Spinal
Cord Disease
Causes of myelopathy
Most common
·
Cervical spondylotic myelopathy (24%)
·
Tumour (16%)
·
MS (18%)
·
Motor neurone disease (4%)
Acute/subacute
·
Compressive
o
Disc prolapse
o
Tumour
o
Epidural abscess
o
Spinal haematoma
o
Spinal cord haemorrhage (Haematomyelia)
·
Non-compressive
o
Spinal cord infarction
o
Inflammatory and immune (Myelitis)
Chronic
·
Spondylitic
·
AVMs of the cord
·
Syringomyelia
·
Chronic MS
·
Subacute combined degeneration of the cord
·
Radiation myelopathy
·
Decompression sickness
·
Tabes dorsalis
·
Other
o
Hypocuric
o
Familial spastic paraplegia
o
Adrenomyeloneuropathy
o
Primary lateral sclerosis
Spinal cord syndromes
Segmental syndrome
·
Lesion affecting whole cord at a certain level
·
Gives the classical – spinal level
Dorsal cord syndrome
·
Affects
o
Dorsal columns
o
+/- Lateral corticospinal tracts
·
Clinical
o
Gait ataxia (sensory) and paresthesias
o
Muscle weakness – UMN
o
Spastic and ataxic gait
o
Plantars up
o
Urinary incontinence may occur
·
Causes
o
Sub-acute combined degeneration (B12)
o
Friedreich ataxia
o
MS
o
Tabes dorsalis
o
Mechanical (posterior)
1.
AVM
2.
Tumours
3.
Cervical spondylosis,
4.
Antlantoaxial subluxation
o
Large fibre sensory neuroapthies may give similar
signs – esp. DM and hypothyroidism.
Ventral cord syndrome
·
Affects
o
Usually affects anterior 2/3 of cord
o
Spinothalamics
o
Both corticospinal tracts
·
Clinical
o
Weakness and reflex changes
o
Loss of pain and temperature
o
Normal touch, vibration, position sense
o
Often incontinence
·
Causes
o
Spinal cord infarction
o
Disc herniation
o
Radiation myelopathy
Brown-Sequard syndrome
·
Hemisection of the cord
·
Affects
o
All tracts unilaterally
·
Clinical
o
Ipsilateral – weakness, loss of vibration and
proprioception
o
Contralateral – loss of pain and temperature
o
No bladder symptoms
·
Causes
o
Trauma most common cause
o
Infection, infarction tumour etc. can also cause.
Central cord syndromes
·
Affects
o
Crossing of spinothalamic pathways in ventral
commissure
o
Larger lesions may affect ascending spinothalamic
tracts
1.
Distal regions affected last due to more peripheral
representation
o
May later encroach on other tracts if enlarges
·
Clinical
o
‘suspended’ sensory level due to blocking of
crossing spinothalamic fibres
o
Dorsal columns spared
o
Usually no bladder symptoms
·
Cause
o
Syringomyelia
o
IM tumour
o
Hyperextension injury in patients with cervical
spondylosis
Conus medullaris syndrome
·
Affects
o
Sacral nerve roots
·
Clinical
o
Sphincter dysfunction and saddle anaesthesia
·
Causes
o
Lesions at vertebral level L2
Cauda equine Syndrome
·
Affects
o
Lumbosacral nerve roots
·
Clinical
o
LBP radiating into legs
o
Lower limb weakness (variable depending on level)
o
Bladder and rectal sphincter paralysis common
o
Sensory loss
·
Causes (many)
o
Disc herniation
o
Tumour
o
Infections
o
Inflammatory conditions
o
Sarcoidosis
Imaging
Radiopaedia 2022
Neoplastic
·
Majority of lesions are epidural
Epidural
·
Most common epidural cancers
o
Breast, lung, kidney, prostate, lymphoma, melanoma,
myeloma
·
Thoracic most common (except ovarian and prostate
which go to lumbo-sacral)
·
Pain often the initial symptom
·
Do not cross disc spaces (unlike infections)
·
Many patients with an epidural lesion have other
lesions so imaging of the whole spine may be warranted.
·
Treatment
o
Dexamethasone
o
Radiation therapy or Surgery
1.
Surgery (anterior decompression NOT laminectomy)
prior to radiation has been shown to improve outcomes (% ambulating) as the
expense of higher immediate complication rate.
2.
Surgery should be considered first line unless –
very poor prognosis of less than a few months OR neurological deficits which
are long standing and likely to be permanent.
Intradural cancers
o
Usually slow growing and benign
o
Meningioma, neurofibromas
Intramedullary
o
Ependymoma
o
Haemangioblastoma, astrocytoma
o
Metastases (rare) – 50% lung cancer
o
Present with hemicord or central cord syndrome
Epidural
abscess
· Present with pain, fever and progressive limb weakness
· 2/3 from haematogenous spread
· 1/3 from local extension
o Vertebral osteomyelitis, surgery, LP, overlying ulcers
· Organisms
o Staph aureus
o Gram-negative bacilli
o Streptococcus
o TB
Myelitis
Systemic inflammatory conditions
· SLE (usually associated with anti-phospholipid syndrome)
· Sjogren’s
· MCTD
· Behcet’s
· Sarcoidosis
Demyelinating
· MS
o Often causes a partial syndrome in Caucasians
o Bilateral involvement is rare (more common in non-caucasians)
Post-infectious
· Implicated organisms
o EBV, CMV, mycoplasma, measles, varicella, mumps
· Onset as infection is clearing
· Glucocorticoids and plasma exchange often tried.
Acute Infectious Myelitis
· Implicated organisms
o HSV-2 (can cause a distinctive recurrent myelitis)
o EBV, CMV
o Rabies
o Poleimyelitis (gray matter only)
o ?Mycoplasma
o Schistosomiasis
o HIV
Vascular
- Spinal cord infarction
- Anterior artery disease most common
- Usually lumbar
- May start with band of pain and paraesthesia followed by development of weakness over minutes/hours
- Pain and temperature are affected but not dorsal columns
- Can affect whole body below lesion or just the level
- Dysfunction of sphincters is common
- Posterior and central cord infarction can occur but are rare.
- Venous infarction
- AV malformations
Anatomy
· Single anterior and paired posterior spinal arteries
· Supplied by vertebral artery and radicular arteries
· Radicular arteries feed in at C4, and a second artery (artery of adamkiewicz) usu between T11-L2.
·
Inherited
- Spinocerebellar ataxia
Metabolic
- Subacute combined
Degeneration of the Cord – Vitamin B12 def
- Proprioceptive
loss first (dorsal columns)
- Followed by
loss of vibration and touch
- Weakness may
also occur
- Reflexes
often diminished
Syringomyelia
- Tubular, slit
like, intraparenchymal cavity in the spinal cord
- Syringobulbia
– same thing in medulla
- Sometimes
communicate with central cannal, but often separate.
Clinical
- Pain – neck ,
headache, back pain, radicular pain.
- Destruction
of anterior horn cells at level of syrinx – LMN signs
- Muscular
atrophy and weakness, sometimes with fasciculations
- Destruction
of decussating spinothalamics
- Segmental
dissociated sensory deficit
- Variable
compression of ascending and descending long tracts
- Sensory disturbance
below lesion, spinothalamic first, cape distribution due to sacral area’s
being more peripheral in tract
- Dorsal
columns often preserved
- Spastic
paraparesis
- Occasionally
all sensory modalities are affected at a particular level
- Autonomic
dysfunction can also occur
- Neuropathic
arthropathies are common
- “Charcot’s’
joint of shoulder or elbow.
Other
- Radiation
myelopathy
- Decompression
illness
