Transcript Disease of Spine and Spinal Cord

Disease of Spine and
Spinal Cord
Assoc. Prof. Dr. Ercan MADENCI
Istanbul Medeniyet University
Medical School
Department of PMR
THE SPINAL CORD

The Spinal Cord is an
extension of the brain; a
thick bundle of nerve
fibres.

takes a message from the
brain, to the muscles to
communicate movement

messages to the brain,
communicating the sense
of touch, pain, pressure of
heat and cold
2
3

anterior
spinothalamic tract
(or ventral) transmits
crude touch.

lateral
corticospinal tract
controls movement
of contralateral limbs
4
Lateral spinothalamic tract Lateral corticospinal
tract: Movement
Pain and Temperature
5
General view

Spinal Cord Injury is damage to the spinal
cord that results in a loss of function such as
mobility or feeling. Frequent causes of
damage are trauma and disease
 Spinal Cord is the major bundle of nerves
that carry impulses to/from the brain to the
rest of the body
 Spinal Cord is surrounded by rings of bonevertebra. They function to protect the spinal
cord
6
Prognosis




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
Patients with a complete cord injury have a less than 5% chance of
recovery. If complete paralysis persists at 72 hours after injury,
recovery is essentially zero
The prognosis is much better for the incomplete cord syndromes
If some sensory function is preserved, the chance that the patient
will eventually be able walk is greater than 50%
Ultimately, 90% of patients with SCI return to their homes and regain
independence
In the early 1900s, the mortality rate 1 year after injury in patients
with complete lesions approached 100%. Much of the improvement
since then can be attributed to the introduction of antibiotics to treat
pneumonia and urinary tract infection
Currently, the 5-year survival rate for patients with a traumatic
quadriplegia exceeds 90%. The hospital mortality rate for isolated
acute SCI is low
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Upper vs. Lower Motor Neuron
 Upper




Motor cortex
internal capsule
brainstem
spinal cord
 Lower





motor neuron lesion
spasticity, muscle
weakness,
exaggerated reflexes,
and an out toeing of
toes and extensor
plantar response
known as the
Babinski sign.
motor neuron lesion
Anterior horn cell
decreased tone, decreased
nerve root
strength and decreased
reflexes in affected areas
plexus
peripheral nerve
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neuromuscular junction and muscle
Basic Features of Spinal Cord
Disease
 UMN

findings below the lesion
Hyperreflexia and Babinski’s
 Sensory
and motor involvement that
localizes to a spinal cord level
 Bowel and Bladder dysfunction common
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Scale of Motor Strength in SCI

The American Spinal Injury Association:






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0 - No contraction or movement
1 - Minimal movement
2 - Active movement, but not against gravity
3 - Active movement against gravity
4 - Active movement against resistance
5 - Active movement against full resistance
Assessment of sensory function helps to identify
the different pathways for light touch,
proprioception, vibration, and pain. Use a
pinprick to evaluate pain sensation
10
Types of Spinal Cord Paralysis

Depending on the location and the extent of the injury
different forms of paralysis can occur.
 Monoplegia- paralysis of one limb
 Diplegia- paralysis of both upper or lower limbs
 Paraplegia- paralysis of both lower limbs, Injury in the
the thoracic, lumbar, or sacral segments, including the
cauda equina and conus medullaris
 Hemiplegia- paralysis of upper limb, torso and lower leg
on one side of the body
 Tetraplegia (Quadraplegia)- paralysis of all four limbs
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History

Onset
 Acute, subacute, chronic
 Symptoms
 Pain
Weakness
 Sensory
 Autonomic
Past history
Family history



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Motor Exam


Strength - helps to localize the lesion
 Upper cervical
• Quadriplegia with impaired respiration
 Lower cervical
• Proximal arm strength preserved
• Hand weakness and leg weakness
 Thoracic T1
• Paraplegia
 Can also see paraplegia with a midline
lesion in the brain
Tone
 Increased distal to the lesion
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Sensory Exam

Establish a sensory level
 Dermatomes
• Nipples: T4-5
• Umbilicus: T8-9
 Posterior columns
 Vibration
Joint position sense (proprioception)
Spinothalamic tracts
 Pain
 Temperature


