SPINAL CORD & TRACTS: APPLIED

PresenterDr. ATM HASIBUL HASANMD Neurology Student(Final part)Department of neurology, DMCH

TOPIC - AT A GLANCE

• Anatomical aspect

• Imaging in spinal cord disease

• Classification of spinal cord pathology

• Clinical approach to spinal cord pathology

• Localization in spinal cord disease

• Special pattern of spinal cord diseases

• Case scenarios

Arrangement of tracts in the spinal cord

Imaging of Spine and Spinal Cord

Plain X-RayComputed Tomographyo Traditionalo Reconstructedo Myelo-CT

MRIDSA

X-Ray

X-Ray

CT SPINE

Myelo-CT

MRI- Spine

Spinal Cord Pathology

I. Vertebral cause-

1) Trauma

2) Disc prolapse

3) Tumour- primary e.g. MM; secondary e.g. breast, thyroid, prostate, bronchus

4) Spinal TB-(Pott’s disease)

II. Meningeal cause-

1) Epidural abscess

2) Tumor - meningioma, neurofibroma, lymphoma, leukaemia

Spinal Cord Pathology

III) Spinal cord itself-

Developmental:o Syringomyelia,o Meningomyelocoeleo Tetherd cord syndrome

Degenerative: o MNDo FAo SCD o HSP

Demyelinating/ Inflamatory:o Transverse myelitiso Multiple Sclerosiso Neuromyelitis Optica

Spinal Cord Pathology

Infective:o Bacterial-TB, Syphiliso Viral-EBV, Polio, HIV, VZV, HSVo Parasitic- Schistosomiasis, Toxoplasmosis

Deficiency:o Vitamin B12 deficiencyo Vitamin E deficiencyo Copper deficiencyo Lathyrism

Spinal Cord Pathology

Vascular:oVasculitisoInfarctionoHaemorhageoAVM

Physical agents:oRadiationoLightening injury

Paraneoplastic :

Localization in Spinal Cord Disease

The Hallmark of spinal cord disease

Presence of horizontally defined level below which there will be impairment of sensory, motor and autonomic function.

Cervical Cord

Above C5: Spastic Quadriplegia and diaphragm weakness

C5-T1: Quadriplegia (LMN signs and segmental sensory

loss in the arms & UMN signs in the legs) and respiratory (intercostal) muscle weakness

At C5-C6:Loss of power & reflex of biceps At C7: Weakness in finger and wrist extensors and

triceps. At C8: Finger & wrist flexion are impaired. Horner’s syndrome may accompany

Cervical Cord

Thoracic Cord

Spastic Paraplegia with a sensory level on the trunk Bowel & Bladder involvementAbdominal reflex (T8-T12) lost above T8 lesion

(segmental lesion T8-T9:above the umbilicus;

T10-T12:below the umbilicus)

Lumbar Cord

L2-L4:Weakness of flexion & adduction of thigh. Weakness in leg extension at knee Absent Knee jerks (L3-L4)

L5-S1: Weakness of foot & ankle and flexion at the knee &

extension of the thigh Absent ankle jerks (S1)

Sacral Cord/ Conus Medullaris

Saddle anesthesia (s3-s5) Prominent bowel & bladder dysfunction

and impotence. Absent bulbocavernous (s2-s4) and anal

reflex (s4-s5).

Myotomes :

•Important in determining level of lesion

•Upper limbs:

C5 - Deltoid

C 6 - Wrist extensors

C 7 - Elbow extensors

C 8 - Long finger flexors

T 1 - Small hand muscles

• Lower Limbs :

L2 - Hip flexors

L3,4 - Knee extensors

L4,5 – S1 - Knee flexion

L5 - Ankle dorsiflexion

S1 - Ankle plantar flexion

Basic Features of Spinal Cord Disease

• UMN findings below the lesion (spasticity, hyper-reflexia). May be flaccid in acute presentation.

• Sensory and motor involvement that localizes to a spinal cord level.

• Bowel and Bladder dysfunction.

