Spinal cord lesion

Degenerative disease of the spine

Pathophysiology: With increasing age the water content of the nucleus pulposus falls and splits appear in the surrounding annulus fibrosus. If the split is located posteriorly, elements of the nucleus pulposus can then herniate through the split into the spinal canal.

A congenital weakness of the annulus may predispose to these changes. At the same time, degenerative changes, including the appearance of osteophytes, develop on the apophyseal joints.

The symptoms associated with degenerative disease of the spine are therefore the consequence either of protrusion of the annulus or the disc, or narrowing either of an intervertebral foramen or the spinal canal by osteophyte formation.

Posterior protrusion of the annulus fibrosus or a herniated nucleus pulposus results in cord compression at the cervical level, but compression of the cauda equina in the lumbar region. Posterolateral protrusion of the annulus or a noncalcified (soft) disc, or osteophytosis or vertebral body, can all produce compression of the nerve root within the intervertebral foramen, more commonly in the cervical than in the lumbar region.

Cervical spondylosis Degenerative disease in the cervical spine occurs most often at the C5/6 and C6/7 levels. Cervical radiculopathy Typically, patients give a history of neck pain accompanied by pain radiating to the scapula, the shoulder or the arm itself. Sensory symptoms, whether paraesthesiae or numbness, serve to localise the affected nerve root. Clinical examination reveals restricted neck movement.

Localization of the involved root Sensory symptoms

The distribution of muscle weakness follows the pattern of innervation of the affected root. Localization of the root involved is aided by examination of the reflexes.

C5-6 disc protrusion C6-7 disc protrusion

Cervical myelopathy Cervical spondylomyelopathy is most often the result of a disease process at the C5/6 or C6/7 disc space, though multiple level compression is common.

The clinical features are dependent on the level of compression. Above C5 there will be a spastic tetraparesis, below this level a combination of radicular features (weakness, atrophy, pain and numbness) in the upper limbs with pyramidal signs (spasticity and exaggerated reflexes) in the lower limbs, accompanied in some instances by long tract sensory signs. Bladder function remains relatively spared.

Investigation Plain X-rays

Oblique views of the cervical spine are essential to demonstrate protrusion into the intervertebral foramen of osteophytes.

Neuro-imaging

The evaluation of cervical myelopathy in CT myelography can demonstrate the degree of cord deformity.

MRI is the best technique for evaluating spondylotic myelopathy, provides an accurate display of the relationship between vertebral body, disc and spinal cord.

Electrophysiological investigation can provide confirmatory evidence of either root or cord involvement.

Management
Most cervical root syndromes are managed by a combination of cervical immobilization, using an appropriately fitting firm collar together with analgesics. Occasionally, surgical decompression of the affected root is necessary, and is usually successful in producing pain relief. In the presence of a progressive myelopathy, surgery is generally recommended.

Thoracic disc disease

Thoracic disc disease is rare and often confused with benign tumours. It predominates in the lower thoracic region and is more likely to affect males than females. The condition may simply present as a slowly progressive spastic paraplegia but many patients complain of exercise induced symptoms, either sensory, motor or both.

Disc calcification is found in perhaps half the cases. The disc protrusion and calcification are best identified using CT myelography or MRI.

Treatment is surgical, though the complication rate is relatively high.

Lumbosacral disc disease

Degenerative disease of the lumbar spine involves the lower two levels in over 90 per cent of cases. Posterolateral, lateral and central patterns of protrusion are described. Pain is a prominent feature.

Posterolateral disc protrusion Pain is a prominent feature in lumbar disc disease and can be referred to the buttock and upper thigh in the absence of root involvement. Areas commonly affected by pain include the lower lumbar spine, in or around the midline and the medial aspect of the buttock. There may be local tenderness in these areas.

Radicular pain may be accompanied by back pain or can appear, at least initially, in isolation. Typically, radicular pain is exacerbated by straining. Pain extending from the back to the anterior thigh suggests involvement of an upper lumbar root. Medial calf pain suggest L5 and lateral calf pain suggest S1, root compression. Sensory symptoms are common and generally segmental.

Examination includes an assessment of the spine, a search for signs indicating nerve root irritation and finally an evaluation of any motor, sensory or reflex change relevant to the particular root. The back is examined for areas of local tenderness and any alteration of the normal lumbar lordosis or paravertebral spasm.

Stretch tests Straight-leg raising is performed by gently elevating the outstretched leg from the horizontal with the patient lying supine. It indicates an irritation of a root at or below L5 level The femoral stretch test is performed by extending the hip with the patient lying on one side. A positive test suggests an irritation of the roots of L2,3 or 4.

Focal signs Focal signs are dependent on the distribution of the affected nerve root. With L4 compression there is weakness of quadriceps and tibialis anterior, with sensory change over the medial aspect of the shin and depression of the knee jerk

L5 root compression may solely declare itself by weakness of extensor hallucis longus with sensory change over the medial aspect of the dorsum of the foot and the lateral shin. In an Sl root syndrome weakness can occur in the buttock muscles, the hamstrings or the calf muscles. The ankle jerk is likely to be depressed or absent. Sensory change particularly occurs over the lateral aspect of the foot and the calf.

Central disc protrusion

Following a central disc protrusion, which can occur without an antecedent history of back pain, cauda equina compression occurs, often in an abrupt fashion. Severe pain results, with paravertebral localization or with radiation into both lower limbs..