14
Autonomic disturbances
 Neurogenic

Urgency, incontinence, retention
 Bowel

bladder
dysfunction
Constipation more frequent than incontinence
 With
a high cord lesion, loss of blood
pressure control
 Alteration in sweating
15
Investigation of Spinal Cord
Disease
 Radiographic




Plain films
Myelography
CT scan with myelography
MRI
 Spinal

exams
tap
If you suspect: inflammation, MS, rupture of a
vascular malformation
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Etiology of Spinal Cord
Disease
Traumatic Spinal Cord Disease
 10,000
new spinal cord injuries per year
 MVA, sports injuries the most common
 Victims under 30 yrs old,
male>>females
 Fx/dislocation of vertabrae most likely
to occur at:



C5,6
T12, L1
C1,2
18
Vertebral column injury, with or without
neurological deficits, must always be sought and
excluded in a patient with
􀂄Multiple trauma.
􀂄Any injury above the clavicle
􀂄Spine injury
􀂄Cervical spine 55%
􀂄Thoracic spine 15%
􀂄Thoracolumbar junction 15%
􀂄Lumboscaral spine 15%
19
 Spinal
cord injury (SCI) is an insult to the
spinal cord resulting in a change, either
temporary or permanent, in its normal
motor, sensory, or autonomic function
20
 Excessive
manipulation and inadequate
immobilization of a patient with a spinal
cord injury can cause additional
neurological damage and worsen the
patient’s outcome
21
SPINAL CORD INJURIES
Caused by sudden trauma
Vehicular
Accidents
41%
Other:
8%
Violence
22%
Sports
8%
Falls
21%
22
Incidence

Race
Whites at 66.4%, African Americans at 21.1%, Hispanics at
8.8%, Asians at 1.6%, Native Americans at 1.1%, and others
at 1%

Sex
The male-to-female ratio of individuals with SCI is 4:1

Age
50% ,aged 16-30 years


Traumatic SCI < 40 years,
Nontraumatic SCI > 40 years.
23
Associated injuries
 Bone
fractures (29.3%),
 Loss of consciousness (17.8%),
 Traumatic brain injury affecting
emotional/cognitive functioning (11.5%).
24
Mechanism

Destruction from direct trauma
 Compression by bone fragments, hematoma,
or disk material
 Ischemia from damage or impingement on
the spinal arteries
 Edema could ensue subsequent to any of
these types of damage. The different clinical
presentations of the above causes of tissue
damage are explained further below
25
Spinal Shock


An immediate loss of reflex function, called areflexia,
below the level of injury
Signs:

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Slow heart rate
Low blood pressure
Flaccid paralysis of skeletal muscles
Loss of somatic sensations
Urinary bladder dysfunction
Spinal shock may begin within an hour after injury
and last from several minutes to several months,
after which reflex activity gradually returns
26
Neurogenic shock

Neurogenic shock is manifested by the triad of
hypotension, bradycardia, and hypothermia

Shock tends to occur more commonly in injuries
above T6, secondary to the disruption of the
sympathetic outflow from T1-L2 and to unopposed
vagal tone, leading to decrease in vascular
resistance with associated vascular dilatation

Neurogenic shock needs to be differentiated from
spinal and hypovolemic shock. Hypovolemic shock
tends to be associated with tachycardia
27
Spinal Shock

An immediate loss of reflex function, called
areflexia, below the level of injury
 Signs:






Slow heart rate
Low blood pressure
Flaccid paralysis of skeletal muscles
Loss of somatic sensations
Urinary bladder dysfunction
Spinal shock may begin within an hour after
injury and last from several minutes to
several months, after which reflex activity
gradually returns
28
Classification

The extent of injury is defined by the ASIA Impairment Scale
(modified from the Frankel classification), using the following
categories:

A - Complete: No sensory or motor function is preserved in sacral
segments S4-S5.
B - Incomplete: Sensory, but not motor, function is preserved below
the neurologic level and extends through sacral segments S4-S5.
C - Incomplete: Motor function is preserved below the neurologic
level, and most key muscles below the neurologic level have muscle
grade less than 3.
D - Incomplete: Motor function is preserved below the neurologic
level, and most key muscles below the neurologic level have muscle
grade greater than or equal to 3.
E - Normal: Sensory and motor functions are normal.