Some terminology

Myelopathy Radiculopathy

Definition Any pathological process in the spinal cord (intrinsic and extrinsic)

Pathological process in the exiting nerve root

Feature • Hypertonia• Pyramidal type weakness• Brisk reflex• Extensor plantar response• Loss of sensation ( with a specific

level)• Loss of sphincter control• Autonomic dysfunction

• Hypotonia• Muscle wasting• Weakness• Fasciculation• Loss of reflex• Loss of sensation

Compressive and non compressive myelopathy

CM (surgical) NCM (Medical)

1. Pain - usual 1. Rare

2. Onset - sub acute (2-6 wks) 2. Acute or chronic (≥ 6 wks)

3. Paralysis - Asymmetrical 3. Symmetrical

4. Bowel bladder – Occasionally late involvement 4. May be involved early

5. Sensory limit - asymmetrical 5. Symmetrical or absent

6. Temporal profile - Progressive 6. Non progressive

Intramedullary and extra medullary syndrome

Trait Intramedullary Extramedullary

1. Early symptoms Motor features Sensory features

2. Pain Poorly localized Prominent radicular

3. Sacral sensation Sacral sparing Early sacral sensory loss

4. Motor weakness Upper limb may be affected early Lower limb affected early

5. Sphincter disturbance Appears early Appears late

ExtraduralIntramedullaryIntradural

ExtramedullaryDuraCord

Epiconus and Conus Syndrome

Epiconus Conus

1. Lesion is between L4-S2 1. Lesion between S3-Co1

2. Motor deficit usually above the knee 2. Motor deficit in lower limb less likely

3. Weakness of hip extensor and knee flexor

3. Not such type

4. Pain may not be present 4. Pain may be present

5. Bladder is involved late 5. Early bladder involvement

Conus and Cauda syndrome

Trait Conus Cauda

1. Onset Sudden and bilateral Gradual and unilateral

2. Pain Less common Severe, radicular

3. Location of pain Symmetric, perineum or thigh Asymmetric, perineum, thigh, leg or back

4. Motor loss If occurs, Symmetric, less marked Asymmetric, more marked

5. Reflex Absent ankle Variable- Absent ankle and knee

6. Sensory deficit Saddle distribution (S3-5), symmetric Saddle but asymmetric

7. Bowel and bladder disturbance

Early and marked Late and less marked

8. Sexual dysfunction Occurs Less prominent

PARAPLEGIA IN FLEXION PARAPLEGIA IN EXTENSION

Following complete transection of SC

Following incomplete transection of SC

Muscle tone reappears in flexor muscles first (reticulospinal tract)

Muscle tone reappears in extensor muscles first (Intact vestibulospinal tract)

Flexor reflexes are first to return (eg, Planter response)

Extensor reflex returns first (eg, crossed extensor reflex)

Occurs late Occurs early

Higher lesion Lower lesion

Spinal shock Neurogenic shock

Definition Immediate temporary loss of total power, sensation and reflexes below the level of injury

Sudden loss of the sympathetic nervous system signals

BP Hypotension Hypotension

Pulse Bradycardia Bradycardia

Bulbocavernosus reflex

Absent Variable

Motor Flaccid paralysis Variable

Time 48-72 hrs immediate after SCI

Mechanism Peripheral neurons become temporarily unresponsive to brain stimuli

Disruption of autonomic pathways loss of sympathetic tone and vasodilation

SPECIAL PATTERN OF PRESENTATION IN

SPINAL CORD

DISEASES

Type of Spinal Cord lesion

Complete or transverse lesion Incomplete lesion

a) Anterior cord syndrome

b) Posterior cord syndrome

c) Hemi cord syndrome

d) Central cord syndrome

e) Foramen magnum syndrome

f) Conus medullaris syndrome

g) Cauda equina syndrome

Complete cord transection syndrome

• Bilateral spastic paraparesis/ quadriparesis

• Bilateral loss of all modalities of sensation.

• Bowel &bladder dysfunction.

• LMN feature at the level of lesion

• Cause : o Trauma o Vasculitiso ATM

Brown-sequard syndrome (Hemi cord syndrome)

Motor-• Ipsilateral spastic weakness

• LMN sign at the level of lesion

Sensory:• Ipsilateral loss of proprioception.

• Contralateral loss of pain and temperature sensation

Anterior cord syndrome

• All cord function are lost below the level of lesion with retained position & vibration sense.

• Cause :

o Disc prolapse o Ant. Spinal artery

occlusion

Posterior cord syndrome

• Common in cervical region

• Both sided joint position and vibration sense are lost sparing the other sensory and motor tract

• Cause:o DMo Neurosyphiliso Spondylosiso Posterior spinal artery occlusion

Central cord syndrome (Schneider syndrome)

• Dissociated sensory loss in a cape distribution.

