Transcript Complete spinal cord syndrome

SPINAL CORD, DISEASES AND
DIFFERENTIAL DIAGNOSIS
Prof.Dr.Ayse ALTINTAS
I.U.CERRAHPASA MEDICAL
SCHOOL, NEUROLOGY DEPT.
3RD GRADE, 2011 OCTOBER
MEDULLA SPINALIS
• The spinal cord, the grayish-white oblong
cylindrical continuation of the medulla oblongata
of the brain,
• ***begins at the foramen magnum of the skull
and
• ***extends within the vertebral canal to
terminate as the cone-shaped conus
medullaris
MEDULLA SPINALIS
• In the adult the caudal tip of the conus
medullaris is located between vertebral levels L1
and L2.
• Thus, the adult spinal cord is approximately 45
cm in length with an average diameter of 1–1.5
cm
MEDULLA SPINALIS
• The spinal cord is a two-way conduit to and from
the brain.
• It functions as a “central relay station”,
receiving incoming information from the body
and the brain,
• and as a “central processing station”, conveying
outgoing information to the body and the brain.
• Each spinal nerve leaves the
vertebral column via its
intervertebral foramen and is
named accordingly.
• The first eight spinal nerves, C1–C8,
exit the vertebral canal above the
correspondingly numbered cervical
vertebrae, whereas all subsequent
spinal nerves (T1–T12, L1–L5, S1–S5,
and Co1) exit below the
correspondingly named vertebrae
• Hence there are 31 pairs of spinal
nerves emerging from the spinal
cord.
• The region of the spinal cord
associated with a particular
• pair of spinal nerves is called a spinal
segment.
Lumbar puncture (LP)
VASCULAR SUPPLY OF THE SPINAL CORD
***The anterior spinal arteries,direct
branches of the vertebral arteries, join
with each other to form a single median
vessel, the anterior spinal artery, which
provides small branches that penetrate
and supply the white and gray matter of
the spinal cord.
VASCULAR SUPPLY OF THE SPINAL CORD
***The posterior spinal arteries also arise
from the vertebral arteries directly or
frequently indirectly by way of the
inferior cerebellar branch of the vertebral
artery.
**penetrate and serve the white and gray
matter of the spinal cord.
VASCULAR SUPPLY OF THE SPINAL CORD
SPINAL CORD LESIONLOCATIONS
SPINAL CORD
• Acute spinal cord dysfunction
• Can develop over seconds to week
• a common reason for neurology referral
SPINAL CORD-STRUCTURE
•
•
•
•
The neurologist’s tasks are to determine
the etiology,
institute treatment to reverse the acute deficit,
subsequently determine whether there is a risk
of recurrence (especially for inflammatory
demyelinating myelopathies)
• and
• where necessary, institute prophylactic
treatment to prevent recurrence.
SPINAL CORD
• Acute and subacute myelopathy occurs for
numerous reasons and should always be
considered a medical emergency.
• Unfortunately, the diagnosis of myelopathy is
often missed at first, leading to missed
opportunities for treatment.
SPINAL CORD
• Any patient who reports, or is found to have a
sensory level on exam should be evaluated as a
potential myelopathy patient. Also, patients who
present with urinary retention should be
considered a spinal cord dysfunction patient until
proven otherwise.
• Patients with either a new sensory level or
urinary retention should not be discharged from
an office or ER to home without complete imaging
of the spinal cord with MRI.
SPINAL CORD DISEASESDIAGNOSTIC ALGORITM
SPINAL CORD AND ROOT
COMPRESSION
• CAUSES:
-TUMOURS (PRIMARY, SECONDARY)
EXTRADURAL, INTRADURAL,
INTRAMEDULLARY
- INFECTIONS (ACUTE, CHRONIC)
- DISC DISEASE AND SPONDYLOSIS
- HAEMATOMA (AVM, SPONTANEOUS,
TRAUMA)
- CYSTIC LESIONS (EXTRADURAL,
INTRADURAL, INTRAMEDULLARY)
SPINAL CORD AND ROOT
COMPRESSION
- LEVEL OF THE LESION:
- A lesion above the L1 vertebral body
may damage both the cord and its
roots.
- Below this, only roots are damaged.
Categories of non-compressive acute
myelopathies
• Disorders that present as acute myelopathy can
be grouped as follows:
• 1. Vascular
• 2. Demyelinating
• 3. Infectious
• 4. Non-infectious inflammatory
• 5. Cancer related
LOCALIZING A PROCESS AT A
SPECIFIC LEVEL IN THE SPINAL CORD
• Foramen magnum and upper cervical cord:
suboccipital pain and neck stiffness,
Lhermitte’s symptom,
occipital and finger tip paresthesias,
syringomyelic-type sensory dissociation,
spastic tetraparesis,
long tract sensory signs,
bladder disturbance,
LOCALIZING A PROCESS AT A
SPECIFIC LEVEL IN THE SPINAL CORD
LOCALIZING A PROCESS AT A
SPECIFIC LEVEL IN THE SPINAL CORD
APPROACH TO MYELOPATHIES
WITH A NORMAL MRI
• Has a compression been missed? (Epidural
lipomatosis, Dynamic compression (flexionextension studies)
• • Is it really a myelopathy? (CNS: parasagittal
meningioma, venous sinus thrombosis, ACA
thrombosis, hydrocephalus, vascular parkinsonism,
other EP disorders/ Ganglionopathy: Sjogren’s ,
B6, paraneoplastic/
• Plexopathy: paraneoplastic/ PNS: AIDP, NMJn:
MG or LEMS, Muscle: periodic paralysis/ Motor
neuronopathy: ALS/ PLS
APPROACH TO MYELOPATHIES
WITH A NORMAL MRI
• • Is it a metabolic/ toxic/ degenerative/
infective myelopathy?