29
Spinal Cord Syndromes can be classified into
either complete or incomplete categories
 Complete – characterized as complete loss of
motor and sensory function below the level of
the traumatic lesion

Incomplete – characterized by variable
neurological findings with partial loss of sensory
and/or motor function below the lesion
30
Injuries by ASIA classification
 Incomplete
tetraplegia - 29.5%
 Complete paraplegia - 27.9%
 Incomplete paraplegia - 21.3%
 Complete tetraplegia - 18.5%
 The most common neurologic level of
injury is C5. In paraplegia, T12 is the most
common level.
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Functional outcome measures
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Several functional-outcome measures are reliable and valid for use
in SCI. A common scale for the measurement of functional ability is
the Functional Independence Measure (FIM), which uses a 7-point
scale to measure 18 items in the following 6 categories:
Mobility
Locomotion
Self-care
Continence of the bowel and/or bladder
Communication
Social cognition
On the FIM scale, a score of 1 indicates total dependence on a
caregiver, and a score of 7 indicates independence. Numbers
between 1 and 7 represent different levels of assistance required
from a caregiver or assistive device to perform a specific skill
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Clinical syndromes

Central cord syndrome often is associated with a cervical region injury
leading to greater weakness in the upper limbs than in the lower limbs
with sacral sensory sparing

Brown-Séquard syndrome often is associated with a hemisection
lesion of the cord, causing a relatively greater ipsilateral
proprioceptive and motor loss with contralateral loss of sensitivity to
pain and temperature

Anterior cord syndrome often is associated with a lesion causing
variable loss of motor function and sensitivity to pain and
temperature, while proprioception is preserved

Conus medullaris syndrome is associated with injury to the sacral
cord and lumbar nerve roots leading to areflexic bladder, bowel, and
lower limbs, while the sacral segments occasionally may show
preserved reflexes (eg, bulbocavernosus and micturition reflexes)

Cauda equina syndrome is due to injury to the lumbosacral nerve
roots in the spinal canal leading to areflexic bladder, bowel, and lower
limbs.
33
Central Cord Syndrome
 Usually
involves a cervical lesion
 May result from cervical hyperextension
causing ischemic injury to the central part
of the cord
 Motor weakness is more present in the
upper limbs then the lower limbs
 More commonly seen in older patients with
cervical arthritis or narrowing of the spinal
cord
34
Brown-Sequard Syndrome

Results from an injury to only half of
the spinal cord and is most noticed in
the cervical region

Motor loss is evident on the same
side as the injury to the spinal cord

Sensory loss is evident on the
opposite side of the injury location
(pain and temperature loss)

Bowel and bladder functions are
usually normal
35
Anterior Spinal Cord Syndrome
 Compression
of the artery that runs along
the front of the spinal cord
 Patients have a variable amount of
motor function below the level of injury
 Sensation to pain and temperature are
lost while sensitivity to vibration and
proprioception are preserved
36
Conus Medullaris vs. Cauda
Equina Lesion
Finding
Conus
CE
Motor
Sensory loss
Pain
Reflexes
Bowel/bladder
Symmetric
Saddle
Uncommon
Increased
Common
Asymmetric
Saddle
Common
Decreased
Uncommon
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Scale of Motor Strength in SCI








The American Spinal Injury Association:
0 - No contraction or movement
1 - Minimal movement
2 - Active movement, but not against gravity
3 - Active movement against gravity
4 - Active movement against resistance
5 - Active movement against full resistance
Assessment of sensory function helps to identify the
different pathways for light touch, proprioception,
vibration, and pain. Use a pinprick to evaluate pain
sensation.
38
39
40





Motor level - Determined by the most caudal key
muscles that have muscle strength of 3 or above
while the segment above is normal (= 5)
Motor index scoring - Using the 0-5 scoring of each
key muscle with total points being 25/extremity and a
total possible score of 100
Sensory level - Most caudal dermatome with a
normal score of 2/2 for both pinprick and light touch
Sensory index scoring - Total score from adding
each dermatomal score with possible total score (=
112 each for pinprick and light touch)
Neurologic level of injury - Most caudal level at
which both motor and sensory levels are intact, with
motor level as defined above and sensory level
defined by a sensory score of 2
41

