Download paraplegia and spinal cor syndromes

Dr. M. Sofi MD;FRCP(London);
FRCPEdin; FRCSEdin
Spinal cord: Overview
 Information highway between
brain and body
 Extends through vertebral canal
from foramen magnum to L1
 Each pair of spinal nerves receives
sensory information and issues
motor signals to muscles and glands
 Spinal cord is a component of
the CNS while the spinal nerves are
part of the peripheral Nervous System
Functions of the Spinal Cord
The spinal cord has two major
functions:
A.
Carrying information:
The spinal cord has three major
functions:
 Conduit for motor
information, which travels
down the spinal cord
 Conduit for sensory
information in the reverse
direction, and finally as a
 Center for coordinating
certain reflexes
Coordinating reflexes:
 Coordinates reflexes without
the involvement of the brain.
 Reflex actions are automatic,
unlearned, involuntary, and
inborn responses.
 These actions are sudden in
nature and have a purpose of
protecting the individual or his
organs from sudden danger
B.
Somato-sensory organization
Pyramidal tracts
Lateral Coticospinal Tract
Anterior Corticospinal
Tract
Extrapyramidal Tracts
Rubrospinal
Reticulaospinal
Olivospinal
Vestibulospinal
Descending Tracts
Somato-sensory Organization
Sensory & Ascending
Pathways
Dorsal Column Medial
Lemniscus
Gracile fasciculus
 Cuneate fasciculus

Spinocerebellar Tracts
Posterior spinocerebellar
 Anterior spinocerebellar

Anterolateral System
Lateral spinothalmic tract
 Anterior spinothalmic tract
 Spino-olivary tract

Ascending tracts
BLOOD SUPPLY SPINAL CORD
Paraplegia & Spinal cord syndromes
Spinal shock is a loss of sensation accompanied by motor paralysis
with initial loss but gradual recovery of reflexes, following a
spinal cord injury (SCI) – most often a complete transaction.
 Reflexes in the spinal cord caudal to the SCI are depressed
hyporeflexia/areflexia), while those rostral to the SCI remain
unaffected.
 ‘Shock' in spinal shock does not refer to circulatory collapse, and
should not be confused with neurogenic shock.
Phase
Time
Physical exam finding
Underlying physiological
event
1
0-1d
Areflexia/Hyporeflexia
Loss of descending facilitation
2
1-3d
Initial reflex return
Denervation supersensitivity
3
1-4w
Hyperreflexia (initial)
Axon-supported synapse growth
4
1-12m
Hyperreflexia, Spasticity
Soma-supported synapse growth
Paraplegia & Spinal cord syndromes
Classification of etiology
COMPRESSIVE
MYELOPATHY
EXTRAMEDULLARY
EXTRADURAL
DISC
INTRAMEDULLARY
INTRADURAL
VERTEBRAL
Meningoma,
Neurofibroma,
Arachnoditis
Syringomyelia,
Ependymymoa,
Glioma,
Astrocytoma
Paraplegia & Spinal cord syndromes
Classification of etiology
Non-compressive
myelopathies
INFAMMATORY
INFECTIOUS: VIRAL, BACTERIAL
FUNGAL PARASTIC
AUTOIMMUNE: SLE, SJOGREN,
SARCOIDOSIS, BECHET S, MCTD
DEMYELINATING: MS,NMO, ADEM,
POST VIRAL POST VACCINIAL
PARANEOPLASTIC
NONINLAMMATORY
INHERITED: HSP, INHERITED METABOLIC
DISORDERS
METABOLIC: VIT B12,COPPER,FOLATE,
AIDS ASSOCIATED, VIT E DEFICIENCY
TOXIC: CASSAVA, LATHYRISM,FLUOROSIS,
SMON, NITROUS OXIDE
VASCULAR: ANT SPINAL ARTERY
THROMBOSIS, AVM, DURAL AV FISTULA
Paraplegia & Spinal cord syndromes
Differences between extradural and intradural
lesions
Extradural
Mnemonic – (3 Ps)
 Pain present - (root pain &
spinal tenderness)
 Pyramidal involvement –
early
 Protein in CSF high
Intradural
 Dissociated anesthesia
Bladder involvement early
 Not so high protein
 Symmetrical involvement
Trophic ulcers common
Determining level of lesion in cord compression
Sensory level

