SPINAL CORD DISORDERS

YARED
MAMUSHET(internist,Neurologis
t)

Meninges

Connective tissue membranes

Dura mater: outermost layer; continuou

with epineurium of the spinal nerves
Arachnoid mater: thin and wispy
Pia mater: bound tightly to surface
Forms the filum terminale

anchors spinal cord to coccyx

Forms the denticulate ligaments that

attach the spinal cord to the dura

Spaces
Epidural: external to the dura
Anesthestics injected here
Fat-fill

Subdural space: serous fluid

Subarachnoid: between pia and
arachnoid
Filled with CSF

12

 Runs through the vertebral canal

Extends from foramen magnum to L1or
Regions

Cervical
Thoracic
Lumbar
Sacral
Coccygeal

Gives rise to 31 pairs of spinal nerves

Not uniform in diameter
Cervical enlargement: supplies upp
limbs
Lumbar enlargement: supplies lowe
limbs
Conus medullaris- tapered inferior end
Ends between L1 and L2

Cauda equina - origin of spinal nerves

extending inferiorly from conus medulla

Spinal Cord Functional Anatomy

Out of 10 or more Long Fibre Spinal Tracts coursing longitudinally in the
spinal cord, only 3 (shown below in Red, Blue and Green) are of prime
importance in clinical neurology practice:

Courtesy of Medical College, University of

Florida.

1. Spinothalamic Tracts (Red

(Red)) = Pain, Temperature, Crude Touch. 2.
Posterior Column Tracts (Green
(Green)) = Position, Vibration, Discriminative
Touch. 3. Corticospinal Tracts (Blue
(Blue)) = Motor efferent (Descending) Fibres.
29

19

small cross-sectional area

reversible if recognized and treated at an early

stage
Neurologic emergency

classification
I-Acute and Subacute Spinal Cord
Diseases
Compressive
Non compressive
II-Chronic spinal chord diseases

A-Compressive
Myelopathies

1-TUMOURS

Extradural tumors
most neoplasms are epidural
resulting from metastases
Most frequent
breast, lung, prostate, kidney, lymphoma, and plasma
cell dyscrasia
The thoracic cord is most commonly involved
except prostate and ovarian cancer sacral and lumbar
vertebrae
Retroperitoneal neoplasms (especially lymphomas or
sarcomas)
enter the spinal canal through the intervertebral
foramina
produce radicular pain and other signs of root
involvement prior to cord compression.

Pain
usually the initial symptom
aching and localized / sharp and
radiating
worsens with movement, coughing, or
sneezing
Rarely, pain is mild or absent

MRI
Excellent anatomic resolution of the extent of spinal tumors
distinguishes malignant lesions from infectious ones
Tumors are usually hypointense relative to a normal bone

marrow
Don't cross disk space unlike infections

the whole length of the spine should be imaged

when epidural malignancy is suspected

40% of patients have asymptomatic epidural disease elsewhere

Plain radiographs of the spine and radionuclide bone scans

miss 1520% of metastatic vertebral lesions
fail to detect paravertebral masses

Epidural spinal cord compression due to breast carcinoma. Sagittal

T1-weighted MRI scans

Epidural spinal cord compression due to breast carcinoma. Sagittal

T2-weighted MRI scans

Treatment
STROIDS to reduce cord edema

dexamethasone up to 40 mg daily
Continued at a lower dose until radiotherapy is completed

LOCAL RADIOTHERAPY to the symptomatic lesion

as early as possible
as effective as surgery, even for radioresistant metastases
new weakness is prevented
some recovery of motor function in half of treated patients
Fixed motor deficits established for >12 hrs do not usually
improve
SURGERY
laminectomy or vertebral body resection
should be considered when
signs of cord compression worsen despite radiotherapy
vertebral compression fracture or spinal instability contributes
to cord compression
specific therapy for the underlying tumor type

Intradural tumors

1.

2.

3.
4.
5.
6.

slow-growing and benign

Therapy is by surgical resection
Meningiomas
can arise from the meninges anywhere along the spinal
canal
Usually located
posterior to the thoracic cord
near the foramen magnum
Neurofibromas
Benign tumors of the nerve sheath
arise near the posterior root
Symptoms usually begin with radicular sensory symptoms
asymmetric, progressive spinal cord syndrome
chordoma
lipoma
dermoid, or
sarcoma

MRI of a thoracic meningioma

intense and uniform enhancement of a well-circumscribed extramedullary
mass

Intramedullary tumors

1.
2.
3.