Zone of partial preservation - This index is used only
when the injury is complete. All segments below the
neurologic level of injury with preservation of motor
or sensory findings
 Skeletal level of injury - Level of greatest vertebral
damage on radiograph
 Lower extremities motor score (LEMS) - Uses the
ASIA key muscles in both lower extremities with a
total possible score of 50 (ie, maximum score of 5 for
each key muscle L2, L3, L4, L5, and S1 per
extremity). A LEMS score of 20 or less indicates
patients are likely to be limited ambulators. A LEMS
of 30 or more suggests that patients are likely to be
community ambulators.
42
Spinal Cord Paralysis Levels
C1-C3
 All daily functions must be totally assisted
 Breathing is dependant on a ventilator
 Motorised wheelchair controlled by sip and puff or chin
movements is required
C4
 Same as C1-C3 except breathing can be done without a
ventilator
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C5
 Good head, neck, shoulder movements, as well as
elbow flexion
 Electric wheelchair, or manual for short distances
C6
 Wrist extension movements are good
 Assistance needed for dressing, and transitions from bed
to chair and car may also need assistance
C7-C8
 All hand movements
 Ability to dress, eat, drive, do transfers, and do upper
body washes
44
45
T1-T4 (paraplegia)
 Normal communication skills
 Help may only be needed for heavy household
work or loading wheelchair into car
T5-T9
 Manual wheelchair for everyday living
 Independent for personal care
T10-L1
 Partial paralysis of lower body
46
L2-S5
 Some knee, hip and foot movements with
possible slow difficult walking with
assistance or aids
 Only heavy home maintenance and hard
cleaning will need assistance
47
Complications after SCI
48
DVT
49
Orthostatic Hypotension
sustained decrease in blood pressure exceeding 20 mmHg
systolic or 10 mmHg diastolic occurring within 3 minutes of
upright tilt.
50
Patients that are most at risk for autonomic hypererflexia are those with
spinal cord injuries above T6. This tends to occur after the spinal shock phase.
Autonomic hyperreflexia occurs because nerve messages that were once able to
go up the spinal cord to the brain are blocked.
•
•
•
•
High blood pressure
Low heart rate
Anxiety
Severe pounding
headache
• Sweating above the
level of the injury
• Nasal stuffiness
•
51
52
Neurogenic bladder: inability to pass
urine without use of a catheter or other
method
53
Heterotopic ossification: Occurs when calcium lost from the bones
build up in muscles, tendons, or joints. This usually begins
between 2 weeks to 4 months after injury. The most common
places where this process may occur in the body are in the hips,
knees, shoulders, and elbows. It can lead to pain, spasms, and a
reduced ability to function.
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55
56
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Treatment





Fifty years ago, a spinal cord injury was usually fatal. At that time,
most injuries were severe, complete injuries and little treatment was
available.
Today, there's still no way to reverse damage to the spinal cord. But
modern injuries are usually less severe, partial spinal cord injuries.
And advances in recent years have improved the recovery of people
with a spinal cord injury and significantly reduced the amount of time
survivors must spend in the hospital.
Researchers are working on new treatments, including innovative
treatments, prostheses and medications that may promote nerve cell
regeneration or improve the function of the nerves that remain after a
spinal cord injury.
In the meantime, spinal cord injury treatment focuses on preventing
further injury and enabling people with a spinal cord injury to return to
an active and productive life within the limits of their disability. This
requires urgent emergency attention and ongoing care.
58
Emergency actions


Urgent medical attention is critical to minimizing the
long-term effects of any head or neck trauma. So
treatment for a spinal cord injury often begins at the
scene of the accident.
Attend to three immediate concerns:
 Maintaining
the ability to breathe
 Keeping the patient from going into
shock
 Immobilizing the neck to prevent
further spinal cord damage
59


Three procedures are crucial in treating spinal cord
injuries:
Treatment with the steroid medication
methylprednisolone to reduce swelling. Used within 8
hours after an injury, this medication may help prevent
nerve damage.

