Cervical medular compression

case presentation
MD. Phd. Amalia Cornea
University of Medicine and Pharmacy ”V. Babes”
Clinica Neurologie II – Clinical Emergency Hospital “Pius Brinzeu”
Timisoara
Admission:
• CC, 41 years
• quadriparesis
Onset of symptoms:
• 2 weeks ago ER presentation with R hemiparesis (A>L)
• Over a month ago paresthesia R hand and arm > R leg , shortly followed
by motor deficit in the same territory
• A couple of days ago – motor deficit in L leg > Larm

Admission date :06 Apr 2020

Past medical history
• Lumbar disc hernia

Life conditions
• Anteriorly fully ambulatory and independent (before the onset of the
symptoms)

Anterior treatment
• No chronic medication
Admission Neurologic examination I

Physical examination: Overweight, otherwise normal

Neurologic examination
• Romberg and Gait – sitting possible
• Coordination
• L MS dysmetria; R MS not possible
• Muscle force
• R MS 1/5 - R MI 2/5
• L MS 4/5 – L MI 3/5
Admission Neurologic examination II
• Sensation
• R hemi body hypoesthesia but…
• T8/T10
• Paraesthesia arms and legs R>L
• ROT normal
• PCR: bilateral extension
• Negative Hoffman - bilateral
Admission Neurologic examination III (continuation)
Cranial nerves
• CN II: normal visual field, normal photo motor response
• CN III, CN IV, CN IV normal
• CN V normal
• CNVII facial symmetry, normal face grimaces
• CN VIII: normal
• CN IX, X: normal
• CN XI (trapezius and SCM), XII (tongue): Normal
• Oriented to himself, place and time
Clinical Syndrome?
• Onset - subacute/chronic – weeks, steady progressing

• MAIN “complaint” – at the moment of evaluation

• Tetra paresis
• Level of sensory impairment

• Level of the lesion?

• UMN/LMN?
• Please identify the anatomical structures involved and mark them on a MRI
spinal chord image-sagittal view

https://pubs.rsna.org/doi/full/10.1148/rg.2018170178
Nerve roots and peripheral nerves
corresponding to the principal movements of
the upper extremity
Location of lesion in dorsal cord syndrome

Location of lesion in central

cord syndrome

Location of
lesion in
Brown-Sequard
syndrome

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Typical Atypical

• Large or disproportionate amount of associated

• Smooth contour
edema Intratumoral cystic change
• Homogeneous
• Extensive bone involvement
enhancement
• Brain or leptomeningeal invasion
• Dural tail
• Low apparent diffusion coefficient
• Calcification
• Elevated cerebral blood volume
 Presentation and course
• a chronic compression syndrome
• displacement of the spinal cord
• back pain
• Meningiomas at a high cervical level or the foramen magnum
• quadriparesis
• lower cranial nerve involvement
• dysphagia
• respiratory disturbances
• Horner syndrome
• facial hypo/paresthesis - compression of the descending sensory root of
the trigeminal nerve.
Treatment
Etiologic treatment:
Neurosurgery

Anatomopathologic result:

• Meningioma grade I
Location of Meningioma and Site-Specific Symptoms

Tumor location Site-specific symptoms

Convexity Headaches, seizures, motor and sensory deficits
Parasagittal Anterior: chronic headaches, memory and behavior changes
Middle: motor and sensory deficits
Posterior: homonymous hemianopsia
All: venous occlusion
Sphenoid ridge Medial: visual loss, cranial nerve III, IV, V1, VI palsies
Lateral: headaches, seizures, motor and sensory deficits
Lateral ventricle Headaches, seizures, hydrocephalus
Location of Meningioma and Site-Specific Symptoms

Tentorium Ataxia, headaches, visual loss, diplopia

Cerebellar convexity Headaches, ataxia, dizziness, facial pain, dysarthria
Tuberculum-sellae Visual loss, headaches, optic atrophy, noncongruent
homonymous hemianopsia
Optic nerve sheath Visual loss
Cerebello-pontine angle Hearing loss, headaches, ataxia, dizziness, tinnitus, facial
palsy
Olfactory groove Anosmia, Foster Kennedy syndrome, headaches
Foramen magnum Nuchal and occipital pain, emesis, ataxia, dysphagia, motor
and sensory deficits
Clivus Headaches, emesis, ataxia, motor and sensory deficits
Other —————
This posterolateral approach shows the deviation of the
spinal cord by the tumor. (Contributed by Dr. Sherman
Stein.)

Contrast enhanced, T1-weighted, sagittal image, showing

an enhancing, discrete, intradural tumor lateral to the
deviated spinal cord. (Contributed by Dr. Sherman Stein.)
 INTRAMEDULLARY TUMORS Pilocytic astrocytoma
Ependymomas Cervical spine MRI postenhancement in a 20-year-
old male.
(A) The sagittal image demonstrates a contrast-
enhancing, circumscribed lesion at the C6-7 level
(arrow).

Sagittal and axial C+ a small, cauda equine

lesion (arrow) found in a 49-year-old
woman with left buttock and leg pain.
diagnosis of myxopapillary ependymoma
was confirmed.

(B) Axial images

INTRADURAL EXTRAMEDULLARY TUMORS

A 70-year-old woman presented with a several-

week history of confusion. Panels (A, B): Non-
contrast and contrast-enhanced head CT shows a
large bifrontal lesion with calcifications and
surrounding edema. Panels (C, D): Non-contrast
and contrast-enhanced T1-weighted axial MR
images of the head also demonstrate large flow
voids representing blood vessels in the center of
the tumor. Panel (E): Non-contrast T1- weighted
sagittal MR image. Panel (F): Contrast-enhanced
T1-weighted coronal MR image.
 Neurofibromas
NF1
INTRADURAL EXTRAMEDULLARY TUMORS
NF2
Schwanommas

Malignant nerve sheath tumors – sarcomas

neurofibromatosis type 1 (NF1), peripheral N

33-year-old presented with a three-

month history of biologic pain and
progressive perineal numbness. MRI T1-
weighted contrast image revealed a
heterogeneously enhancing lesion at L2-
3; Sagittal (a) and Axial (b) images show
the lesion filling the thecal sac. The
tumor was approached via an L2-3
laminectomy with intradural exploration.
The tumor was debulked followed by
sacrifice of the sensory roots from which
it arose. Patient had increased perineal
numbness postoperatively which
completely resolved at one month.
 EXTRADURAL PRIMARY TUMORS Thoracic spine osteoblastoma on MRI
Chondrosarcoma

Bone window of a coronal CT scan

shows a chondrosarcoma of the right
clivus.

A 15-year-old male who presented with back pain and was found to have an osteoblastoma of the
thoracic spine. Image A is an axial MRI T2-weighted image of the thoracic spine (arrow).