Spinal Cord syndromes
Clinical features of LARGE central cord syndrome:
• weakness/atrophy/fasciculations at the level of lesion • arms weaker than legs • loss of pain/temperature sensation at the level of lesion • loss of pain/temperature sensation in a "band" below the lesion • preserved pain/temperature sensation below that band
Clinical features of SMALL central cord syndrome:
•weakness/atrophy/fasciculations at the level of lesion: LMN problems, reduced reflex • loss of pain/temperature sensation at the level of lesion: bilateral bc anterolateral are crossing right at the level they are coming in entering through the dorsal horn and crossing little band of numbness (not there DOWN)
Where can hemmorhage occur that effects spianl cord?
parenchyma or space around usually result of trauma or vascular malformation
What is syringomyelia and what causes it?
-a cavity in the spinal cord parenchyma, notcontiguous with the central canal of the cord -caused by: trauma, OR congeintal
Why does an external compression of spinal cord (such as degenerative spine disease, a tumor, an abscess, or any other mass lesion), make symptoms as if the spinal cord were getting squeezed from all sides?
1) spinal cord encased in fairly tight bony compartment, so external mass pushing on left side will displace spinal cord until the right side abutting vertebra 2) venous drainage : focal mass can result in more generalzied venous congestion at that level
What does a spinal cord transection cause?
complete loss of motor control of the body below the level of injury and a loss of ability to detect all sensory modalities below that level
A central lesion in the cervical cord will preferentially affect
portions of anterolateral system devoted to cervical dermatomes followed by portions devoted to upper throacic dermatomes
A pathologic process outside the spinal cord but within the spinal canal can cause what kind of pattern of deficits?
pushes on spinal cord and cause pattern of deficitis corresponding to location of underlying pathologic process BUT often you see what you would excpet if it were squeezing in from all directions
Extrinsinc cord compression: clinical features
• weakness below spinal cord level X • loss of sensation to all modalities below spinal cord level X • (if long-standing): spasticity and hyperreflexia below spinal cord level X Level X is at or below the lesion (remember: the homunculus hugs the gray matter)
If a spinal cord transection has been present for long enough,
there is usually spasticity and hyperreflexia below the level of the lesion at the level=LMN findings due to damage to anterior horns of gray matter at the level
Where is the most common site for epidural abscess?
thoracic spine then lumbar spine cervial= least common you need to do prompt surgical drainage and abs
What are the subacute causes of spinal cord syndromes?
transverse myelitis epidural abscess
What can cause cord transection?
trauma demyelination any structural lesion extensive enough to affect entire spinal cord at some level
acute disease processes affecting spinal cord
trauma ischemia hemmorhage
What can unilateral hemi cord syndrome arise from?
trauma tumors vascular malformations degenerative spine disease abscess demyelination rare to see in "pure" form, often just a few suggestive features
what can cause central cord syndrome?
trauma, especially when the injury results in contusion rather than frank hemorrhage regions of contusion can progress to form cavity: syringomyelia, syrix OR also an be tumors, infection, autoimmune
Meningioma
tumor of meninges can compress spinal cord
Schwannoma
tumor of myelin nerve sheath around nerve root can compress spinal cord
Neurofibroma
tumor of nerve root can compress spinal cord
What are chronic causes of spinal cord syndromes?
tumors degenerative spine disease toxic metabolic neurosyphilis con-genital
What can cause posterior cord syndrome?
typical of tabes dorsals syndrome of tertiary neurosyphilis can also occur as result of structural lesion or inflammation
What causes epidural abscess?
usually result of hematogenous spread to vertebral body or disc space from infections elsewhere immunocompromised, or IV drugs
What is the diff between neurogenic claudication and vascular?
vascular: can stand in one place for as long as they want, but walk/run--> pain -stop moving but remain standing: pain resolves neuro: pain even standing, but often improves when they bend forward more comfortable walking in grocery stores, bent over cart, or can ride a bike
What are intrinsic tumors of spinal cord?
very uncommon ependymomas or astrocytomas usually present as central cord syndrome, but hemi-cord syndrome, anterior cord syndrome, or posterior cord syndrome are also possible tx: decompression and radiation (palliative care)
What is subacute combined degeneration?
vitamin B12 affects posterior columns AND corticospinal tracts mimiced by: copper deficiency and NO toxicity
Can pts have degenerative spine disease without symptoms?
yes also, people who have non-specific back pain also have degenerative spine disease
Unilateral hemi cord syndorme: clinical features
• ipsilateral weakness below the level of lesion • contralateral loss of pain/temperature sensation below the level of lesion • ipsilateral vibration/position sensation below the level of lesion • (if long-standing): ipsilateral spasticity and hyperreflexia below the level of lesion
Posterior cord syndrome: clinical features
• loss of vibration/position sensation below the level of lesion • preserved motor function below the level of lesion • preserved pain/temperature sensation below the level of lesion
Subacute combined degeneration features:
• loss of vibration/position sensation below the level of lesion • weakness (also ataxia) below the level of lesion • preserved pain/temperature sensation below the level of lesion • spasticity and hyperreflexia below the level of lesion
What can traumatic injury to the spinal cord result in?