Primary intramedullary tumors are rare

Secondary tumors are common in advanced
metastatic disease
present as central cord or hemicord syndromes,
often in the cervical region
there may be poorly localized burning pain in the
extremities and sparing of sacral sensation
Ependymomas,
Hemangioblastomas
low-grade astrocytomas
Ependymomas :Complete resection
Astrocytoma (slowly growing lesions) : Debulking
adjunctive radiotherapy and chemotherapy is
uncertain

MRI of an intramedullary astrocytoma. Sagittal T1-weighted

2-Spinal Epidural Abscess

triad of midline dorsal pain, fever, and progressive limb
weakness
Risk factors include

1.
2.
3.

Aching pain is almost always present

either over the spine or in a radicular pattern

The duration of pain prior to presentation is generally <2 weeks

impaired immune status (diabetes mellitus, renal failure, alcoholism,

malignancy)
intravenous drug abuse
infections of the skin , viscera, bone and other tissues

may be several months or longer

Further spinal cord damage results from venous congestion and

thrombosis
Once weakness and other signs of myelopathy appear,
progression may be rapid
elevated white blood cell count and sedimentation rate
A more chronic sterile granulomatous form of abscess is also
known, usually after treatment of an acute epidural infection.

 2/3rd :hematogenous spread of bacteria

from
1. the skin
2. soft tissue (pharyngeal or dental abscesses)
3. deep viscera (bacterial endocarditis)
1/3rd : direct extension of a local infection
1. vertebral osteomyelitis
2. decubitus ulcers
3. lumbar puncture
4. epidural anesthesia

Etiology
Staphylococcus aureus
TUBERCULOSIS in assocition with Pott Disease
(Tuberculous Spinal Osteomyelitis )
pus or caseous granulation tissue extrudes from an

infected vertebra to an epidural space

gram-negative bacilli
Streptococcus
Anaerobes
fungi
Diagnosis
MRI scans

MRI of a spinal epidural abscess due to tuberculosis

Sagittal T2-weighted

MRI of a spinal epidural abscess due to tuberculosis

Sagittal T1-weighted image after contrast administration

Lumbar puncture is only required if encephalopathy or other

clinical signs raise the question of associated meningitis, a
feature that is found in <25% of cases

passage of the needle through infected tissue or herniation

A high cervical tap is often the safest approach

Tuberculous Spinal Osteomyelitis (Pott

Disease)

Children and young adults are most often affected

An infectious endarteritis causes bone necrosis

collapse of a thoracic or upper lumbar (less often cervical) vertebral body

resulting in a characteristic angulated kyphotic deformity

gibbus deformity

Most patients have active tuberculous infection as evidenced by fever,

night sweats, and other constitutional symptoms

the sedimentation rate is invariably elevated

A compressive myelopathy occurs in some cases as a result of the spinal

deformity, but it is surprisingly infrequent and an epidural tuberculous
abscess is a more common cause of cord compression

excellent result may be obtained by external stabilization of the spine and

long-term antituberculous medication

spinal surgery required only in the presence of severe deformities or a

compressive myelopathy

Treatment
decompressive laminectomy with debridement
treatment of choice unless the abscess is
1. limited in size and causes few or no neurologic signs.
2. If surgery is contraindicated or
3. if there is a fixed paraplegia or quadriplegia : long-

term administration of systemic and oral antibiotics

may improve or reverse paralysis in evolution
unlikely to improve deficits of more than several
days duration
Anti Tb for tuberculous epidural abscess

3-Spinal Epidural Hematoma

acute focal or radicular pain followed by spinal cord disorder

predisposing conditions
Therapeutic anticoagulation
Trauma
Tumor
blood dyscrasia
lumbar puncture :Rare
lumbar puncture should be avoided whenever possible in
patients with severe thrombocytopenia or other
coagulopathies
Dx
MRI and CT confirm the clinical suspicion

Rx
prompt reversal of any underlying clotting disorder
surgical decompression

4-Hematomyelia

Hemorrhage into the substance of the spinal cord

rare
result from

Trauma
intraparenchymal vascular malformation
vasculitis (polyarteritis nodosa, SLE)
bleeding disorders
a spinal cord neoplasm

acute painful transverse myelopathy

extension into the subarachnoid space may occur, resulting in
subarachnoid hemorrhage
Diagnosis is by MRI or CT
Therapy

Supportive
surgical intervention not useful except in underlying vascular
malformation

ss

From Dr China T. (Prospective Neurosurgeon)

35

))

From Dr China T. (Prospective Neurosurgeon)

