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DISEASES OF THE SPINALDISEASES OF THE SPINAL CORDCORD

Dr. Khairul P Surbakti , SpSDr. Khairul P Surbakti , SpS

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DISEASES OF SPINAL CORDDISEASES OF SPINAL CORD Related to special physiologic and anatomic Related to special physiologic and anatomic Including: Including:

1. Complete sensory motor myelopathy1. Complete sensory motor myelopathy2. Combined painful radicular & 2. Combined painful radicular &

transverse transverse cord cord syndromessyndromes

3. Hemicord (Brown-Squard syndromes)3. Hemicord (Brown-Squard syndromes)4. Ventral cord syndromes, sparing 4. Ventral cord syndromes, sparing

posteriorposterior column functioncolumn function5. High cervical-foramen magnum 5. High cervical-foramen magnum

syndromessyndromes6. Central cord or syringomyelic 6. Central cord or syringomyelic

syndromessyndromes7. Syndrome of conus medullaris7. Syndrome of conus medullaris8. Syndromes of cauda equina8. Syndromes of cauda equina

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The syndrome of acute paraplegia due to The syndrome of acute paraplegia due to complete transverse lesion of the spinal cord complete transverse lesion of the spinal cord (Transverse myelopathy)(Transverse myelopathy)

1.1. Trauma to the spine and Spinal cordTrauma to the spine and Spinal cord

Clinical Effects of spinal cord injuryClinical Effects of spinal cord injury

a. All involuntary movements in parts of the body a. All involuntary movements in parts of the body

below the lesion is immediately and below the lesion is immediately and permanentlypermanently

lostlost

b. All sensation from the lower parts is abolishedb. All sensation from the lower parts is abolished

c. Reflex functions in all segments of the isolated c. Reflex functions in all segments of the isolated

spinal cord are suspendedspinal cord are suspended

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Spinal shockSpinal shock

- Involves tendon as well as autonomic - Involves tendon as well as autonomic reflexreflex

- Duration : 1 to 6 weeks as, but - Duration : 1 to 6 weeks as, but sometimessometimes

longerlonger

- Riddoch : spinal cord transection- Riddoch : spinal cord transection

- spinal shock & areflexia- spinal shock & areflexia

- heightened reflex activity- heightened reflex activity

- Less complete lesions - Less complete lesions little or no spinal little or no spinal

shocksshocks

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Stage of Spinal shock or AreflexiaStage of Spinal shock or Areflexia

- Loss of motor function: - Loss of motor function:

Cervical cord Cervical cord Tetraplegia Tetraplegia

Thoracic cord Thoracic cord Paraplegia Paraplegia

- Immediate atonic paralysis of bladder and bowel- Immediate atonic paralysis of bladder and bowel

- Gastric atony- Gastric atony

- Loss of sensation below a level corresponding to - Loss of sensation below a level corresponding to the spinalthe spinal

cord lesioncord lesion

- Muscular flaccidity- Muscular flaccidity

- Almost complete suppression of all spinal - Almost complete suppression of all spinal segmental segmental

reflex activity below the lesion reflex activity below the lesion

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- Impaired of autonomic control in the segments - Impaired of autonomic control in the segments belowbelow

the lesionthe lesion

- Abolished of vasomotor tone, sweating, and- Abolished of vasomotor tone, sweating, and

piloerection in the lower parts of the body piloerection in the lower parts of the body temporarilytemporarily

- Systemic hypotension- Systemic hypotension

- The lower extremities lose heat- The lower extremities lose heat

- The skin becomes dry and pale- The skin becomes dry and pale

- The spinchters of bladder and the rectum remain- The spinchters of bladder and the rectum remain

contracted to some degree due to loss of inhibitorycontracted to some degree due to loss of inhibitory

influences of higher CNS centers, but detrussor of influences of higher CNS centers, but detrussor of the the

bladder and smooth muscle of the rectumbladder and smooth muscle of the rectum atonic atonic

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- Overflow incontinence- Overflow incontinence

- Passive distension of the bowel- Passive distension of the bowel

- Retention of feces- Retention of feces

- Absence of peristaltic (paralytic ileus)- Absence of peristaltic (paralytic ileus)

- Genital reflexes are abolished or - Genital reflexes are abolished or profoundly depressedprofoundly depressed

