ACUTE SPINAL CORD LESSION
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Transcript of ACUTE SPINAL CORD LESSION
ACUTE SPINAL CORD LESSION
MEITI FRIDA
DEPARTMENT OF NEUROLOGY FACULTY OF MEDICINE ANDALAS UNIVERSITY
ANATOMY OF SPINE AND SPINAL CORDThe spine has three major components:the spinal column (bones and discs)neural elements (the spinal cord and nerve roots)supporting structures (muscles and ligaments)
The spinal column consists of:seven cervical vertebrae (C1–C7) i.e. necktwelve thoracic vertebrae (T1–T12) i.e. upper backfive lumbar vertebrae (L1–L5) i.e. lower backfive bones (that are joined, or "fused," together in
adults) to form the bony sacrum three to five bones fused together to form the
coccyx or tailbone
Inside vertebral canal31 segments, each
associated with a pair of dorsal root ganglia
Extends to L1/ L2 (Conus medularis)
Cauda equina - origin of spinal nerves extending inferiorly from conus medullaris
Adult spinal cord:
Spinal Meningen
3) Pia mater
2) Arachnoid
1) Dura mater
Three membranes surround all of CNS1) Dura mater - "tough mother", strong2) Arachnoid - spidery looking, carries blood vessels, etc.Subarachnoid space3) Pia mater - adheres tightly to surface of spinal cord
Organization of Cord Cross Section Gray matter
posterior - somatic and visceral sensory nucleianterior (and lateral) gray horns – somatic and visceral motor controlgray commissures - axons carrying information from side to side
White matter posterior white column - anterior white columnlateral white columnanterior white commissure
Functions ascending tracts - sensory toward brain descending tracts - motor from brain
White Matter: Pathway Generalizations
Vascular anatomy - Anterior spinal artery
Anterior spinal artery originates in upper cervical region, from anterior spinal branches of vertebral artery.
6-10 anterior radicular arteries contribute to it throughout its length.
Supplies anterior two thirds of cord, via central branches and penetrating branches of pial plexus
Vascular anatomy – posterior spinal artery
Run along posterolateral cordSometimes discontinuousOriginates from verterbral arteryHas contribution from 10-23
posterior radicular a.Supplies posterior one third of cord
Vascular anatomy - arteries and venous
Acute lession of spinal cordTraumatic spinal cord injuryVascular MyelopathiesInfectious MyelopathiesInflammatory Myelopathies
Traumatic spinal cord injuryMechanism of injuryFlextion and flextion-rotation injuryCompression injuryHyperextention injury
Level of injuryQuadriplegia :
injury in cervical regionall 4 extremities affected
Paraplegia :injury in thoracic, lumbar or sacral segments2 extremities affected
Complete and IncompleteSpinal Cord Syndromes can be classified
into eithercomplete or incomplete categoriesComplete – characterized as complete
loss of motor and sensory function below the level of the traumatic lesion
Incomplete – characterized by variable neurological findings with partial loss of sensory and/or motor function below the lesion
Spinal ShockAn immediate loss of reflex function,
called areflexia, below the level of injury
Signs: ◦ Slow heart rate◦ Low blood pressure◦ Flaccid paralysis of skeletal muscles◦ Loss of somatic sensations◦ Urinary bladder dysfunction
Spinal shock may begin within an hour after injury and last from several minutes to several months, after which reflex activity gradually returns
Brown-Sequard Syndrome(Special Form of Spinal Cord Injury) Results from an injury to only half of
the spinal cord and is most noticed in the cervical and thoracal region
Often caused by spinal cord penetrating trauma
Motor loss is evident on the same side as the injury to the spinal cord
Sensory loss is evident on the opposite side of the injury location (pain and temperature loss)
Bowel and bladder functions are usually normal
Person is normally able to walk although some bracing or stability devices may be required
ASIA Impairment Scale of spinal cord injuryASIA – American Spinal Injury Association :
A – Complete: no sensory or motor function preserved in sacral segments S4 – S5 B – Incomplete: sensory, but no motor function in sacral segmentsC – Incomplete: motor function preserved below level and power graded < 3D – Incomplete: motor function preserved below level and power graded 3 or moreE – Normal: sensory and motor function normal