• • Are the images of adequate quality? (Include
contrast?)
• • Were the images taken too early or too late?
• • Is the lesion too small to be seen on MRI?
• • Is there subtle focal or generalized cord
atrophy?
APPROACH TO MYELOPATHIES
WITH A NORMAL MRI
• • Is there a history of radiation?, Is there
evidence of CSF hypovolemia?,
• Is there evidence of superficial siderosis?
• • Is it functional?
SPINAL CORD-SYNDROMES
• Clinical presentation of spinal cord disorders:
• The differential diagnosis of an acute myelopathy
is dictated by the clinical setting in which the
myelopathy occurs, by the specific spinal
syndrome,
 the occurrence of systemic/non-neurological
symptoms,
 Radiographic appearance,
 Clinical and radiological response to corticosteroid therapy
SPINAL CORD-SYNDROMES
• Spinal cord disorders are conventionally
classified as ‘syndromes’ due to the typical signs
and symptoms produced as a result of the
location of lesions and tract involvement.
SPINAL CORD-SYNDROMES
• For example, Brown-Séquard hemi cord syndrome
indicates a structural myelopathy, either
compressive or inflammatory and less often
neoplastic disorders; it would be rarely
• seen in vascular, paraneoplastic and metabolic
disorders. In contrast, myelopathies with
selective tract
• involvement are characteristic of metabolic,
paraneoplastic and degenerative myelopathies,
rather than
• inflammatory or infectious; for example,
SPINAL CORD-SYNDROMES
• In contrast, myelopathies with selective tract
involvement are characteristic of metabolic,
paraneoplastic and degenerative myelopathies,
rather than inflammatory or infectious; for
example, corticospinal and posterior columns
involvement is typical of B12 and copper
deficiency, adrenomyeloneuropathy, Friedreich’s
ataxia.
SPINAL CORD-SYNDROMES
• Complete spinal cord syndrome:
• Description: Bilateral involvement of all tracts
• Causes: Myelitis (parainfectious/ postvaccinal/
“transverse”), NMO, compression (trauma, tumor,
hematoma, abscess), vascular, (rare with MS)
SPINAL CORD-SYNDROMES
• Brown-Sequard syndrome (often incomplete):
• Description: Pain and temperature loss
contralateral to weakness, ipsilateral spastic
weakness and loss of proprioceptive function
• Causes: compression or intrinsic cord lesion like
demyelination
BROWN-SEQUARD SYNDROME
SPINAL CORD-SYNDROMES
• Central cord syndrome:
• Description: suspended analgesia, sacral sparing,
dissociation of sensory loss, ipsilateral Horner,
anterior horn dysfunction
• Causes: syrinx, intramedullary tumors,
hyperextension neck injuries (“man-in-a-barrel”)
CENTRAL CORD LESION
SPINAL CORD-SYNDROMES
• Posterolateral column disease:
• Description: foot > hand paresthesias, dorsal
column dysfunction, intact pain and temperature,
corticospinal dysfunction, associated PN
• Causes: Cbl/ copper deficiency, HTLV or HIV,
extrinsic compression as in spondylotic
myelopathy
SPINAL CORD-SYNDROMES
• Posterior column disease:
• Description: sensory ataxia, absent reflexes,
hypotonic but not weak, hyperextensible joints,
trophic changes,crises, decreased deep pain,
Lhermitte’s
• Causes: Tabes
SPINAL CORD-SYNDROMES
• Anterior horn cell syndrome:
• Description: weakness, atrophy, fasciculations,
reduced tone and reflexes, intact sensations,
possible involvement of cranial motor nuclei
• Causes: spinal muscular atrophy (infantile/
Werdnig-Hoffman, intermediate, juvenileKugelberg-Welander, motor neuron disease)
SPINAL CORD-SYNDROMES
• Combined anterior horn cell and pyramidal
tract disease:
• Description: anterior horn cells and pyramidal
tract, sphincteric sparing, asymmetric, cramping,
bulbar or pseudobulbar involvement, sensory
sparing, preserved superficial abdominals,
reflexes variable, rare for extraocular muscles to
be involved
• Causes: ALS
SPINAL CORD-SYNDROMES
• Anterior spinal artery syndrome:
• Description: Bilateral corticospinal and
spinothalamic involvement without dorsal column,
bladder
• dysfunction
• Causes: Anterior spinal artery infarct or MS
SPINAL CORD-SYNDROMES
• Posterior spinal artery syndrome;
• Description: posterior column dysfunction with
loss of segmental reflexes, infarction of
unilateral posterior
• horn and lateral column with sparing of posterior
columns may also occur
• Causes: posterior spinal artery infarct
SPINAL CORD-SYNDROMES
THANK YOU VERY MUCH