36

Noncompressive
Myelopathies
After spinal cord compression is

excluded the following should be

considered
1. spinal cord infarction
2. myelitis

infectious (primarily viral)

Postinfectious/ post vaccinal

systemic inflammatory disorders

SLE and sarcoidosis

3. demyelinating diseases

multiple sclerosis and neuromyelitis optica

1-Spinal Cord Infarction

A- With systemic hypotension
cord infarction occurs at the level of
greatest ischemic risk
usually T3-T4
boundary zones between the anterior

and posterior spinal artery territories

rapidly progressive syndrome over

hours of weakness and spasticity

little sensory change

Spinal Cord Blood Supply

http://medic.med.uth.tmc.edu.

http://medic.med.uth.tmc.edu.

Courtesy of MD Images.

35

b-anterior spinal artery

produces "anterior cord syndrome

Sharp midline or radiating back pain localized to the area of

ischemia
paraplegia or quadriplegia
loss of sphincter control
dissociated sensory loss
usually progressive over minutes or a few hours
unlike stroke in the cerebral hemispheres

Areflexia due to spinal shock is often present initially

with time, hyperreflexia and spasticity appear
A few patients have vertigo at the onset
Rarely, infarction is preceded by transient spinal ischemic attacks
Many patients regain a substantial degree of motor function, mainly
in the first month but extending over a year

C- posterior spinal arteries

not common

cause

Atherosclerosis and thrombotic occlusion of the anterior

spinal artery is quite uncommon
aortic atherosclerosis
dissecting aortic aneurysm
vertebral artery occlusion or dissection
profound hypotension
Cardiogenic emboli
vasculitis
intraoperative surgical occlusion
cocaine users
embolism of nucleus pulposus

dural fistula

Diagnosis
MRI
Usually detects the abnormality
may fail to demonstrate limited infarctions of the cord,
especially in the first day
In the chronic stages, the infarcted region collapses and
has an attenuated signal on MRI

Treatment
presumed thromboembolism, acute anticoagulation is
probably not indicated, with the exception of the unusual
transient ischemic attack or incomplete infarction with a
stuttering or progressive course
?CSF drainage

 confined to gray matter: poliomyelitis

if confined to white matter

:leukomyelitis
If approximately the whole crosssectional area of the cord is
involved :transverse myelitis
multiple and widespread over a long
vertical extent: diffuse or
disseminated

Acute Infectious Myelitis

often difficult to distinguish

from postinfectious
Herpes zoster

best characterized

HSV types 1 and 2

recurrent sacral myelitis in
association with outbreaks
of genital herpes
EBV, CMV, rabies virus,

Poliomyelitis
Bacterial and mycobacterial
myelitis
less common
most are essentially
abscesses
Almost any pathogenic
species

parasitic myelitis

Schistosomiasis
Toxoplasmosis cause a
focal myelopathy in HIV
pts

treatment
Herpes zoster, HSV, and

EBV intravenous acyclovir

or oral valacyclovir for 10
14 days

CMV with ganciclovir plus

foscarnet or cidofovir

Post infectious /post vaccinal

The characteristic features of these diseases are
(1)their temporal relationship to certain viral infections or

vaccinations
(2)the delayed development of neurologic signs over the
period of a few days
(3)a monophasic temporal course, i.e., a single attack of
several weeks' duration with variable degrees of recovery
and no recurrence.
immunologic in nature more or less confined to spinal cord
myelin
Often begins upon recovery from an AFI or in the
subsequent days or weeks
infectious agent cannot be isolated
If it also affects the brain it is called acute disseminated
encephalomyelitis (ADEM)

Epstein-Barr virus
cytomegalovirus
Mycoplasma
Influenza
Measles
Varicella
Rubeola
mumps

Mycoplasma is unique in being a bacterial trigger of

the disease
The list of antecedent infections is otherwise much the
same as for the Guillain-Barr syndrome with the
notable difference of Campylobacter jejuni, which has
not led to myelitis and is a frequent precedent to the
polyneuropathy

The latency between infection and myelitis :uncertain

febrile episode may blend into the neurologic syndrome
In others latency has been 2 weeks

In 50% of cases the patient can identify a recent infectious illness, usually
upper respiratory syndrome

