Diseases of the spine and spinal

cord
 outline
• Anatomy of the spinal cord: longitudinal
organization of the vertebra and spinal nerves,
blood supply of the spinal cord, white matter tracts
• Localizing disorders of the spinal cord i.e Spinal
cord syndromes
• Spinal cord compression
• Intrinsic medical disorders of the spinal cord
• Laboratory and imaging evaluation of a patient
presenting with symptoms of a spinal cord lesion
 Anatomy of the spinal cord
• There are 29 vertebral bodies, the spinal cord is found in the
spinal canal
• There are 31 spinal cord segments, each with a pair consisting
the ventral (anterior) and dorsal (posterior) spinal nerve roots
• Anterior spinal nerve roots mediate sensory function
• The posterior spinal nerve roots mediate motor function
• The ventral and dorsal nerve roots combine on each side to
form the spinal nerves and exit from the vertebral column
through the neuroforamina
• 31 spinal nerves: cervical(8), thoracic(12), lumbar(5), and
sacral cord(5), Coccygeal nerve(1)
Spinal nerve roots
 Anatomy of the S/c
Longitudinal organization 
- The spinal cord is divided longitudinally into four regions:
cervical, thoracic, lumbar, and sacral cord
- The spinal cord extends from the base of the skull and
terminates near the lower margin of the first lumbar
vertebral body (L1)
- At this level, the filum terminale descends and anchors the
cord to the bodies of L3, L 4,L5 and the coccygeal bone
- Below L1, the spinal canal contains the lumbar, sacral, and
coccygeal spinal nerve roots that comprise the cauda equina
 SC: Longitudinal organization
• Because the spinal cord is shorter than the vertebral
column, vertebral and spinal cord segmental levels are
not necessarily the same ( embryonic development)
• The vertebral level is higher than the spinal segment
- Pathology at the T12 and L1 vertebral level affects the
lumbar cord
- Injuries to L2 frequently damage the conus medullaris
- Injuries below L2 usually involve the cauda equina and
represent injuries to spinal roots rather than to the
spinal cord)
 S.C: longitudinal organization
Spinal Cord Level (spinal nerve) Corresponding Vertebral Body
Upper cervical Same as cord level
Lower cervical 1 level higher
Upper thoracic 2 levels higher
Lower thoracic 2 to 3 levels higher
Lumbar T12-L1

Conus medularis L2
Cauda equina below L2
 White matter Tracts
1. The tracts
2. Location in the spinal cord (anterior,
posterior etc)
3. Ascending, descending
4. Motor, sensory
5. What point do they cross(decussate)?: at
spinal cord, higher than spinal cord?
Anatomy: white matter tracts
 White matter tracts
 Dorsal or posterior columns : contain sensory information regarding joint
position (proprioception) and vibration.
These pathways will cross in the medulla; hence, in the spinal cord, these tracts
contain ipsilateral sensory representation.
 The corticospinal tracts contain the upper motor neurons that originate in M1
of the primary motor cortex
The lateral corticospinal tract contains the majority (80 to 85 percent) of these
fibers,
which have previously decussated (crossed) at the cervicomedullary junction
and therefore provide input to the ipsilateral musculature
 The anterior and lateral spinothalamic tracts contain sensory information
regarding pain, temperature, and touch
These axons have crossed in the ventral commissure in the gray matter in the
spinal cord and therefore contain contralateral sensory representation
 Anatomy: blood supply
• The anterior spinal artery supplies the anterior
two-thirds of the cord
• The posterior spinal arteries primarily supply
the dorsal columns.
Blood supply
 Localizing a spinal cord lesion

- Spinal cord syndromes: Tracts affected , tract

spared
- Clinical features
- likely etiologies
 Spinal cord syndromes
1. Segmental (transection) syndrome
Clinical features: Loss of all sensory modalities,
weakness below affected level and bladder
dysfunction