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Stage of Heightened Reflex activityStage of Heightened Reflex activity

- The more familiar neurologic state that - The more familiar neurologic state that emerges emerges

within several weeks or months after within several weeks or months after spinal injuryspinal injury

- Heightened flexion reflexes- Heightened flexion reflexes

- Babinski sign (+)- Babinski sign (+)

- The Achilles and patellar reflexes return- The Achilles and patellar reflexes return

- Retention of urine becomes less - Retention of urine becomes less completecomplete

- Reflex defecation also begins- Reflex defecation also begins

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TRANSIENT CORD INJURY ( SPINAL CORDTRANSIENT CORD INJURY ( SPINAL CORDCONCUSSIONCONCUSSION))

Transient loss of motor and /or sensory Transient loss of motor and /or sensory functions of the spinal cord that recovers functions of the spinal cord that recovers within minutes or hours but sometimes persist within minutes or hours but sometimes persist for a day or several daysfor a day or several days

The syndromes including:The syndromes including:- bibrachial weakness- bibrachial weakness- quadriparesis ( occasionally hemiparesis )- quadriparesis ( occasionally hemiparesis )- paresthesia or dysesthesias in a similar - paresthesia or dysesthesias in a similar distribution todistribution to the weakness or sensory symptom alonethe weakness or sensory symptom alone

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Central cord syndrome (Schneider syndrome) and Central cord syndrome (Schneider syndrome) and Cruciate ParalysisCruciate Paralysis

- The loss of motor function is more severe in the- The loss of motor function is more severe in the upper limb than lower limbs and particularly upper limb than lower limbs and particularly severe in severe in the handsthe hands- Bladder dysfunction with urinary retention- Bladder dysfunction with urinary retention- Sensory loss is often slight (hyperpathia over - Sensory loss is often slight (hyperpathia over shoulder shoulder and arms may be the only sensory abnormalityand arms may be the only sensory abnormality- Damage of the centrally ituated gray matter - Damage of the centrally ituated gray matter atrophic, areflexic paralysis, segmental loss of atrophic, areflexic paralysis, segmental loss of pain,pain,

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CausesCauses : :

- Retroflexion injury of the head and neck- Retroflexion injury of the head and neck

- Hematomyelia- Hematomyelia

- Necrotizing myelitis- Necrotizing myelitis

- Fibrocartilagenous embolism- Fibrocartilagenous embolism

- Infarction due to dissection- Infarction due to dissection

- Compression of the vertebral artery in - Compression of the vertebral artery in the medullary-the medullary-

cervical regioncervical region

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Examination and Management of the spine Examination and Management of the spine injured patientinjured patient

- The level of the spinal cord and vertebral The level of the spinal cord and vertebral lesions canlesions can

be determined from clinical findingsbe determined from clinical findings

- Diaphragmatic paralysis : lesion of the - Diaphragmatic paralysis : lesion of the upper three upper three

cervical segmentscervical segments

- Complete paralysis of arm and legs : - Complete paralysis of arm and legs : fractures orfractures or

dislocation C4 to C5 vertebraedislocation C4 to C5 vertebrae

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The level of sensory loss on the trunk The level of sensory loss on the trunk determined determined by perception of pinprick by perception of pinprick an accurate guide to the an accurate guide to the level of the lesionlevel of the lesion

If any movement or sensation is elicitable during te If any movement or sensation is elicitable during te first 48 to 72 hours first 48 to 72 hours the prognosis is more favorable the prognosis is more favorable

If the spine can be examined safely If the spine can be examined safely inspection of inspection of angulation/irregularity, signs of bony injuryangulation/irregularity, signs of bony injury

In all cases of suspected spinal injury In all cases of suspected spinal injury the the immediate immediate

concern is that the movement (especially flexion) of concern is that the movement (especially flexion) of the cervical spine be avoided.the cervical spine be avoided.

