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12.4.09 Laudate Spinal Lesions
12.4.09 Laudate Spinal Lesions
Darrell Laudate
12/4/09 AM Report
Overview of Acute Myelopathy
Localization of the lesion depends upon the level of the spinal cord involved
and the extent of the involvement of the various long tracts. In some cases,
there is almost total paralysis and sensory loss below the level of the lesion,
others only partial loss
If cervical area is involved, all four limbs may be involved and there is risk
of respiratory paralysis (segments C3,4,5 to diaphragm)
Lhermitte's sign: an electric shock-like sensation down the neck,
back, or extremities that occurs with bending of the neck
Lesions of the lower cervical (C2-T1) region will cause a combination of
upper and lower motor neuron signs in the upper limbs, and exclusively
upper motor neuron signs in the lower limbs.
A lesion of the thoracic spinal cord (T1-12) will produce a spastic
paraplegia.
A lesion of the lower part of the spinal cord (L1-S5) often produces a
combination of upper and lower motor neuron signs in the lower limbs
Upper vs Lower Motor Neuron Lesions
Lower motor neuron lesion is a lesion which affects nerve fibers traveling from the
anterior horn of the spinal cord to the relevant muscle(s)
Associated with areflexia
leads to flaccid paralysis (paralysis accompanied by muscle loss)
Upper motor neuron lesion is a lesion of the neural pathway above the anterior horn
cell or motor nuclei of the cranial nerves and are marked by:
Spasticity, increase in tone in the extensor muscles (lower limbs) or flexor muscles
(upper limbs)
Clasp-knife response where initial resistance to movement is followed by relaxation
Weakness in the flexors (lower limbs) or extensors (upper limbs), but no muscle
wasting
Brisk tendon jerk reflexes
Babinski or Hoffman sign is present
increase deep tendon reflex
Pronator drift
(Spinal Shock - loss of sensation accompanied by motor paralysis with initial loss but
gradual recovery of reflexes
Occurs following a spinal cord injury, thus what may have looked like a lower motor
neuron lesion can later reveal itself to be an upper motor lesion)
Important Dermatomal Landmarks
Lumbar Puncture
Serologic Studies as clinically indicated
CT myelogram may be beneficial in
patients with suspected inflammatory
or demyelinative lesions of the spinal
cord
Noncompressive Myelopathies
Vascular
Arteriovenous malformation
Antiphospholipid syndrome and other hypercoagulable states
Inflammatory
Multiple sclerosis
Neuromyelitis optica (Devics Disease)
Transverse myelitis (idiopathic)
Sarcoidosis
Vasculitis
Infectious/Postinfectious
Viral: VZV, HSV-1 & -2, CMV, HIV, HTLV-I, enteroviruses,
flaivaviruses
Bacterial and mycobacterial: Borrelia, Listeria, syphilis, Mycoplasma
pneumoniae
Parasitic: schistosomiasis, toxoplasmosis
Metabolic
Vitamin B12 deficiency (subacute combined degeneration)
Copper deficiency
Compressive Myelopathies
Cervical spondylosis
Epidural, intradural, or intramedullary neoplasm
Epidural abscess
Epidural hemorrhage/hematoma
Herniated disc
Posttraumatic compression by fractured or displaced vertebra or
hemorrhage
These features help to distinguish this form of viral myelitis from Guillain-
Barr syndrome, which usually produces symmetric deficits, with no MRI
abnormalities, and is associated with elevated CSF protein levels without
pleocytosis.