Common Causes: Transverse myelitis, Trauma,

hemorrhage, epidural abscess, epidural
metastasis
 Spinal cord syndromes
2. Dorsal cord syndrome results from the bilateral involvement of the
dorsal columns and the corticospinal tracts, autonomic fibers (sphincter
involvement)
- Dorsal column symptoms: include gait ataxia and paresthesias
-Corticospinal tract dysfunction produces motor weakness: acutely
LMN(flaccidity), later UMN (spastic)
- Bladder dysfucntion
Pain, temperature modalities are spared
Common Causes:
Specifically affects dorsal collums: Tabes dorsalis(syphilis), subacute
combined degeneration(B12), AIDS myelopathy
Others: Epidural metastases, cervical spondylotic myelopathy, multiple
sclerosis , Friedreich ataxia
Dorsal/posterior cord syndromes
 Spinal cord syndromes
3. Ventral cord or anterior syndrome usually includes tracts in the
anterior two-thirds of the spinal cord, which include the
corticospinal tracts, the spinothalamic tracts
- Corticospinal tract involvements produce weakness and reflex
changes
- A spinothalamic tract deficit produces the bilateral loss of pain and
temperature sensation
- Bladder dysfunction
position, and vibratory sensation are normal.
Causes:
Anterior spinal artery ds: Spinal cord infarction/ischemia,
disc herniation
Anterior cord syndrome
 Spinal cord syndromes
4. Brown-Sequard (hemi-cord) syndrome 
- A lateral hemi-section syndrome, involves the dorsal
column, corticospinal tract, and spinothalamic tract
unilaterally
- This produces weakness, loss of vibration, and
proprioception ipsilateral to the lesion
loss of pain and temperature on the opposite side
(contralateral to the lesion).
Common causes: knife or bullet injuries, spinal cord tumors,
disc herniation, infarction, MS lesions, tuberculoma etc
Brown sequard ( lateral hemisection)
 Spinal cord syndromes
Conus medullaris syndrome — Lesions at vertebral
level L2 often affect the conus medullaris
- There is early and prominent sphincter dysfunction
with flaccid paralysis of the bladder and rectum,
impotence, and saddle (S3-S5) anesthesia
- Causes include disc herniation, spinal fracture, and
tumors
Cauda equina syndrome : NB=Bundle of nerves:
Radiculopathies, LMN, sphincter dysfucntion
 Investigations
Investigation of acute spinal cord syndrome
• Plain X-rays of spine,
• Chest X-rays
• Ct scan of he spine
• MRI of spine
• CSF
• Serum Biochemstry, CBC, Serum B12 level
 Disorders of the spinal cord
1. Spinal cord compression
2. Intrinsic diseases of the spinal cord
 Spinal cord compression: Causes
Extra dural : Vertebra, intervertebral disc: 80%
Trauma , fractures vertebra  
 Intervertebral disc prolapse    
Metastatic carcinoma (e.g. breast, prostate, bronchus)    
Myeloma    
Tuberculosis
Intradural, extramedullary: Meninges : 15%
Tumours (e.g. meningioma, neurofibroma, ependymoma, metastasis,
lymphoma, leukaemia)  
  Epidural abscess
Intradural, intramedullary : Spinal cord 5%
Tumours (e.g. glioma, ependymoma, metastasis)
 S.C Compression: clinical
Sensory : Paraesthesia, numbness or cold
sensations, especially in the lower limbs,
which spread proximally, often to a level on
the trunk
Motor : Weakness, heaviness or stiffness of the
limbs, most commonly the legs
Sphincters: Urgency or hesitancy of micturition,
leading eventually to urinary retention )
 SC compression: clinical
Cervical, Below C5
Upper motor neuron signs and sensory loss in
all four limbs
Diaphragm weakness (phrenic nerve)
Thoracic cord : Spastic paraplegia with a sensory
level on the trunk )
 SC compression: clinical
Conus medullaris : Weakness of legs, sacral loss
of sensation and extensor plantar responses
Cauda equina : Spinal cord ends at
approximately the T12/L1 spinal level and
spinal lesions below this level can only cause
lower motor neuron signs by affecting the
cauda equina
Intrinsic diseases of the spinal cord

Infective Vascular ( abrupt onset)