Relief of pressure on the spine using surgery or
traction (a mechanical system of weights).

Treatment to stabilize the spine using screws, metal
plates, and other devices. This is often done during an
operation. Sometimes, traction may be used instead.
60
Ongoing care
 Medications.
 To
control pain and muscle spasticity,
 İmprove bladder control, bowel control
and sexual functioning.
 Short-term medications from time to time,
such as antibiotics for urinary tract
infections.
61
SCI Rehabilitation:






Physiotherapy for patients with spinal cord
injuries can include;
exercises and stretches
joint care
pain control
breathing exercises and chest clearance
techniques
anticipating and minimising secondary
complications
62
Rehab







provision of equipment, orthoses, and
wheelchairs
advice on handling techniques
teaching how to use specialised exercise
equipment
teach transfers (getting in and out of a
wheelchair, bed, car, shower/bath and onto
and off a toilet).
teaching wheelchair skills
hydrotherapy treatment
referral to appropriate health professionals
63
The effects of physiotherapy can
be:
 increased
quality of life
 increased independence
 increased muscle strength
 increased energy levels
 reduced pain and muscle spasms
 reduced stiffness
 reduced risk of chest infections
64
Tumors
 Metastatic
or primary
 Extramedullary

Extradural - most common
• Bony - breast, prostate

Intradural - very rare
• Meninges - meningioma
• Nerve root - schwannoma

Intramedullary - very rare
• Metastatic
• Primary - astrocytoma or ependymoma
65
Transverse myelitis
 Inflammation



of the spinal cord
Post-infectious
Post-vaccinial
Multiple sclerosis
 Pain
at level of lesion may preceed
onset of weakness/sensory change /
b&b disturbance
66
B12 Deficiency
 Subacute
combined degeneration of the
cord
 B12 deficiency


malabsorption of B12 secondary to pernicious
anemia or surgery
insufficient dietary intake - vegan
 Posterior
columns and CST involvement
with a superimposed peripheral
neuropathy
67
Infections Involving the
Spinal Cord
 Polio

only the anterior horn cells are infected
 Tabes



dorsal root ganglia and dorsal columns are
involved
tertiary syphillis
sensory ataxia, “lightening pains”
 HIV

dorsalis
myelopathy
mimics B12 deficiency
 HTLV-1
myelopathy - tropical spastic
68
Multiple Sclerosis
 Demyelination
is the underlying
pathology
 Cord disease can be presenting feature
of MS or occur at any time during the
course of the disease
 Lesion can be at any level of the cord


Patchy
Transverse
 Devic’s

syndrome or myelitis optica
Transverse myelitis with optic neuritis
69
Vascular Diseases of the
Spinal Cord
 Infarcts
 Anterior
spinal artery infarct
70
Vascular Diseases of the
Spinal Cord

Arteriovenous malformation (AVM) and venous
angiomas
 Both occur in primarily the thoracic cord
 May present either acutely, subacutely or
chronically (act as a compressive lesion)
Can cause recurrent symptoms
 If they bleed
• Associated with pain and bloody CSF
 Notoriously difficult to diagnose
Hematoma - trauma, occasionally tumor


71
Other Disease of the Spinal
Cord

Hereditary spastic paraparesis
 Usually autosomal dominant
 Infectious process of the vertabrae
 TB, bacterial
 Herniated disc with cord compression
 Most herniated discs are lateral and only
compress a nerve root
 Degenerative disease of the vertabrae
 Cervical spondylosis with a myelopathy
 Spinal stenosis
72
Syringomyelia

Fluid filled cavitation in the center of the cord
 Cervical cord most common site
 Loss of pain and temperature related to the crossing
fibers occurs early
• cape like sensory loss
 Weakness of muscles in arms with atrophy and
hyporeflexia (AHC)
 Later - CST involvement with brisk reflexes in the legs,
spasticity, and weakness
 May occur as a late sequelae to trauma
 Can see in association with Arnold Chiari malformation
73
Syringomyelia
74
75
76