Spinal disease

Upper vs. Lower Motor Neuron
Upper motor neuron lesion
Motor cortex internal capsule brainstem
spinal cord
Lower motor neuron lesion
Anterior horn cell nerve root plexus
peripheral nerve neuromuscular junction
muscle

Basic Features of Spinal Cord Disease
UMN findings below the lesion
Hyperreflexia and Babinski’s
Sensory and motor involvement that localizes to a spinal cord level
Bowel and Bladder dysfunction common
Remember that the spinal cord ends at about T12-L1

History
Onset
Acute, subacute, chronic
Symptoms
Pain
Weakness
Sensory
Autonomic
Past history
Family history

Tempo of Spinal Cord Disease

Motor Exam
Strength - helps to localize the lesion
Upper cervical
Quadriplegia with impaired respiration
Lower cervical
Proximal arm strength preserved
Hand weakness and leg weakness
Thoracic
Paraplegia
Can also see paraplegia with a midline lesion in the brain
Tone
Increased distal to the lesion

Sensory Exam
Establish a sensory level
Dermatomes
Nipples: T4-5
Umbilicus: T8-9
Posterior columns
Vibration
Joint position sense (proprioception)
Spinothalamic tracts
Pain
Temperature

Autonomic disturbances
Neurogenic bladder
Urgency, incontinence, retention
Bowel dysfunction
Constipation more frequent than incontinence
With a high cord lesion, loss of blood pressure control
Alteration in sweating

Investigation of Spinal Cord Disease
Radiographic exams
Plain films
Myelography
CT scan with myelography
MRI
Spinal tap
If you suspect: inflammation, MS, rupture of a vascular malformation

Etiology of Spinal Cord Disease

Traumatic Spinal Cord Disease
10,000 new spinal cord injuries per year
MVA, sports injuries the most common
Victims under 30 yrs old, male>>females
Fx/dislocation of vertabrae most likely to occur at:
C5,6
T12, L1
C1,2

Tumors
Metastatic or primary
Extramedullary
Extradural - most common
Bony - breast, prostate
Intradural - very rare
Meninges - meningioma
Nerve root - schwannoma
Intramedullary - very rare
Metastatic
Primary - astrocytoma or ependymoma

B12 Deficiency
Subacute combined degeneration of the cord
B12 deficiency
malabsorption of B12 secondary to pernicious anemia or surgery
insufficient dietary intake - vegan
Posterior columns and CST involvement with a superimposed peripheral neuropathy

Transverse myelitis
Inflammation of the spinal cord
Post-infectious
Post-vaccinial
Multiple sclerosis
Pain at level of lesion may preceed onset of weakness/sensory change/b&b disturbance
Spinal tap may help with diagnosis

Infections Involving the Spinal Cord
Polio
only the anterior horn cells are infected
Tabes dorsalis
dorsal root ganglia and dorsal columns are involved
tertiary syphillis
sensory ataxia, “lightening pains”
HIV myelopathy
mimics B12 deficiency
HTLV-1 myelopathy -
tropical spastic paraparesis

Multiple Sclerosis
Demyelination is the underlying pathology
Cord disease can be presenting feature of MS or occur at any time during the course of the disease
Lesion can be at any level of the cord
Patchy
Transverse
Devic’s syndrome or myelitis optica
Transverse myelitis with optic neuritis

Vascular Diseases of the Spinal Cord
Infarcts
Anterior spinal artery infarct
from atherosclerosis, during surgery in which the aorta is clamped, dissecting aortic aneurysm
less often, chronic meningitis or following trauma
posterior columns preserved (JPS, vib)
weakness (CST) and pain/temperature loss (spinothalamic tracts)
Artery of Adamkiewicz at T10-11
Watershed area
upper thoracic

Vascular Diseases of the Spinal Cord, cont
Arteriovenous malformation (AVM) and venous angiomas
Both occur in primarily the thoracic cord
May present either acutely, subacutely or chronically (act as a compressive lesion)
Can cause recurrent symptoms
If they bleed
Associated with pain and bloody CSF
Notoriously difficult to diagnose
Hematoma - trauma, occasionally tumor

Other Disease of the Spinal Cord
Hereditary spastic paraparesis
Usually autosomal dominant
Infectious process of the vertabrae
TB, bacterial
Herniated disc with cord compression
Most herniated discs are lateral and only compress a nerve root
Degenerative disease of the vertabrae
Cervical spondylosis with a myelopathy
Spinal stenosis

Classical spinal cord syndromes
Anterior spinal artery infarct
Brown Sequard syndrome
Syringomyelia
Conus medullaris/caude equina lesions

Brown Sequard Syndrome
Cord hemisection
Trauma or tumor
Dissociated sensory loss
loss of pain and temperature contralateral to lesion, one or 2 levels below
crossing of spinothalamic tracts 1-2 segments above where they enter
loss of vibration/proprioception ipsilateral to the lesion
these pathways cross at the level of the brainstem
Weakness and UMN findings ipsilateral to lesion

Syringomyelia
Fluid filled cavitation in the center of the cord
Cervical cord most common site
Loss of pain and temperature related to the crossing fibers occurs early
cape like sensory loss
Weakness of muscles in arms with atrophy and hyporeflexia (AHC)
Later - CST involvement with brisk reflexes in the legs, spasticity, and weakness
May occur as a late sequelae to trauma
Can see in association with Arnold Chiari malformation