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The patient should be placed supine on a firm, flat The patient should be placed supine on a firm, flat surface, keep the head and neck immobile surface, keep the head and neck immobile

A neurologic examination wit detailed recording of A neurologic examination wit detailed recording of motor, sensory, and spinchter function is necessary motor, sensory, and spinchter function is necessary to follow the clinical progress of SCIto follow the clinical progress of SCI

Common practice to define the injury:Common practice to define the injury:

1. Complete : motor and sensory loss below lesion1. Complete : motor and sensory loss below lesion

2. Incomplete : some sensory preservation below the 2. Incomplete : some sensory preservation below the

zone of injuryzone of injury

3. Incomplete : motor and sensory sparing, but the 3. Incomplete : motor and sensory sparing, but the patientpatient

is nonfunctionalis nonfunctional

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4. Incomplete : motor and sensory sparing 4. Incomplete : motor and sensory sparing and theand the

patient is functional (stands patient is functional (stands and walks)and walks)

5. Complete functional recovery : reflex 5. Complete functional recovery : reflex may be may be

abnormalabnormal

Group 2, 3, and 4 have a more favorable Group 2, 3, and 4 have a more favorable prognosisprognosis

for recovery than does group 1for recovery than does group 1

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Radiologic examination: Radiologic examination:

- alignment of vertebrae and pedicles- alignment of vertebrae and pedicles

- fractures of pedicle or vertebral body- fractures of pedicle or vertebral body

- compression of spinal cord or cauda - compression of spinal cord or cauda equina due to malalignment , bone debris equina due to malalignment , bone debris in the spinal canal, the presence of tissue in the spinal canal, the presence of tissue damage within corddamage within cord

The MRI is ideally suited to display these The MRI is ideally suited to display these process, but if it is not available process, but if it is not available myelography with CT scanning is an myelography with CT scanning is an alternativealternative

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Once the degree of injury to spine and cord have Once the degree of injury to spine and cord have been assessed been assessed Administer of metylprednisolone in Administer of metylprednisolone in high high

dosage ( bolus of 30 mg/kg followed by 5.4 dosage ( bolus of 30 mg/kg followed by 5.4

mg/kg every hour), beginning within 8 h of mg/kg every hour), beginning within 8 h of

the injury and continued for 23 h.the injury and continued for 23 h.

The greatest risk to the patient with spinal cord The greatest risk to the patient with spinal cord injury isinjury is

the first 10 days : gastric dilatation, ileus, shock, the first 10 days : gastric dilatation, ileus, shock, infectioninfection

The mortality rate falls rapidly after 3 monthsThe mortality rate falls rapidly after 3 months

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Aftercare of patient with paraplegia :Aftercare of patient with paraplegia :- psychologic support- psychologic support- management of bladder and bowel - management of bladder and bowel dirturbancesdirturbances- care of skin- care of skin- prevention of pulmonary embolism- prevention of pulmonary embolism- maintenance of nutrition- maintenance of nutrition- decubitus ulcers can be prevented by - decubitus ulcers can be prevented by frequent turning frequent turning to avoid pressure necrosisto avoid pressure necrosis- use of special mattresses- use of special mattresses- morning suppositories- morning suppositories- physical therapy- physical therapy

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MYELITISMYELITIS

= infective and non infective inflammatory = infective and non infective inflammatory process of process of

the spinal cord.the spinal cord.

If it is confined to gray matter If it is confined to gray matter poliomyelitispoliomyelitis

white matter white matter leukomyelitisleukomyelitis

If approximately the whole cross-sectional If approximately the whole cross-sectional area of thearea of the

cord is involved cord is involved transverse myelitis transverse myelitis

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The evolution of myelitic symptoms :The evolution of myelitic symptoms :

- Acute - Acute more or les within days more or les within days

- Sub acute - Sub acute 2 to 6 weeks 2 to 6 weeks

- Chronic - Chronic more than 6 weeks more than 6 weeks

CLASIFICATION OF INFLAMMATORY CLASIFICATION OF INFLAMMATORY DISEASEDISEASE

OF THE SPINAL CORDOF THE SPINAL CORD

I. Viral myelitisI. Viral myelitis

A. Enteroviruses ( groups A and B A. Enteroviruses ( groups A and B Coxsackie virus,Coxsackie virus,

poliomyelitis, others)poliomyelitis, others)

