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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