compresion, laceration, contusion of spinal cord (central cord syndrome) most often: no immediate spinal cord injury but alteration of biomechanics of spine, so it cant protect spinal cord from injury during routine activities
Neuofibromas, meningiomas, and schwannomas can present as
compression of spinal cord, hemicord syndrome, anterior cord syndrome, posterior cord syndrome
How do we manage degenerative spine disease?
conservative: analgesics, PT decompressive surgery/ microsurery- for spinal stenosis, rarely for radiculopathy
When spondylosis narrows one or both of the laterally positioned neural foramena, through which the nerve roots pass
it can result in radiculopathy= dysfunction of nerve root
If a degenerative spine disease is causing radiculopathy...
it often improves with time physical therapy can be helpful
As a mass grows and squeezes the spinal cord more,
more medial portions of corticospinal and spinothalamic tracts will be affected SENSORY LEVEL MARCHES UP THE BODY (and weakness and spasciticty follow suit)
What is spina bifida oculta?
most mild form of spina bifida incomplete closure of the posterior portion of one or more vertebral bodies
Anterior cord syndrome: clinical features
• weakness below the level of lesion • loss of pain/temperature sensation below the level of lesion • preserved vibration/position sensation below the level of lesion • (if long-standing): spasticity and hyperreflexia below the level of lesion
Clinical features: spinal cor dtransection
• weakness below the level of lesion • loss of sensation to all modalities below the level of lesion • (if long-standing): spasticity and hyperreflexia below the level of lesion
If a patient has a sensory level at T8, there could be ...
(a) severe ("complete") compression at T8, or (b) milder ("incomplete") compression anywhere in the spinal cord above T8 ⇒ first scan T8, but if things look OK, scan higher
What is lumbar spinal stenosis?
narrowing of the central canal in the lower lumbar spine, at the level of the cauda equina (i.e., below the level where the spinal cord ends) results in pain in the lower extremities that is precipitated by standing upright--> compression of one or more nerve roots in the cauda equina and/ or blood vessels that supply them
Spinal stenosis is...
narrowing of the central canal which contains the spinal cord
What causes ischemia in anterior spinal artery? posterior spinal artery?
ASA: usually NOT intrinsic disease -usually in the setting of aortic surgery but sometimes can be due to cardiogenic like endocarditis posterior have more collaterals and 2 vessels: not often site of infarct
What is a myelomeningoceole?
neural tube fails to close, leaving the bony spine and dorsal spinal cord opens posteriorly and leaving the anterior aspect of the spinal cord exposed at the skin surface most common form of spina bifida
If a patient has focal pain and a known cancer elsewhere should get...
CT or MRI bc pts often get focal pain before neuro manifestations from metastases of cancer in spinal region
how do you diagnose and manage spinal cord hemorrhage?
MRI (ordered due to spinal cord syndrome) manage: drainage of epidural hematoma resection or embolization of vascular malformation rehab
How do you diagnose transverse myelitis? treat?
MRI to look for abscess and brain MRI to straitfy risk for MS LP treat: high dose steroids, initiate MS treatment if u see brain MRI lesions
When is surgery indicated for hemmorhage in spinal cord?
blood in epidural space usualy not for parenchymal hemm
If a cord transection lesion is in the thoracic or high lumbar level of the spinal cord, the sensory level will be...
on the trunk so its important to test sensation (pain/temp) along the trunk
What is posterior cord syndrome?
affects vibration and position sense below the level of lesion w relative sparing of motor function and pain/temp
What is syrinx?
aka syringomyelia when injury results in contusion that progresses t cavity can occur also as congenital condition
What is a Chiari malformation
associated w syringomyelia cerebellar tonsils are displaced downward so that they extend into the foramen magnum if displacement is great enough, tonsils exert pressure on cervical spinal cord and low medulla esp w increased ICP (cough, sneeze)
What would you excpet from a unilateral hemi cord syndrome?
below the level of a unilateral hemi-cord lesion there will be weakness, upper motor neuron findings, and reduced vibration/position sensation on the side of the lesion, and reduced pain/temperature sensation on the side opposite the lesion
What is anterior cord syndrome?
blood flow from ASA is blocked at some level of the spinal cord, loss of motor control and pain/temp sensation everywhere below that level, but preserved vibration and position sense
What causes transverse myelitis?
can be due to infection, most often: auto immune like MS, NMO, lupus, Sjorens can cause unilateral or any other
What kind of syndrome would give you a cape like pattern/ suspended sensory level of sensory loss?
central cord syndrome preferentially affects portions devoted to cervical dermatomes, followed by portions of anterolateral system devoted to cervical dermatomes, followed by portions devoted to upper dermatomes w relative sparing of portions devoted to lower throacic dermatomes and below
What is nuerogenic claudication?