ATLS principles A irway; protect spine B reathing C irculation D isability E xpose patient Treat Secondary survey
Pharmacologic TherapyOption: Methylprednisolone
NASCIS II (1992) ◦ 30mg/kg IV loading dose + 5.4 mg/kg/hr
(over 23hrs) effective if administered within 8 hours of injury
NASCIS III (1997) ◦ If initiated < 3hrs continue for 24 hrs, if 3-
8 hrs after injury, continue for 48hrs (morbidity higher - increased sepsis and pneumonia)
Vascular Myelopathies Spinal Cord Ischemia Spinal Hemorrhage
Spinal Cord ischemia In most cases Sensory features ( pain ) emerge first ,
followed by weakness within minutes or hours Pain often follows radicular pattern ( common presentation
) Maximum weakness is observed within 12 hrs of onset Lower thoracic and lumbar spinal levels are most
commonly affected Urinary retention : in acute phase Involuntary voiding or defecation : associated with onset
of ischemic insult
STROKE SYNDROME FEATURE
ANTERIOR SPINAL ARTERY INFARCT
Bilateral motor deficit with Spinothalamic sensory deficit
ANTERIOR UNILATERAL INFARCT Hemiparesis with Contralateral spinothalamic sensory deficit
POSTERIOR UNILATERAL INFARCT Hemiparesis with Homolateral lemniscal sensory deficit
CENTRAL INFARCT Bilateral Spinothalamic sensory deficit without motor deficit
POSTERIOR SPINAL ARTERY INFARCT
Bilateral motor deficit with lemniscal sensory deficit
TRAVERSE INFARCT Bilateral motor deficit with complete sensory deficit
Spinal Cord HemorrhageSpinal cord dysfunction – due to
hemorrhage into Sub arachnoid space Sub dural space Epidural space Onset : Sudden & Painful Triggers : Trauma Bleeding diatheses Vascular malformations
Investigations : CSF Analysis : usually normal can be xanthochromic raised protein MRI Contrast enhanced CT scan with sagittal / coronal
reformatting is useful in pts who cannot undergo MRI MR Angiography Selective Spinal Angiography using Digital Substraction
Techniques
Treatment : SCH is surgical emergencies Immediate surgery Laminectomy and clot evacuation Angiographically directed embolization of vascular
malformation
Infectious MyelopathiesVirus
Enteroviruses (poliovirus, coxsackie virus, and enterovirus 71), Flaviviruses (West Nile virus and Japanese encephalitis virus) have been known to target the gray matter (Anterior horn cells) producing acute lower motor neuron disease
CMV, VZV, HSV I &II, HCV, and EB HIV
Bacterial Mycoplasma (acute and post infectious),
Listeria monocytogenes TB Lyme disease
Schistosomiasis (in endemic areas)
Clinical features of infectious processFeverMeningismus Encephalopathy Rash LymphadenopathyKnown systemic infection Immunocompromised statusKnown exposure to infectious agent
Inflammatory Myelopathies Acute Disseminated Encephalomyelitis Transverse Myelitis
Acute Disseminated Encephalomyelitis Characterized by acute to subacute onset of fever,
meningismus, encephalopathy and multifocal symptoms & signs of CNS dysfunction
More common in children Recent vaccination or systemic infection is noted
in ½ of cases Brain MRI reveals numerous medium to large size ,
fairly symmetrical subcortical white matter lesions often with involvement of deep gray matter
Transverse Myelitis (TM)Immune-mediated process
results in neural injury to the spinal cord
Varying degrees of weakness, sensory alterations and autonomic dysfunction
Up to half of idiopathic cases will have a preceding respiratory or gastrointestinal illness
TM Diagnostic Criteria
Treatment of Myelitis Acute myelitis attacks are typically
treated with IV Corticosteroids Methyl prednisolone Resistant cases : PlasmapheresisVery severe attacks : combination of
Corticosteroids, Plasmapheresis, CyclophosphamideNo evidence supports use of IV Ig in
inflammatory myelitis
Neoplastic & Paraneoplastic Myelopathies Most primary tumors of cord do not cause
acute myelitis syndromes Lymphoma is the only exception – causes a
subacute myelopathy - corticosteroid responsiveBreast carcinoma : antiamphiphysin
antibodies and severe spastic myelopathy Ovarian and Non small cell lung cancer :
glutamic acid decarboxylase 65 autoantibodies causing stiff man like syndrome with brain stem features and ataxia
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