• Symptoms depend on

extension of lesion around

the central canal.

• Weakness of muscles in

arms with atrophy and

hyporeflexia.

• Later - Spastic weakness

with brisk reflexes in the

legs

C/F• Neck pain –radiating to shoulder

• Occipital H/A

• Variable sensory loss

• Weakness and wasting of hand and neck muscles

• Quadriparesis-round the clock (LA→LL→RL→RA)

Cause- Compressive lesion (meningioma, neurofibroma) in the region of foramen magnum

Foramen magnum syndrome:

Spinal shock syndrome

• This clinical condition follows acute severe damage to the cord.

• All cord function below the level of lesion becomes depressed or lost.

• Usually lasts less than 24 hrs but may last for 4-6 wks• On recovery : reflex-tone-power may regain

this fashion.

• 5-10% patients may not recover from spinal shock

Phases of Spinal shock :

Phase Time Physical exam. finding Underlying physiological events

1 0-1 day Areflexia/Hyporeflexia Loss of descending facilitation

2 1-3 day Initial reflex return Denervation super sensitivity

3 1-4 wks. Hyper reflexia (initial) Axon supported synapse growth

4 1-12 months Spasticity Soma supported synapse growth

Conus medullaris syndrome

• Bilateral saddle anesthesia

• Prominent bowel & bladder dysfunction (urinary retention and anal incontinence)

• Impotence

• Absent anal reflex.

Cauda equina syndrome

• Radicular low back pain

• Asymmetrical lower limb weakness & sensory loss

• Variable areflexia

• Relative sparing of bowel & bladder.

• Planter may be flexor or absent.

• Cause : o Disc prolapse o Tumouro Trauma

Combined posterior & lateral column lesion:

Causes include-

Vitamin B12 deficiency Copper deficiency Myelopathy with AIDS HTLV-1 associated myelopathy

Thoracic cord is most commonly affected

Combined posterior&lateral column lesion:

C/F-

• Paresthesia in the feet

• Loss of position and vibration sense in the legs

• Sensory ataxia

• Positive Romberg sign

• Bladder function disturbance

• Spasticity, hyperreflexia and bilateral Babinski sign

CLINICAL APPROACH TO

SPINAL PATHOLOGY

CLINICAL APPROACH ...

POINTS TO BE CONSIDERED:

•Onset e.g. acute, subacute, chronic

•Progression e.g. static, improving, worsening

•Bladder involvement e.g. early, late, none

•Presence of pain e.g. mechanical pain, radicular pain, none

•Presence of fever e.g. abscess, Potts

•Flaccid/ Spastic

•Other systemic features e.g. weight loss, skin/lymph nodes/joints- malignancy, vasculitic

CLINICAL APPROACH . . .

ONSET:

• Acute (minutes to hours): Traumatic Inflammatory Vascular lesion

•Subacute (days to weeks): Neoplastic (compressive) Pott’s

•Chronic (months to years): Neoplastic Degenerative

CLINICAL APPROACH . . .

PROGRESSION: Static:

TM

Improving : MS Vascular lesion

Worsening : Pott’s disease Compressive Neoplastic Degenerative

CLINICAL APPROACH . . .

BLADDER INVOLVEMENT: Early:

TM

Late: Neoplastic Compressive Potts

No involvement: Degenerative e.g. HSP Nutritional e.g. SACD, lathyrism

CLINICAL APPROACH . . .

PAIN: Mechanical:o Vertebral cause

Radicular:o Meningeal causeo Inflammatory cause

No pain:o Spinal cord cause

CLINICAL APPROACH . . .

NATURE OF PARAPLAGIA:Flaccid-•Spinal shock (up to 6 wks.)•Cauda equina lesion•Conus medullaris lesion

Spastic-•Lesion usually in Cervical and Dorsal cord due to any cause (after spinal shock is recovered)

EXAMINATION

A) Types of deficit - Motor deficit only Sensory deficit only Mixed deficit

B) Types of motor deficit - UMN, LMN

C) Pattern of sensory loss - Posterior column loss Spinothalamic loss Dissociative loss

D) Bladder involvement Involved : Tumor, TM, Demyelination. Not involved : Degenerative, Deficiency, Toxin