Acute Viral Myelitis
CMV, VZV, HSV I &II, HCV, and EBV are associated with a second
form of viral myelitis has clinical and diagnostic test features that
are similar to transverse myelitis
Association between the myelitis and the virus is not always
clear, some may represent post-infectious transverse myelitis,
others, a positive polymerase chain reaction (PCR) test in the
CSF suggests that the myelitis is directly related to the viral
infection
Treated with Herpes zoster, HSV, and EBV myelitis are treated
with intravenous acyclovir (10 mg/kg q8h) or oral valacyclovir
(2 gm tid) for 1014 days; CMV with ganciclovir (5 mg/kg IV
bid) plus foscarnet (60 mg/kg IV tid), or cidofovir (5 mg/kg per
week for 2 weeks).2
Other Infectious Myelopathies
HIV
More of a chronic myelopathy, Often found mostly in late stages of AIDS and
associated with AIDS related dementia in half
slowly progressive spastic paraparesis is accompanied by loss of vibration and
position sense and urinary frequency, urgency, and incontinence
CSF may show nonspecific protein elevation
ART may reverse the symptoms3
Bacterial
Mycoplasma (acute and post infectious), Listeria monocytogenes
TB
via secondary cord compression from verterbral osteomyelitis, aka Potts disease
Also via compressive tuberculomas
Lyme disease
Cases have been described in which clinical and MRI features resembling
acute transverse myelitis have been attributed to Lyme disease.4
CSF in these cases typically demonstrates a lymphocytic pleocytosis and elevated
protein
Schistosomiasis (in endemic areas)
Tabes Dorsalis (Locomotor Ataxia)
Form of tertiary neurosyphilis in which the nerves of the dorsal (or posterior)
columns degenerate
Loss of sense of position (proprioception), vibration, and discriminative
touch
Latency period of 3-20 years
Cardinal signs of tabes are loss of reflexes in the legs; impaired position and
vibratory sense; Romberg's sign
also:
bilateral Argyll Robertson pupils
fleeting and repetitive lancinating pains, primarily in the legs
Paresthesias/ formincation
visceral crisis (Bladder disturbances, and acute abdominal pain with vomiting
personality changes, dementia, deafness, visual
skeletal musculature is hypotonic due to destruction of the sensory limb of the
spindle reflex
Ataxia of the legs and (tabetic) gait due to loss of position sense occurs in half
of patients
Tabes dorsalis (cont.)
Symptoms include
paresthesias in the hands and feet
loss of vibration and position sensation
progressive spastic and ataxic weakness
Loss of reflexes due to an associated peripheral neuropathy in a
patient who also has Babinski signs, is an important diagnostic
clue
Optic atrophy and irritability or other mental changes may be
prominent in advanced cases
Diagnosis usually confirmed with low levels of serum copper are found
and often there is also a low level of serum ceruloplasmin
Autoimmune, inflammatory disorder in which the optic nerves and spinal cord are
targeted but may also affect the brain,
Lesions are different from those observed in MS in that the attacks appear to be not
mediated by the immune system's T cells but rather by antibodies called NMO-IgG that
target aquaporin 4 of astrocytes.6
Acts as a channel for the transport of water across the cell membrane
Found in the processes of the astrocytes that surround the blood-brain barrier,
This blood-brain barrier is weakened in Devic's disease, but it is unclear how
NMO-IgG immune response leads to demyelination
Oncologic emergency
2) Hauser et al. "Chapter 372. Diseases of the Spinal Cord" (Chapter): Harrison's Principles of Internal Medicine, 17e:
http://www.accessmedicine.com/content.aspx?aID=2904373.
3) Meurs et al. Acute transverse myelitis as a main manifestation of early stage II neuroborreliosis in two patients. Eur Neurol 2004;
52:186.
4) Staudinger et al. Remission of HIV myelopathy after highly active antiretroviral therapy. Neurology 2000; 54:267.
5) Lennon et al. IgG marker of optic-spinal multiple sclerosis binds to the aquaporin-4 water channel. J. Exp. Med. 2005. 202 (4): 4737.
6) Transverse myelitis as the first manifestation of systemic lupus erythematosus or lupus-like disease: good functional outcome and
relevance of antiphospholipid antibodies. AU D'Cruz DP; Mellor-Pita S; Joven B; Sanna G; Allanson J; Taylor J; Khamashta MA;
Hughes GR SO J Rheumatol 2004 Feb;31(2):280-5.
7) Transverse myelopathy in systemic lupus erythematosus: an analysis of 14 cases and review of the literature. AU Kovacs B; Lafferty
TL; Brent LH; DeHoratius RJ SO Ann Rheum Dis 2000 Feb;59(2):120-4.
8) Acute transverse myelopathy in systemic lupus erythematosus: clinical presentation, treatment, and outcome. AU Mok CC; Lau CS;
Chan EY; Wong RW SO J Rheumatol 1998 Mar;25(3):467-73
9) Porter et al. Endocrine and reproductive manifestations of sarcoidosis. QJM 2003; 96:553.
10) McCormick et al. Cervical Spndylotic myelopathy: make the difficult diagnosis, then refer to surgery. Cleve Clin J Med. 2003;70:899-
904
11) Patchell et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a
randomised trial. Lancet. 2005;366:643.
12) Darouiche, RO. Spinal epidural abscess. N Engl J Med 2006; 355:2012.