pain due to compression of one or more nerve roots in the cauda equina (and/or the blood vessels that supply them)
How do you diagnose and treat epidural abscess?
diagnose: MRI esp w tenderness, fever manage: surgical drainage or decompression antibioitcs spine stabilization
What are clinical syndromes associated w degenerative spine disease?
extrinsic cord compression nerve root compression lumbar spinal stenosis: neurogenic claudication diagnose: MRI
What is the typical clinical syndrome of a tumor affecting the spinal cord?
extrinsic cord compression, although hemi-cord syndrome, anterior cord syndrome, or posterior cord syndrome are also possible
What kinds of tumors are the most common in affecting the spinal cord?
hematogenous metastases to vertebral body or disc space from primary tumors elsewhere in the body (lung, breast, prostate, myeloma) bony: compress cord or fracture vertebral body which presses the cord
How do you tret bony metastases causing spinal cord compression?
high dose steroids, surgical decompression, and radiation therapy resect neurofibromas, schwanomas, and meningiomas as soon as possible
What is the treatment for those with Chiari malformations?
if its causing significant symptoms, surgical decompression and or shunting esp if syrinx is enlarged over time
Patients with spine pain, altered mental status, or any abnormality on neuro exam need
imaging on spine, usualy w CT if you find abnormalities, may neeed to be removed or realigned, followed by spine stabilizion (repair dislocation, stabilize the sppine) --> RISK of neurogenic shock w high cord injuries-- bc sympathetics travel w thoracic cord, altered autonomic responses -placement of stabilizing device as scaffold
After any major trauma, the head, neck, and back should be
immbolized until assessed for spianl cord and spinal column injury
What is a meningocele?
intermediate form of spina bifida herniation of small region of meninges between vertebrae, but not spinal cord itself
If a patient has a long standing lesion affecting the left side of the spinal cord at C2 level in the neck...
reduced motor control of left arm and left leg, as well as spasticity and increased reflexes on that side (bc corticospinal tract already crossed) also reduced vibration and position sensation in left arm and leg (posterior column doesnt cross midline until medulla) reduced pain/temp on the right arm and leg bc anterolateral crossd already loss of sensation to all modalities in C2 distro, bc damage of sensory fibers entering at the level, some lower neurons supplied by C2 root, and damage to axons of motor neurons leaving spinal cord at C2
How do you manage spinal cord ischemia?
rehab primary stroke preventtion no direct treatment
What does the anterior spinal artery supply?
runs midline just anterior to spinal cord, supplies anterior 2/3 of spinal cord (gray matter + all white matter EXCEPT posterior columns) corticospinal tracts and anterolateral system
What does compressive myelopathy mean?
same thing as extrinisic cord compression syndrome myelopathy= dysfunction fo spinal cord
How do you diagnose spinal cord ischemia?
spared position vibration sesnation MRI well known complication of aortic surgery
What is a lipomyelomingocele?
spinal cord fails to separate from the surrounding fatty tissues during development, leaving the spinal cord attached to subcutaneous fat (but at least it is fully covered by skin, unlike a myelomeningocele) can have stretch injury w growth
When does spine trauma require imaging?
spine pain altered mental status any possiblibility of intox any abnormality on neuro exam
Why would you image (CT) for spine trauma?
spine pain altered mental status (even if just distracted) any possibility of intoxication any abnormality on neuro exam
What kinds of degenerative changes can the spinal cord undergo?
spondylosis: bony degeneration and overgrowth degenerative disc disease: change in fluid content and elascitiy of intervertebral discs, resulting in thinning and dislocation of discs can occur independelty, but often occur together
Degenerative spine disease (whether from spondylosis, degenerative disc disease, or both) that is producing symptoms of lumbar spinal stenosis (in the lumbar spine) or clinical evidence of spinal cord compression (in the cervical or thoracic spine) usually requires....
surgical decompression effective for symptoms of lumbar spinal stenosis, but doesnt necesarily improve manifestations of myelopathy, just prevents progression
Who gets surgery for degenerative spine disease?
symptoms of lumbar spinal stenosis, or spinal cord compresssion unless there is compelling evidence that the degenerative spine disease is producing clinical manifestations of myelopathy, lumbar spinal stenosis, or progressively worsening radiculopathy, surgery should be avoided.
What is vascular claudication?
syndrome of pain that results from stenosis of the iliac or femoral arteries, which is precipitated by exercise
A lesion in the central spinal cord can effect fibers outside the gray matter, or...
the gray matter, resulting in lower motor neuron findings at that level, amnd medial portions of corticospinal tract weakness more promineent in upper over lower extremities
If you see a patient for the first time and observe a sensory level at T10, this could mean either...
the patient has a severe compressive lesion at the T10 level, orthat the patient has a less severe compressive lesion somewhere above the T10 level start looking for lesion at the level and then look up