Clinical clues

A) Motor deficit

UMN LMN

B/B+ B/B- B/B+ B/B-

Cortical

paraplegia Tumor

•MND •HSP •Lathyrism•Tumor

•ATM with Spinal shock •Trauma •Post vaccine •Tumor

• Polio • SMA• GBS• MMNCB

Clinical clues

B) Sensory deficit only C) Mixed deficit • Posterior cord syndrome ● Tumour

• Foramen magnum syndrome ● Cauda equina syndrome

• Tabes ● Conus syndrome

• Paraneoplastic

• MS

Spinal cord disease

Acute Subacute Chronic

UMN

Motor

LMN

Sensory Mixed

B/B + B/B --Cortical lesion-Tumour

-Tumour-Vascular

B/B + B/B --Tumour-Spinal shock

-GBS-AHC eg Polio-SMA

Posterior column

Spinothalamic

-Trauma-Tumour-Spondylosis

-Partial cord syndrome

-Trauma-Tumour-Vascular-ATM-Infective

Approach to Spinal cord disease

Spinal cord disease

Subacute Chronic

UMN

Motor

LMN

Sensory Mixed

B/B + B/B --Tumour-Chronic infection

-MND-Toxic eg Lathyrism-Tumour

B/B + B/B --Tumour-Vascular

-CIDP-MMNCB-SMA

Posterior column

Spinothalamic

-Trauma-Tumour-Spondylosis

-Partial cord syndrome

-Infection-Tumour-Degenerative-Demyelinating

Approach to Spinal cord disease

Case scenarios

A 17 yr old boy presented with tingling, numbness and paresthesia in hand and leg. Examination revealed dissociated and suspended sensory loss.

Syringomyelia

A 38 yr old man presented with chronic back pain, low grade fever and progressive weakness of both the lower limbs. Examination revealed a gibbus at D1 level.

Potts Disease

A 62 old man, known case of psoriasis, presented with new onset back pain and high grade fever. Lower cervical and upper thoracic spine was tender on palpation. Investigation revealed neutrophilic leucocytosis with high ESR and CRP.

Spinal Epidural Abscess

A 25 yr old man presented with progressive weakness of both the lower limb along with a severe sensory loss up to mid chest and bladder problem for last 2 weeks following a H/O vaccination against Hepatitis B.

Acute Transverse Myelitis (Vaccine related)

A 35 yr old lady presented with progressive paraparesis with impaired sensorium extending to D4 level. Two weeks later she developed dimness of vision in both eyes.

Neuromyelitis Optica

A 17 yr old boy presented with sudden weakness of all 4 limbs along with difficulty in speech and deglutition with impaired level of consciousness following an episode of flu like illness.

ADEM

A 24 yr old lady presented with sensory disturbance of both the lower limbs. She had a H/O visual disturbance in one eye and weakness of all four limbs a couple of years back.

Multiple Sclerosis

Differentiating by MRI

Differentiating by MRI

Short segment:o MS

Long segment:o TMo NMO

Differentiating by MRI

A 34 yr old man presented with gait ataxia, tingling and numbness in all four limbs, brisk reflexes but absent ankle jerk with extensor planter response. He gave H/O illeal resection 10 years back. PBF showed megalocyte and there was decreased Vit B12 level.

Subacute combined degeneration of spinal cord

A 42 yr old woman noticed chronic pain in cervico-thoracic region followed by progressive weakness of all four limbs and mild bladder disturbance for last 11 months.

Extradural Meningioma

A 28 yr old man presented with pain in neck and shoulder and numbness in limbs followed by progressive weakness of all four limbs (Lt arm-Lt leg-Rt leg-Rt arm).

Foramen magnum syndrome Neurofibroma

A 3 yr old boy presented with cervical pain and weakness of all four limbs without any bowel or bladder problem.

Astrocytoma

A 65 yr old woman presented with radicular pain and distal weakness of both upper limb. She is a known case of apical lung tumour.

Multiple Metastasis to spine and spinal cord

Tumours of Spinal cord

A 22 yr old lady presented with progressive weakness of both lower limbs along with retention of urine for last two years. Examination revealed spastic paraplegia with ill defined sensory deficit up to umbilicus.

Spinal AVM

A 42 yr old man presented with radiating low back pain, progressive difficulty in walking along with tingling and numbness in limbs, urinary retention and erectile dysfunction for last two years.

Spinal DAVF

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