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B. Herpes zosterB. Herpes zosterC. Myelitis of AIDSC. Myelitis of AIDSD. Epstein-Barr virus (EBV), cytomegalovirus D. Epstein-Barr virus (EBV), cytomegalovirus (CMV), herpes simplex.(CMV), herpes simplex.E. RabiesE. RabiesF. Arboviruses-flaviviruses (Japanese, West Nile, F. Arboviruses-flaviviruses (Japanese, West Nile, etc.)etc.)G. HTLV-1 (tropical spastic parapareis)G. HTLV-1 (tropical spastic parapareis)II. Myelitis secondary to bacterial, fungal, II. Myelitis secondary to bacterial, fungal, parasitic, andparasitic, and primary granulomatous diseases of the primary granulomatous diseases of the meninges meninges and spinal cordand spinal cord

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A. Mycoplasma pneumoniaeA. Mycoplasma pneumoniae

B. Lyme diseaseB. Lyme disease

C. Pyogenic myelitisC. Pyogenic myelitis

1. Acute epidural abscess and 1. Acute epidural abscess and granulomagranuloma

2. Abscess of spinal cord2. Abscess of spinal cord

D. Tuberculous myelitisD. Tuberculous myelitis

1. Pott disease with spinal cord 1. Pott disease with spinal cord compressioncompression

2. Tuberculous meningomyelitis2. Tuberculous meningomyelitis

3. Tuberculoma of spinal cord3. Tuberculoma of spinal cord

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E. Parasitic and fungal infections producing E. Parasitic and fungal infections producing

epidural granuloma, localized meningitis, orepidural granuloma, localized meningitis, or

meningomyelitis and abscess, especially meningomyelitis and abscess, especially certaincertain

form of shistosomiasisform of shistosomiasis

F. Syphilitic myelitisF. Syphilitic myelitis

1. Chronic meningoradiculitis (tabes 1. Chronic meningoradiculitis (tabes dorsalis)dorsalis)

2. Chronic meningomyelitis2. Chronic meningomyelitis

3. Meningovascular syphilis3. Meningovascular syphilis

4. Gummatous meningitis including chronic4. Gummatous meningitis including chronic

spinal pachymeningitisspinal pachymeningitis

G. Sarcoid meningitisG. Sarcoid meningitis

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III. Myelitis (myelopathy) of noninfectiousIII. Myelitis (myelopathy) of noninfectious

inflammatory typeinflammatory type

A. Postinfectious and postvaccinal myelitisA. Postinfectious and postvaccinal myelitis

B. Acute and chronic relapsing or progressiveB. Acute and chronic relapsing or progressive

multiple sclerosis (MS)multiple sclerosis (MS)

C. Subacute necrotizing myelitis and Devic C. Subacute necrotizing myelitis and Devic diseasedisease

D. Myelopathy with lupus or other forms of D. Myelopathy with lupus or other forms of

connective tissue disease and antipospholipidconnective tissue disease and antipospholipid

antibodyantibody

E. Paraneoplastic myelopathy and poliomyelitisE. Paraneoplastic myelopathy and poliomyelitis

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TUBERCULOUS SPINAL OSTEOMYELITIS TUBERCULOUS SPINAL OSTEOMYELITIS

( POTT’ DISEASE )( POTT’ DISEASE )

- Tuberculous osteitis of the spine with kyphosis- Tuberculous osteitis of the spine with kyphosis

(Pott disease) is well known in regions of (Pott disease) is well known in regions of endemic endemic

tuberculosistuberculosis

- Children and young adults are most often - Children and young adults are most often affectedaffected

- The osteomyelitis is the result of reactivation of - The osteomyelitis is the result of reactivation of

tuberculosis at a site previously established by tuberculosis at a site previously established by

hematogenous spreadhematogenous spread

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An infectious endarteritis An infectious endarteritis bone necrosis and bone necrosis and collapsecollapse

of a thoracic or upper lumbar ( of a thoracic or upper lumbar (

less often cervical ) vertebral bodyless often cervical ) vertebral body

angulated kyphotic deformityangulated kyphotic deformity

Symptoms : fever, night sweats, elevated Symptoms : fever, night sweats, elevated sedimentationsedimentation

raterate

In some cases : spinal deformity In some cases : spinal deformity compresive compresive myelo-myelo-

pathypathy

Treatment :- external stabilization of the spineTreatment :- external stabilization of the spine

