Syndromes Flashcards
Dorsal cord syndrome
Bilateral involvement of dorsal columns, corticospinal tracts, and descending central autonomic tracts to bladder control centers in sacral cord.
- gait ataxia
- corticospinal tract –> weakness
- acute = muscle flaccidity and hyporeflexia
- chronic = hypertonia and hyperreflexia
- extensor plantar responses and urinary incontinence may be present
Causes
- MS
- tabes dorsalis
- friedrich ataxia
- subacute combined degeneration
- vascular malformation
- epidural and intradural extramedullary tumours
- cervical spondylotic myelopathy
- atlantoaxial subluxation
Ventral cord or anterior spinal artery syndrome
Tracts in anterior 2/3 of spinal cord:
- corticospinal tracts
- spinothalamic tracts
- descending autonomic tracts to sacral centers for bladder control
- weakness and reflex changes
- bilateral loss of pain and temperature sensation
- tactile, position and vibratory sensation NORMAL
- urinary incontinence usually present
Causes
- spinal cord infarction
- intervertebral disc herniation
- radiation myelopathy
Transverse myelitis
Bilateral leg weakness
Loss of voluntary control of bladder
Diminished sensation of all modalities
Tight banding sensation around trunk, tenderness
Recent gastro
MS
Cord segmental syndrome
Eg acute transection
- spinal shock with flaccid paralysis
- urinary retention
- diminished tendon reflexes
then progression to hypertonia, spasticity and hyperreflexia over days to weeks
Above C3 –> cessation of respiration, usually fatal
Above L2 –> impotence, spastic paralysis of bladder, loss of voluntary control and emptying by reflex action
Causes
- acute myelopathies such as traumatic injury and spinal cord haemorrhage
- epidural or intramedullary tumours, abscess
- transverse myelitis
Brown Sequard Syndrome
Lateral hemisection syndrome
Involves dorsal column, corticospinal tract, and spinothalamic tract unilaterally
- weakness, loss of vibration and proprioception IPSILATERAL to lesion
- loss of pain and temperature CONTRALATERAL to lesion
- unilateral involvement of autonomic fibers doesn’t produce bladder symptoms
Causes
- being stabbed in the back
- or shot
- demyelination
- rarely: spinal cord tumours, disc herniation, infarction, and infection
Central cord syndrome
- loss of pain and temperature sensation in the distribution of one or several adjacent dermatomes at the site of the spinal cord lesion caused by disruption of crossing spinothalamic fibers in the ventral commissure
- dermatomes above and below have normal pain and temperature sensation - “suspended sensory level”
- vibration and proprioception often spared
- may produce weakness in analgesic areas as the lesion enlarges and encroaches on corticospinal tracts
- loss of tendon reflexes in analgesic areas
- no bladder symptoms
Causes
- slow-growing lesions eg syringomyelia or intramedullary tumour
- most frequently the result of a hyperextension injury in patient with long-standing cervical spondylosis –> this results in disproportionately greater motor impairment in UL > LL, bladder dysfunction, and variable degree of sensory loss below level of injury
Conus medullaris syndrome
- L2
- early and prominent sphincter dysfunction with flaccid paralysis of bladder and rectum, impotence, and saddle anaesthesia
- leg muscle weakness may be mild if lesion very restricted
Causes
- disc herniation
- spinal fracture
- tumours
Cauda Equina Syndrome
- Not truly a spinal cord syndrome
- loss of function of two or more of the 18 nerve roots constituting the cauda equina
- deficits usually involve both legs, but often asymmetric
- back pain
- sciatica
- change in sensation and weakness in LLs
- urinary incontinence
- bowel dysfunction
- sexual dysfunction (impotence)
- decreased or absent reflexes in LLs
- saddle anaesthesia
- hypotonia/atrophy of LLs
- decreased or absent rectal tone
Ramsay Hunt Syndrome
HSV infection within dermatomal distribution of one of the branches of the trigeminal nerve
- vertigo
- +/- hearing loss
- ipsilateral facial paralysis
- ear pain
- vesicles in auditory canal and auricle
Vestibular neuronitis vs labyrinthitis
Both:
- rapid onset
- severe, persistent vertigo
- nausea and vomiting
- gait abnormality
- spontaneous nystagmus
- positive head impulse test
- gait instability with preservation of ambulation
Labyrinthitis only:
- unilateral hearing loss
Wallenberg syndrome
AKA lateral medullary infarction, PICA syndrome (posterior inferior cerebellar artery), vertebral artery syndrome
- acute onset vertigo + disequilibrium
- infarction of ipsilateral posterior inferior cerebellar artery (or obstruction of the vertebral artery from which it arises)
- vertigo is main feature but may also get:
- abnormal eye movements
- ipsilateral horner syndrome
- ipsilateral limb ataxia
- dissociated sensory loss (loss of pain and temp on ipsilateral face and contralateral trunk with preserved vibration and position sense)
- hoarseness and dysphagia
Can also occur due to traumatic vertebral artery dissection
MRI establishes diagnosis; MRA assesses for dissection
Horner Syndrome
Ipsilateral
- miosis
- partial ptosis
- anhydrosis
- enophthalmos (inset eyeball)
Causes Central (with anhidrosis of face, arm, trunk) - syringomyelia - MS - encephalitis - brain tumours - lateral medullary syndrome
Preganglionic (anhidrosis of face)
- cervical rib
- thyroid carcinoma, thyroidectomy
- bronchogenic carcinoma (Pancoast tumour)
- thoracic aortic aneurysm
- trauma or surgery
Postganglionic (no anhidrosis)
- cluster headache
- carotid artery dissection/aneurysm
- cavernous sinus thrombosis
- middle ear infection
Neuroleptic malignant syndrome
- Association with drugs that block dopamine signalling (neuroleptics, antiemetics etc) and a tetrad of clinical features:
- fever
- rigidity
- mental status changes
- dysautonomia
Mostly starts with mental status changes –> rigidity, hyperthermia, autonomic dysfunction.
NB - CK elevation 4x normal
SNS lability - BP fluctuation/elevation, diaphoresis, urinary incontinence
Hypermetabolism, HR increase, RR increase
Specific treatments = dantrolene, bromocriptine, ECT
Serotonin Syndrome
Classic triad =
- mental status changes
- autonomic hyperactivity
- neuromuscular abnormalities
HUNTER CRITERIA
Patient must have taken serotonergic agent and meet ONE of the following:
- spontaneous clonus
- inducible clonus PLUS agitation or diaphoresis
- ocular clonus PLUS agitation or diaphoresis
- tremor PLUS hyperreflexia
- hypertonia PLUS temperature > 38 PLUS ocular clonus or inducible clonus
(84% sensitive, 97% specific)
Cholinergic syndrome
Agitation CNS depression Coma Convulsions Seizures Fasciculations and muscle weakness Bradycardia Bronchoconstriction and bronchorrhoea D&V lacrimation miosis salivation urinary incontinence
nicotinic: - HTN - mydriasis - sweating - tachycardia (note paradox with muscarinic effects)
