Spinal Cord Syndromes

Question 1

AETIOLOGY:

1. Trauma
2. Neoplasms
3. Inflammatory disease
4. Infection
5. Degenerative cervical disc disease
6. Vitamin B12 and folate deficiency
7. Genetic
8. Syringomyelia
9. Vascular

Answer 1

1. • Prevalence: 50/100k
     - young men
2. a) Extrinsic
   - from mets
   - common primaries include bronchus, breast, myeloma, lymphoma, prostate
   - primary extrinsic tumours include benign neurofibromas/meningiomas
   - benign lesions usually painless and very slow progression
   - malignant lesions painful with acute/subacute presentation
   b) Intrinsic
   - rare, include astrocytomas/ependymomas
   - gradual progression over many years, often painless.
3. • Multiple sclerosis(60/100k)
     - Sarcoidosis, SLE, Sjorgen’s syndrome
     - neurological deficit developing over few days/slow progression
4. a) HIV and syphilis
   - chronically developing myelopathy
   - In neurosyphilis(tabes dorsalis), dorsal column usually affected
   b) Paraspinal/epidural abscesses
   - acute development(pyogenic)
   - insidious onset(tuberculous)
   - associated systemic Sx ie weight loss, fever, sweats
   c) Brucellosis
   - consumption of unpasteurized milk
   - subacute development
   d) HTLV-I
   - tropical setting
   - tropical spastic paraparesis
5. • most common cause of spinal cord compression
     - frequency proportional to age
     - can be acute/chronic
     - associated radiculopathy
6. • subacute myelopathy, dorsal columns prominently affected
     - megaloblastic anaemia and other neurolgocial changes eg: mental slowing, cerebellar ataxia, peripheral neuropathy
7. • Friedrich’s ataxia: onset at 8-15y, spinocerebellar degeneration, loss of reflexes(axonal neuropathy), optic atrophy and late cardiomyopathy.
     - Familial spastic paraparesis: relative preservation of power, compensatory hypertrophy of upper limb muscles.
8. • presents as slow-progressing central cervical cord lesion. Horner’s syndrome also seen
     - Causes: Chiari malformation, tumour, trauma
9. • most commonly anterior spinal cord syndrome related to T8-11
     - Vascular malformations
     - Symptoms exacerbated by exercise, claudication

Question 2

PATTERNS OF SPINAL CORD LESIONS:

1. Total spinal transection
2. Hemicord ‘Brown-Sequard’ Syndrome
3. Central cord lesion
4. Dorsal column loss
5. Anterior cord syndrome

Answer 2

1. Paraplegia/Tetraplegia, urinary retention, constipation. In acute phase, ‘spinal shock’ with transient arreflexia and flaccidity
2. Ipsilateral spasticity and posterior column loss sensory loss. contralateral spinothalamic loss
3. Early sphincter disturbance, spinothalamic loss(possibly bilateral), loss of pain and temperature sensation. Wasting, weakness, arreflexia(LMN)
4. Ataxia, loss of propioception and vibration sense.
5. Only dorsal column sensation preserved.

Question 3

INVESTIGATIONS:

Answer 3

1. MRI spine
   - needed in progressive myelopathies to exculde treatable cause
2. Brain scan
   - Brain pathology ie parasaggital meningioma can mimic spnal cord disease

Question 4

TREATMENT:

1. Emergency
2. Specific treatments
3. Long-term rehabilitation

Answer 4

1. a) C-spine immobilisation
   b) Steroids once infective cause excluded
   - temporarily reverses deficits esp in malignant compression
   c) Immediate neurosurgical referral for decompression if spinal cord compression suspected
2. a) Radiotherapy, chemotherapy for malignant lesions
   b) High-dose corticosteroids for non-infective inflammatory causes
   c) Surgery for most progressive neurological deterioration
   - cervical spondylosis
   - extrinsic compression by disc, tumour

Question 5

RED FLAGS:

Answer 5

1. History of cancer
2. New onset thoracic back pain.
   - neck and lower back pain so common in population so often unhelpful.
3. Pyrexia
   - Discitis
   - Extradural empyema
   - Vertebral osteomyelitis
4. Rapidly progressing sphincter disturbance