesting
- lumbar if neuro neg
- therapy directed to cause of treatment
History/Exam of patient with Myelopathy
- other illness, fever, location of pain, neuro symptoms, pace of symptoms
- neuro exam: motor, sensory, reflexes, gait
Progression of Epidural Lesion A
hours to days
- motor symptoms usually early (hyperreflexia, Babinski sign, hard to walk) may NOT be weak
- Sensory: root irritation, hypersensitive to touch, band or girdle-like sensation in abdomen
- Urinary Urgency
Progression of Epidural Lesion B
- Motor: legs are spastic & weak, brisk reflexes, babinski sign +
- Sensory: root area totally numb (ipsilateral), pain in contralateral LE is dec. (spinothalamic)
- Partial Brown-Sequard (hemi-cord syndrome)
- Definite sphincter dysfunction
Progression of Epidural Lesion C
hours to days (may be acute)
- Motor: flaccid, arflexic due to spinal cord shock or spastic paraparesis if more chronic or subacute
- Sensory: complete sensory level to all modalities at level of lesion
Myelopathy - Disc Disease
-severe disc disease in the cervical or thoracic cord - can cause epidural cord compression & myelopathy
(herniated & degenerative)
Treatment: steroids & surgery
Spinal Cord Trauma
- Paraparesis/paraplegia
- Quadriparesis/Quadriplegia
- Vertebral body compression
- Hematoma
- Spinal Cord Infarct
- Cord transection
Spinal Cord Trauma: Injury Protocol
-Methyprednisolone
Causes of Spinal Cord Dysfunction in Patients with Cancer
- Epidural cord compression: tumor, abscess, hematoma
- Intramedllary processes: metastases, abscess, hematoma, syrinx
- Other: radiation, chemo, paraneoplastic
- Neoplastic meningitis
- Spinal arachnoiditis
Epidural Myelopathy due to metastatic cancer
- compression is common complication
- cancer enters vertebral body (weakens, expands then compresses the spinal cord)
- Lung, breast, prostate
When to get spinal tap?
-when no evidence of cord compression form imaging
Where does most metastatic cancer begin>
-vertebral body
Where does most spinal abscesses begin?
-disc space
then expand to cause spinal cord compression
Most common spinal cord infection?
-staph aureus (IV drug users)
Test of choice for spine?
-MRI
Epidural Abscess
- fever, pain on percussion, elevated white count, elevated ESR
- Risk factors: IV drug use, HIV, immunosuppression
Osteomyelitis
- infection of vertebral bodies
- causes weakness of the bones, collapse of the vertebral body & subsequent cord compression
- irregular vertebral body end plates
Pott’s Disease
-class neurologic syndrome of osteomyelitis resulting from TB infection
Spinal Meningioma
- intradural, extramedullary
- common in thoracic spine
- although occasional benign herniated disc can occur in thoracic spine, most are bad
- middle age women
Nerve Sheath Tumors
- schwannoma & neurofibroma are extramedullary, intradural
- Classic: dumbbell shape (not common)
- middle-age
- symptoms mimic disc herniation
Central Cord Lesion
A: begins with pain in shoulders (cervical lesion)
-loss of pain & temp, crossing spinothalamic tracts are involved early
B: as lesion involves root entry zones, reflexes are lost in arms, loss of pain & temp is sever (burn), Horner’s syndrome (involve sympathetic path), Touch & joint position are intact “dissociated sensory level”, legs develop spastic paraparesis, Babinski, hyperreflexia due to corticospinal change
C: worsening of symptoms, Sacral sparing b/c these fibers are the most lateral of the spinothalamics, may involve face due to sensory nucleus of trigeminal nerve
Syrinx
- Central Spinal Cord Syndrome
- large expanding space in spinal cord
- result of trauma or tumor
Spinal Cord Astrocytoma
- enhancement with gadolinium
- large amount of edema
Vascular disease of spinal cord
- Aneurysm, AVM, less common
- “watershed zone” at periphery of central gray matter
Anterior Spinal Artery Syndrome (artery of Adamkiewicz = great radicular artery)
- supplies anterior 2/3 of spinal cord (located in mid thoracic region)
- symptoms referable to spinothalamic (loss of pain & temp., sensory level), corticospinal function (weakness), but intact posterior column function (vibration & joint position sense)
Acute Non-compressive myelopathies
- Transverse myelitis
- NMO
Complete Transection of the Spinal Cord - Spinal Cord Shock
- Transverse myelitis
- other causes
- acute = spinal shock
- flaccid paralysis
- complete sensory level to all modalities
- loss of bladder, bowel & sexual function
- autonomic malfunction
- chronic - no shock (spastic paralysis with above)
Brown-Sequard Syndrome
- hemi-section
- rare: stab wound or myelitis
- on side of lesion: ipsilateral spastic paralysis (after spinal shock) below the level of the lesion
- Hyper-reflexia, Babinski signs
- Ipsilateral loss of vibration & joint position sense
- Contralateral loss of pain & temp
Subacute Combined Degeneration of Spinal Cord
- B12 deficiency - pernicious anemia
- spastic weakness of lower extremities
- dec. sensation to vibration & postision
- Romberg’s sign
- Ataxia (non-cerebellar)
- Babinski signs & hyperreflexia
- peripheral neuropathy (mixed signs)
Treatment for Subacute Combined Degeneration of Spinal Cord
-IM injections of vit B12
HTLV-1
- human T-lymphotropic virus type 1
- first human retrovirus discovered
- reservoir is CD4+ T-lymphocytes
- associated with (HAM/TSP, ATL, uveitis, polymyositis, arthritis, ALS)
- causes spastic paraparesis & spinal cord disease
HAM/TSP
- HTLV-1 associated myelopathy/tropical spastic paaraparesis
- patients infected with HTLV-1
- develop paraparesis
- CNS is infiltrated by monocytes
- CNS demyelination & axonal degeneration (corticospinal tract > posterior columns)
- CFS shows ligoclonal bands & inc. IgG
Vacuolar Myelopathy
- neurologic complication of HIV infection (late with AIDS)
- progressive spastic paraparesis (hyperreflexia, extensor plantar responses)
- sensory ataxia & incontinence
- vacuolation & myelin pallor (posterior & lateral columns)
- Resembles B12 deficiency
Tabes Dorsalis
- one complication of neurosyphilis
- posterior column dysfunction
- loss of vibration & joint position sense
- Romberg sign