1. Transverse myelitis 1. Anterior spinal artery infarct
2. Intervertebral disc
2. Viral myelitis: HZV,
3. embolus
3. schistosomiasis, 4. Spinal AVM/dural fistula
4. Hiv myelopathies Neoplastic
Inflammatory : Glioma, ependymoma, metastases
Metabolic
3. Multiple Sclerosis
5. Vitamin B12 deficiency
4. Sarcoidosis
Degenerative
Paraneoplastic syndrome 1. Motor neuron disease:
 Intrinsic diseases of the S.C
1. Transverse myelitis (TM):
• Is a segmental spinal cord injury caused by acute
inflammation
• Inflammation can result from infection or autoimmune
ds
• Most cases of TM are idiopathic and presumably result
from an autoimmune process; up to half of these
patients have a preceding infection
• The inflammation of TM is generally restricted to one or
two segments, usually in the thoracic cord.
 Transverse myelitis
Autoimmune causes of TM:
o Systemic lupus erythematosus
o Mixed connective tissue disease
o Sjogren's syndrome
o Scleroderma
o Antiphospholipid antibody syndrome
o Ankylosing spondylitis
o Rheumatoid arthritis
 Transverse myelitis
• Symptoms typically develop rapidly over several hours ,
raerely, subacute
• Motor and sensory deficits below the lesion, sphicter
dysfuction bilateral, (sometimes unilateral) Brown sequard
syndrome)
• Acutely, LMN, Subacute: UMNL
• DDX of GBS: TM sensory level
• Cortico steroids( IV methyprednisone 1000mgfor five doses,
then oral prednisone at 1mg/kg, slowly tapered over 3
months
(variable response though)
 Medical disorders affecting the S.C
2. Sarcoidosis:
The granulomatous inflammation of sarcoidosis can affect the spinal
cord and produce an acute or subacute segmental myelopathy
3. Acute viral myelitis
• (Two distinct syndromes of spinal cord involvement are associated
with acute viral disease.
1. In the first, the virus targets the gray matter of the spinal cord,
producing acute lower motor neuron disease
- Enteroviruses, such as poliovirus, coxsackie virus, and enterovirus 71
- Flaviviruses, such as West Nile virus and Japanese encephalitis virus)
 Viral myelitis
2. Viral myelitis that has clinical and diagnostic
test features that are similar to transverse
myelitis.
Associated viruses include cytomegalovirus,
varicella zoster, herpes simplex virus, hepatitis
C, and Epstein Barr virus
 S.C: intrinsic diseases
4. AIDS myelopathy
A vcuolar myelopathy most often occurs in late stages
of AIDS with AIDS dementia ; most patients die within
six months of developing symptoms of myelopathy.
A slowly progressive spastic paraparesis is accompanied
by loss of vibration and position sense and urinary
frequency, urgency, and incontinence, often sparing
upper limbs
.
 S.C: intrinsic diseases
5. Subacute combined degeneration 
•  Deficiency in vitamin B12 (cyanocobalamin) leads
to degeneration of the dorsal and lateral white
matter of the spinal cord
• A slowly progressive weakness, sensory ataxia,
and paresthesias, and ultimately spasticity,
paraplegia, and incontinence
• Often presents before anemia or macrocytosis
RX: Supplemental treatment with vitamin B12
 S.C: intrinsic diseases
6. Degenerative : Motor neuron disease:
Relentlessly progressive LMN and UMN features,
associated bulbar weakness, no sensory
involvement
 Structural abnormalities
1. Spinal spondylosis
2. Lumber spine spondylosis
3. Lumbar canal stenosis
 Cervical spondylotic myelopathy  
• Degenerative changes in the vertebral bodies, discs, and
connecting ligaments encroach on the cervical canal,
producing a progressive myelopathy
• Clinical: symptoms begin insidiously, usually with a spastic
gait , Sensory loss, radicular pain, muscle weakness
• The diagnosis is made by correlating clinical features with
evidence of cervical spondylosis and cord compression on
MRI
• Treatment options include cervical immobilization and
surgical decompression
 Further reading
Up to date notes on:
- Spinal cord anatomy, localization
- Disorders of the spinal cord