Motor level

Reflex level
Root pain – dermatome
Type of bladder involvement



Sensory level – below that level,
sensory impairment of loss
Motor level –
Beevor’s sign indicates T10 lesion
Reflex level – Inverted supinator C5
lesion
Clinical approach to Spinal cord syndromes
What is the onset of paraplegia
Is it acute within
minutes or hours?
Sub-acute within
days or weeks?
Is it chronic within
months or years?
Was there a history of trauma?
Fall from a
Height?
Road traffic
accident?
Direct injury to
spine?
Clinical approach to Spinal cord syndromes
Symmetry of symptoms?
Is motor weakness
symmetrical?
Is sensory symptoms
symmetrical?
Or they are
asymmetrical?
Any wasting or fasciculation?
Anywhere in the
body?
Small muscles of the
hand?
Thigh and gluteal
muscles?
Clinical approach to Spinal cord syndromes
Symmetry of symptoms?
Is motor weakness
symmetrical?
Is sensory symptoms
symmetrical?
Or they are
asymmetrical?
Any wasting or fasciculation?
Anywhere in the
body?
Small muscles of the
hand?
Thigh and gluteal
muscles?
Clinical approach to Spinal cord syndromes
Is there a history of root pains?
Is it unilateral or
bilateral?
Does it radiate to
Limbs?
Does it aggravate
with coughing?
Any pyramidal tract involvement?
Buckling of knees
while walking?
Slipping of foot
Wear?
Tipping on small
Objects?
Clinical approach to Spinal cord syndromes
History of vaccinations?
Anti Rabies
Vaccination?
Polio vaccination?
Others?
History of increased ICT
Fever and
headache?
Projectile vomiting?
Seizures or loss of
consciousness?
Clinical approach to Spinal cord
What is the mode of onset of paraplegia
syndromes
Acute
within days
Transverse myelitis
Anterior spinal artery syndrome
Traumatic paraplegia
Sub-acute
2- 6 weeks
Pott’s paraplegia
Spinal epidural abscess
Spinal cord tumors
Chronic
˃ 6weeks
Familial spastic paraplegia
Amyotrophic lateral sclerosis
Cranio-vertebral junction anomalies
Lesion of the right dorsal
column at L1 produces what
impairment?
R
L
Damage to the right dorsal column at L1 causes
the absence of light touch, vibration, and
position sensation in the right leg. Only
fasciculus gracilis exists below T6.
R
L
Lesion of the right
fasciculus cuneatus at C3
produces what impairment?
Damage to the right fasciculus cuneatus at C3
causes the absence of light touch, vibration, and
position sensation in the right arm and upper trunk.
R
L
Lesion of the right lateral
corticospinal tract at L1
produces what impairment?
Damage to the right lateral corticospinal tract at
L1 causes upper motor neurons signs (weakness or
paralysis, hyperreflexia, and hypertonia) in the
right leg.
Right Lateral Spinothalamic Tract Lesion
R
L
L1
Common causes
include MS,
penetrating
injuries, and
compression
from tumors.
Lateral spinothalamic tract
lesion
Contralateral loss of pain
and temperature sense
Central Cord Syndrome
R
L
C5-C6
Common
causes include
posttraumatic
contusion and
syringomyelia,
and intrinsic
spinal cord
tumors.
Lateral
Spinothalamic
Tract
Impaired pain and temperature
sensation, C5-C6 dermatomes,
bilaterally
Postraumatic central cord syndrome
Postraumatic
central cord
syndrome
MRI of the cervical
spine focal posterior
disc protrusion at
C3/4 level causing
spinal stenosis
obliterating CSF
space and impressing
onto the spinal cord.
There is increased
intramedullary T2
signal without
abnormal T1 signal
noted
Hemicord Lesion (Brown-Sequard Syndrome)
R
L
L1
Common
causes
include
penetrating
injuries,
lateral
compression
from
tumors, and
MS.
Hemicord lesion
Dorsal column lesion
Ipsilateral loss of light touch,
vibration, and position sense
Lateral corticospinal tract lesion
Ipsilateral upper motor neurons signs
Lateral spinothalamic tract lesion
Contralateral loss of pain
and temperature sense
Hemicord Lesion (Brown-Sequard Syndrome)
Cervical spine MRI showing a T2 hyperintense enhancing lesion at C2-3
Transverse Cord Lesion
R
Common
causes
include
trauma,
tumors,
transverse
myelitis, and
MS.
L
Transverse cord lesion
Dorsal column lesion
Bilateral loss of light touch,
vibration, and position sense
Lateral corticospinal tract lesion
Bilateral upper motor neurons signs
Lateral spinothalamic tract lesion
Bilateral loss of pain and
temperature sense
Anterior Cord Syndrome
UMN
UMN
DRG
DRG
R
Common
causes
include
anterior
spinal artery
infarct,
trauma, and
MS.
L
Anterior cord lesion
Lateral corticospinal tract lesion
Ipsilateral upper motor neurons signs
Lateral spinothalamic tract lesion
Contralateral loss of pain
and temperature sense
Anterior Cord Syndrome
Hyperintense
intramedullary
lesion in T2 at
the level C3-C7
(arrows),
indicate acute
cervical spinal
cord infarction.
Right: MR
sagittal T2:
myelomalacia
cavity C3-C7 in
control after a
month.
Posterior Cord Syndrome
DRG
DRG
R
Common
causes
include
trauma,
compression
from
posteriorly
located
tumors, and
MS.
L
Dorsal column lesion (bilateral)
Bilateral loss of light touch,
vibration, and position sense,
generalized below lesion level
Posterior Cord Syndrome