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SPINAL CORD DISEASES

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Spinal cord anatomy
• A thin tubular extension of CNS within the bony spinal
canal.
• from the level of cranial border of Atlas (continuous
with medulla) lower border of the L1 vertebrae
• Average length-45cm.
• 31 pairs of nerves originate from it (8 cervical, 12
thoracic, 5 lumbar, 5 sacral, 1coccygeal)

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Relationship of spinal cord to vertebral
level

• Growth rate of the spinal cord lags behind that of the


vertebral column
• The lower spinal nerves take a longer downward course
to exit via the respective interverte. Foramina.

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Vertebrae Spinal cord segments
Upper Cervical Corresponds
vertebrae
Lower Cervical Add 1
vertebrae
Thoracic vertebrae 1 – Add 2
6
Thoracic vertebrae 7 – Add 3
10
Thoracic vertebrae 11 Overlies L3
Thoracic vertebrae 12 Overlies S1
1st lumbar arch Overlies sacral &
coccygeal segments
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Cross-sectional Anatomy of the spinal cord

(1) Pia Mater


(2) Arachnoid
(3) Dura Mater
(4) Subarachnoid Space Containing CSF
(5) Subdural Space
(6) Epidural Space (Contains Adipose Tissue)

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Lateral spinothalamic tract:

 Pain & temperature


 cross midline at a few segments higher

Anterior spinothalamic tract


 Pressure & crude touch

Dorsal column system


 Proprioception, light touch & vibratory senses

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..
.

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Descending Tracts
• 5 descending systems:
1 Corticospinal tract (Pyramidal tract).
2. Medial reticulospinal tract
3 Vestibulospinal tract
4. Corticorubrospinal tract
5. Lateral reticulospinal tracts

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Corticospinal Tract
 Distal limb movements

Primary motor cortex, lateral premotor cortex



Corona radiata

Posterior limb of internal capsule

Ventral portion of midbrain & pons

Ventral portion of medulla

At caudal portion of medulla

90%
10%
Decussate
Not
decussate
Lateral corticospinal tract

Anterior (Ventral)
corticospinal tract
Decussate & terminate in lamina VIII in
cervical & upper thoracic region
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Spinal cord
Spinal Cord – Functional Anatomy
Out of 10 or more Long Fibre Spinal Tracts coursing longitudinally in the
spinal cord, only 3 (shown below in Red, Blue and Green) are of prime
importance in clinical neurology practice:

Courtesy of Medical College, University of Florida.

1. Spinothalamic Tracts (Red) = Pain, Temperature, Crude Touch. 2.


Posterior Column Tracts (Green) = Position, Vibration, Discriminative
Touch. 3. Corticospinal Tracts (Blue) = Motor efferent (Descending) Fibres.
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Spinal Cord – Vital Functions
• Respiration (mainly C4).
• Autonomic functions (Blood Pressure
and Heart rate).
• Brachial plexus = Upper limbs.
• Thoracic segments = Inter-costal nerves.
• Lumbosacral plexus = Lower limbs.
• Segmental sensations.
• Segmental autonomic nervous supply
(e.g. Sweating).
• Reflex control (e.g. withdrawal).
• Gait control (Walking).
• Bowel (regulation).
• Bladder (control).
• Sexual functions (Sympathetic and
Parasympathetic neurovascular inputs). Courtesy of MD Images.

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Spinal Cord – Autonomic Nervous System

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Courtesy of MD Images.
Spinal Cord – Key Symptoms
• Paralysis:
- Onset = Acute, Sub-Acute, Gradual, Chronic,
.
- Progress = Rapid, Slow, None, Improvement, Recovery,
- Proximal (Myelopathy), Distal, Global weakness,
- Fluctuation = Syringomyelia, Lipoma, Disc disease,
- Unilateral (Brown-Sequard) or Bilateral.

• Increased Tone & Reflexes (signs of UMN lesion) versus diminished


or absent reflexes, normal or decreased tone and presence of
Fasiculations (signs of LMN lesions).

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• Pattern of Sensory Loss:
– Descending or Ascending
– Sensory level (localising value). Spinothalamic, Dorsal
Column, Dissociated or Segmental
– Brown-Sequard syndrome.
• Sphincter Involvement:
– Early incontinence occurring with relatively late
corticospinal weakness (Intramedullary lesion).
• Fluctuation of (motor & sensory) symptoms suggest:
1. Syringomyelia
2. Foramen Magnum pathology
3. Spinal Cord Lipoma (commonly Lumbo-Sacral in location).