- long term antituberculous medication- long term antituberculous medication

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TUBERCULOUS MYELITISTUBERCULOUS MYELITIS

- Pus or caseous granulation tissue may - Pus or caseous granulation tissue may extrude fromextrude from

infected vertebra and gives rise to an infected vertebra and gives rise to an epidural epidural

compression of the cord compression of the cord Pott Pott paraplegiaparaplegia

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DEMYELINATIVE DISEASEDEMYELINATIVE DISEASE( ACUTE MULTIPLE SCLEROSIS )( ACUTE MULTIPLE SCLEROSIS )

- The most typical mode of clinical expression of - The most typical mode of clinical expression of demyelinative myelitis is with numbness that demyelinative myelitis is with numbness that spreadspread over one or both sides of the body:over one or both sides of the body: from the sacral segments to the feet from the sacral segments to the feet ant. ant. ThighsThighs up over the trunk up over the trunk coincident with coincident with asymmetricasymmetric weakness weakness then paralysis then paralysis

- As this process becomes complete, bladder is - As this process becomes complete, bladder is affectedaffected

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Acute spinal MS is relatively painless and Acute spinal MS is relatively painless and without feverwithout fever

the patient usually improves with variable the patient usually improves with variable residual signsresidual signs

Treatment :Treatment :

- Corticosteroid - Corticosteroid may lead to regression may lead to regression of symptomsof symptoms

sometimes with relapse sometimes with relapse when the when the

medication is discontinued.medication is discontinued.

- Plasma exchange - Plasma exchange

- IVIG - IVIG

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The combination of spinal cord The combination of spinal cord necrosis and optic neuritis necrosis and optic neuritis Neuromyelitis optica (Devic’s Neuromyelitis optica (Devic’s disease)disease)

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VASCULAR DIEASE OF THE PINAL CORDVASCULAR DIEASE OF THE PINAL CORD

- In comparison with the brain , the spinal - In comparison with the brain , the spinal cord is an uncommon site of vascular cord is an uncommon site of vascular diseasedisease

- The spinal arteries tend not to be - The spinal arteries tend not to be susceptible susceptible

to atherosclerosis and emboli rarely lodge to atherosclerosis and emboli rarely lodge

there.there.

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Vascular disorders of spinal cord :Vascular disorders of spinal cord :

- infarction- infarction

- dural fistula- dural fistula

- bleeding- bleeding

- arteriovenous malformation- arteriovenous malformation

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INFARCTION OF THE SPINAL INFARCTION OF THE SPINAL CORDCORD

( MYELOMALACIA)( MYELOMALACIA)

HEMORRHAGE OF THE SPINAL HEMORRHAGE OF THE SPINAL CORD AND SPINAL CANAL CORD AND SPINAL CANAL (HEMATOMYELIA)(HEMATOMYELIA)

VASCULAR MALFORMATIONS OF VASCULAR MALFORMATIONS OF THE SPINAL CORD AND THE SPINAL CORD AND OVERLYING DURAOVERLYING DURA

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SYRINGOMYELIA SYRINGOMYELIA

SYRINX = “PIPE” OR “TUBE” SYRINX = “PIPE” OR “TUBE” A A CHRONIC PROGRESSIVE CHRONIC PROGRESSIVE DEGENERATIVE OR DEVELOPMENTAL DEGENERATIVE OR DEVELOPMENTAL DISORDER OF THE SPINAL CORDDISORDER OF THE SPINAL CORD

CLINICALLY : PAINLESS WEAKNESS CLINICALLY : PAINLESS WEAKNESS AND WASTING OF THE HAND AND AND WASTING OF THE HAND AND ARMS ARMS

PATHOLOGICALLY: CAVITATION OF PATHOLOGICALLY: CAVITATION OF THE CENTRAL PARTS OF SPINAL CORDTHE CENTRAL PARTS OF SPINAL CORD

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USUALLY IN THE CERVICAL USUALLY IN THE CERVICAL REGION BUT EXTENDING REGION BUT EXTENDING UPWARD IN SOME CASES INTO UPWARD IN SOME CASES INTO MEDULLA OBLONGATA AND PONS MEDULLA OBLONGATA AND PONS ( SYRINGOBULBIA ) OR ( SYRINGOBULBIA ) OR DOWNWARD INTO THE THORACIC DOWNWARD INTO THE THORACIC OR OR

EVEN THE LUMBAR SEGMENTSEVEN THE LUMBAR SEGMENTS