Typically, there is severe distal lower limb weakness with foot drop, depression of the ankle reflexes and impaired sphincter function. Saddle anaesthesia is common.

Investigation of lumbosacral disc disease Plain X-rays Plain X-rays are of very limited value in the investigation of a lumbar radiculopathy.

Plain CT High-resolution CT, without contrast, had been previously recommended as the initial investigation for the evaluation of lumbar disc disease & lumbar canal stenosis.

CT myelography CT myelography achieves a 60-80 per cent accuracy in the diagnosis of herniated lumbar disc.

MRI MRI is now the screening technique of choice for the accurate definition of lumbar disc herniation.

Spinal stenosis Though in many patients spinal stenosis is congenital, in others it is secondary to hypertrophy of the bony elements of the lumbar canal, ligamental hypertrophy or disc degeneration.

Canal stenosis usually affects middle-aged men. Typically, (Intermittent neurogenic claudication) paroxysmal numbness or paraesthesiae, rather than pain, appear in the lower limbs during walking and sometimes in certain standing postures. The symptoms often march from the distal parts of the extremities to the proximal.

High-resolution CT is the investigation of choice, allowing definition both of the central canal and of the lateral recess.

Spinal or foraminal stenosis is managed surgically if the symptoms are disabling. Lumbar disc prolapse, if central, is managed by immediate surgery. Posterolateral disc prolapse is managed conservatively initially but by surgery if symptoms fail to resolve with rest.

Spinal cord infections

Spinal epidural abscess Haematogenous spread of infection is the usual source of an epidural abscess, but in some cases the condition is triggered by a spinal procedure which can include epidural injection as well as open surgery.

Typically, the infective process, which is usually due to Staphylococcus aureus, begins in the vertebral body before spreading to the epidural space. The abscesses occur most often in the lumbosacral region.

Clinical features Back pain with evidence of a febrile illness then Radicular pain followed by neurological deficit include motor, sensory and sphincter disturbance. An elevated ESR is usual. CSF findings: an elevated white cell count (polymorphonuclear leucocytes or lymphocytes) and protein concentration but with a normal glucose level.

Investigation Plain radiographs may establish the presence of a vertebral destructive process but can be normal.

CT Myelography, characteristically reveals a total or partial block of the subarachnoid space, associated with cord compression. Rarely, MRI has been reported as normal in this condition. .

Tuberculous disease of the spine Tuberculous disease of the spine is usually secondary to tuberculosis elsewhere in the body and concentrates in the thoracolumbar region. Multiple vertebral involvement is the rule. The disease usually commences in the vertebral body. The vertebral interspace is relatively spared but becomes involved when the disease is extensive.

Eventually, passage through or round the anterior or posterior longitudinal ligaments leads to paraspinal abscess formation. Vertebral collapse with kyphosis is an additional mechanism sometimes responsible for spinal cord damage.

Clinical features Initial features of the illness include fever, malaise and weight loss. Subsequently, pain emerges, associated with focal tenderness. A radicular element to the pain is often prominent.

Tracking of the abscess in the cervical region can lead to a neck swelling, while from the thoracolumbar region, tracking along the psoas sheath results eventually in a mass in the iliac fossa, pelvis or groin.

The neurological deficit which follows in a proportion of cases is typically a spastic paraparesis.

Investigation Blood tests are of limited value in diagnosis. Plain X-rays are usually but not inevitably abnormal.

Typically, there is erosion of the vertebral bodies with disc space narrowing and, in the later stages, shadowing secondary to paravertebral abscess formation.

Later more frank bone destruction with vertebral collapse or deformity become evident.

Plain CT is highly accurate in establishing the diagnosis. With contrast, rim enhancement is seen in any paravertebral collection.

The MRI revealed a multiple vertebral involvement with relative preservation of the intervening discs, a picture liable to cause confusion with metastatic disease.

Treatment is with standard anti-tuberculous therapy, combined, where there is neurological involvement, with surgery. Laminectomy is required if the disease is affecting the posterior neural arch. For anterior paravertebral masses an anterior approach is usually undertaken.

Brucellosis
Brucella spondylitis most frequently involves the lumbar spine at the L4 level. CT demonstrates rounded defects in the vertebral end plates though vertebral collapse is rare.
Incidence is more common in veterinarians and those who are in contact with milk products.

Brucella myelitis can occur in isolation or as part of a meningo-encephalitic syndrome. In addition, cord involvement may follow primary vertebral disease with or without extradural granuloma formation. Most patients have evidence of systemic brucellosis. Back pain is common, associated with a spastic paraparesis or quadriparesis with sphincter involvement in some cases. The sensory deficit is less conspicuous.

Plain X-rays of the spine are often normal. The vertebral and extradural manifestations are more successfully demonstrated by MRI than CT.

Schistosomiasis Spinal cord disease in patients with schistosomiasis is usually due to infection by S. mansoni.

Expanded conus

Granuloma formation most frequently involves conus medullaris. Granuloma formation both within and outside the cord have been described.

The cauda equina can also be affected. Typically, a transverse myelitis appears, sometimes acutely. The CSF shows a raised protein concentration, a lymphocytic pleocytosis and elevated antibody levels. Treatment combines steroids with antischistosomal drugs with surgery in some cases.