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Spinal Cord – Patterns of LMN Diseases

http://www.neuroanatomy.wisc.edu.
Four anatomic stations underlying lower motor neuron (LMN) weakness:

1. Anterior (ventral) Horn Cell,

2. Peripheral Nerve (Ventral & Dorsal Roots = Radiculopathy or Nerve = Neuropathy),

3. Neuromuscular Junction,

4. Muscle (Myopathy), drdanielgk@gmail.com * LMN = Lower Motor Neruon.


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Arterial supply
• Anterior spinal artery
supply ant 2/3 the spinal cord &ventral
surface of medulla
• Two posterior spinal arteries
supply the posterior one-third of the
spinal cord.
• Radiculomedullary arteries
6 to 10 join the ASA
10 to 20 join the PSA
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Arterial supply to the spinal cord

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Spinal Cord – Disease Classification
• Vascular – Infarction, AV Malformations, Haemorrhage, Fibro-
cartilaginous embolism..

• Infectious (Abscess) – Viral, Bacterial, Fungal, TB, Brucella,


Parasitic..

• Immune-Mediated – Mixed Connective Tissue Disease, Anti-


Phospholipid & Anti-Ro (SSA) causing Recurrent Transverse
Myelitis, as well as SLE & Rheumatoid Arthritis..

• Demyelinating – Primary (Multiple Sclerosis, Devic’s Disease),


Secondary (ADEM)..

• Granulomatous – Sarcoidosis

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• Neoplastic (Tumours) – Primary or Metastatic – Extradural, Extra or
Intra-medullary..
• Genetic – Hereditary & Familial Spastic Paraplegias, Friedreich
Ataxia
• Developmental – Meningomyelocele, Tethered Cord, Lumbosacral
Lipomas..
• Metabolic – Deficiency (B12) and Toxic (Cassava)..
• Traumatic (Injury) – e.g. Fracture dislocation: RTA, Sports, Domestic
falls, Violence..
• Degenerative – Prolapsed inter-vertebral Disc, Osteophyte
formation..
• Miscellaneous – Iatrogenic, Paraneoplastic,

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Lesions of .
the spinal cord

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Complete SC transection (transverse myelopathy)

• All ascending & descending tracts are interrupted


• Sensory
– loss of all sensation below the level of lesion
Localization
– sensory level
– radicular pain
– vertebral tenderness

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Complete SC transection (transverse myelopathy)

• Motor
– weakness below the lesion
– LMN at the level
– UMN below the level
• In spinal shock LMN weakness is seen
• Autonomic
– Bladder, bowel and sexual dysfunction
– Anhidrosis, trophic skin, impaired T0 control

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Hemisection of the Spinal Cord /Unilateral Lesions/
(Brown- sequard syndrome)

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Brown- sequard syndrome
• Ipsilateral spastic weakness(corticosp.tr.
Damage)
• Segmental LMNS and sensory signs.(ant.horn
cell damage)
• Loss of pain and temp. Sensation contra lateral
to hemi section
• Ipsilateral propioceptive fn loss
• Eg. Extramedullary lesions

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CENTERAL CORD SYNDROME
common causes are syringomyelia, intramedullary cord
tumors
• damage starts centrally and extend centrifugally
• Initially
• decussating spinothalamic tract
– touch, position and vibration intact
– dissociation of sensory loss.
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• Forward extension -anterior horn cell with segmental sign .
• Lateral extension:
– ipsilateral Horner syndrome
– spastic paralysis below the level of the lesion.
• Dorsal extension
– position and vibration loss
• With extreme ventrolateral extension
– pain and temperature loss below the level of the lesion
with sacral sparing

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Posterolateral Column Syndrome

causes of posterolateral column damage:


• SCDS(Vit B12 Def.)
• Vacuolar myelopathy associated with AIDS
• Tropical spastic paraparesis
• Extrinsic cord compression e.g. cervical spondylosis
 Dorsal column dysfn,sensory ataxia with positive Romberg sign&spasticity
 Pain &temperature remain intact

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Posterior Cord Lesions /syndrome

• The posterior columns are selectively damaged by tabes dorsalis


(tabetic neurosyphilis).
• impaired vibration and position sense and decreased tactile
localization below that level
• disturbances in the knowledge of extremity movement and
position (temporal and spatial disturbances)

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Posterior Cord Lesions /syndrome
• sensory ataxia, noted first at night or in the dark, and a
positive Romberg sign.
• The gait is ataxic – it is more pronounced in darkness or
with eye closure
• Often pt fall forward immediately following eye closure
(+ve Sink sign)
• Affected limb is hypotonic but not weak.
• Absent ankle & patellar reflexes
• In cervical region  neck flexion may elicit a sudden
“electriclike” sensation down the back or into the arms
(Lherrmitie’s sign or “barber’s chair” syndrome).
• Other Causes , compressive cervical ds, MS

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Anterior Horn cell syndrome

• Diffuse anterior horn cell damage  diffuse muscle


weakness, atrophy, and fasciculations –in muscles of the
trunk & extremities
• Muscle tone usually reduced & DTR may be depressed or
absent
• Sensory changes are absent b/se the sensory tracts remain
unaffected

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Anterior Horn cell syndrome

•E.g. of spinal muscle atrophies


- infantile progressive spinal muscular atrophy of
Werdnig-Hoffman
- intermediate spinal muscular atrophy or type II
spinal muscular atrophy
- juvenile progressive spinal muscular atrophy or
Kugelberg-Welander disease
- progressive spinal muscular atrophy in motor
neuron disease

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Combined ant. Horn cell &pyramidal tract disease

• ALS
• Diffuse LMN signs superimposed on UMN
signs
• Sensory changes are absent
• Bulbar and pseudo bulbar impairment
• Urinary and rectal sphincters unaffected
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Vascular syndrome of the spinal cord

• Spinal cord infarction very rare compared to


cerebral infarction
• Most spinal cord infarction –from inv’t of the
territory of ASA

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Anterior spinal artery syndrome:

• Abrupt onset & often associated with radicular or


“girdle” pain
• Deficit in pin prick, light touch, temperature sensations
–starting one or 2 segments below the level of the
lesion  lateral spinothalamic tracts bilaterally
• Deficit in light touch below the level of the lesion 
ventral spinothalamic tracts bilaterally
• Loss of motor function (flaccid tetraplegia or
paraplegia) –within minutes to hrs below the lesion 
bilateral corticospinal tract
• Impaired bladder & bowel control
 T1 to T4 segments & The L1 segment; common sites

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Extamedullary vs. intramedullary

Symptoms & signs Intramedullary Extramedullary


Radicular pain Unusual Common, early
Vertebral pain Unusual Common
Funicular (central) pain Common Less Common

UMN signs late Yes, early


LMN signs e.g. anterior horn Prominent & diffuse Unusual, if present
cells segmental
Parasthesias progression Descending progression Ascending progression
Sphincter abnormalities e.g. Early with caudal Late
bladder inv’t lesions (conus –cauda
equina)

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II/ Localization SC lesions at
different levels
A) Foramen magnum syndrome
– tumors, syringobulbia, joint subluxation
– Hemiplegia cruciata
– Sub occipital pain , neck stiffness

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B) Cervical cord
C1- C4:
– may also involve CN XI
– weakness of sternocleidomastoid and trapezium
– Spastic quadriparesis with diaphragmatic
paralysis.
C5-C6:
– LMN at segmental level and UMN below the lesion
– LMN sign at deltoid, biceps, brachioradialis
– spastic paraparesis of the lower extremity
– Biceps and brachioradialis reflex absent or
diminished
– triceps and finger flexors reflex exaggerated

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C7:
– paresis involve flexors and extensors of the wrists and fingers
– Biceps and brachioradialis reflex preserved (C5- C6)
– Finger flexor reflex (C8- T1) - exaggerated.
C8 and T1:
– weakness of the small hand muscles
– spastic Paraparesis
– C8 lesion -triceps and fingers flexor reflex decreased
– T1 lesion -triceps reflex preserved
– Horner syndrome

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C) Thoracic cord
 Root pain and paraesthesia
 Paraplegia
 sensory loss below a thoracic level
 segmental LMN sign is difficult to detect clinically.
D) Lumbar cord
L2- L4:
 paralyze flexion and adduction of the thigh &
extension of the knee
 absent knee reflex
 exaggerated ankle jerk.
L5-S1:
 paralyze movement of foot and ankle, flexion at the knee ,
and extension of the thigh
 Absent ankle jerk (S1).
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E) Sacral cord/conus medullaris
– Bilateral saddle anesthesia (S3- S5)
– Prominent bladder and bowel dysfunction
– Impotence
– Bulbocavernosus(S2 – S4) and anal ( S4- S5)
reflexes are absent
– Muscle strength largely preserved
F) Caudal equina syndrome
– Early radicular pain
– Asymmetric flaccid paralysis and sensory finding
– Ankle reflex absent
– Sphincter abnormality late
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THANK YOU

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