The illness evolves over several days,

sometimes a single day or on the other extreme, over 1 or 2 weeks

fewer than half of cases are truly "transverse

weakness and numbness of the feet and legs (less often of the hands and
arms), which typically develop over a few days

the sensory symptoms ascend from the feet to the trunk

simulate a polyneuropathy, are common early symptoms

Sphincteric disturbances and backache are also common

Differentiated from a rapidly progressive polyneuropathy such as the

Guillain-Barr by

1. A slight asymmetry of the symptoms and signs

2. sensory level on the trunk
3. Babinski sign

 CSF

lymphocytes and other mononuclear cells :10 -100/mm3

Some times normal
slightly raised protein and normal glucose content

MRI

slight T2 signal abnormalities

minimal gadolinium enhancement extending over 2 or 3 spinal
segments
the cord may be swollen in these regions
several patients with mild and partial myelitis may have normal
MRI studies

Treatment
Once symptoms begin, it is not clear if any treatment is

of consistent value
?high doses of corticosteroids :no evidence that this

alters the course of the illness

?plasma exchange or intravenous immune globulin
The prognosis of this illness is better than the initial

symptoms might suggest

Usually the myelitic disease improves, sometimes to a

surprising degree
Pain in the midthoracic region or an abrupt, severe

onset usually indicates a poor prognosis

Tabes Dorsalis

Post. Column

Now rare

Occurs 18-25 yrs after initial lesion.

presentation :
-Lightning pain (sudden and severe)
-Ataxia
-Sensory loss and paresthesia
-Visceral crisis(abdominal pain and diarrhea)
-Rectal crisis(tenesmus)
-Charcot jt
-Associated ARP and optic atrophy

Systemic Inflammatory
Disorders
SLE
Sjgren's syndrome
mixed connective tissue disease
vasculitis
sarcoid myelopathy

3-Demyelinating
Myelopathies

Acute Demyelinating Myelitis of MS

the clinical manifestations of MS tend to evolve more slowly, over a period

of 1 to 3 weeks or even longer.

antecedent infections is not often seen

Only the occurrence of subsequent attacks or additional lesions revealed

by MRI or evoked potentials indicates that the basic illness is one of
chronic recurrent demyelination

numbness that spreads over one or both sides of the body from the sacral
segments to the feet, anterior thighs, and up over the trunk

asymmetric weakness and then paralysis of the legs

When this process becomes complete, the bladder is also affected

The sensorimotor disturbance may extend to involve the arms

a sensory level can be demonstrated on the upper parts of the trunk.

relatively painless and without fever, and the patient usually improves,
with variable residual signs

The CSF often normal

may show a mild lymphocytosis, as in the postinfectious variety

Oligoclonal bands may be absent with the first attack

Treatment

Corticosteroids

may lead to a regression of symptoms, sometimes with relapse when the

medication is discontinued (after 1 to 2 weeks)
No apparent response in some
a proportion of cases have even continued to worsen on steroids

Plasma exchange and intravenous immune globulin

particularly in those with an explosive onset

II-Chronic Myelopathies

1-Spondylitic Myelopathy
most common cause of gait difficulty in the elderly
involve the lower and midcervical vertebrae
Neck and shoulder pain with stiffness are early
symptoms
Radicular arm pain, most often in a C5/C6
distribution
Compression of the cervical cord
fewer than one-third of cases
produces a slowly progressive spastic paraparesis, at

times asymmetric
accompanied by paresthesias in the feet and hands
Vibratory sense is diminished in the legs
positive Romberg sign

 occasionally there is a sensory level for

vibration on the upper thorax

coughing or straining produces leg weakness
or radiating arm or shoulder pain
Dermatomal sensory loss in the arms, atrophy
of intrinsic hand muscles,
increased deep-tendon reflexes in the legs,
and extensor plantar responses
the biceps is most often affected (C5-C6)

Urinary urgency or incontinence occurs in

advanced cases

Diagnosis
MRI or myelography
Treatment
A cervical collar in milder cases
surgical decompression : definitive
therapy
Posterior laminectomy
resection of the protruded disc and bony

material

2-Syringomyelia
Developmental cavitary expansion of the cervical cord
prone to enlarge and produce progressive myelopathy
Symptoms

begin insidiously in adolescence or early adulthood

progress irregularly
may undergo spontaneous arrest for several years
Many young patients acquire a cervical-thoracic scoliosis
More than half of all cases are associated with Chiari type 1
malformations
cerebellar tonsils protrude through the foramen magnum
and into the cervical spinal canal
syrinx cavities
Acquired cavitations of the cord in areas of necrosis
trauma, myelitis, necrotic spinal cord tumors, and chronic
arachnoiditis due to tuberculosis and other etiologies

classification
Type I. Syringomyelia with obstruction of the foramen magnum and dilatation
of the central canal (developmental type)
A. With type I Chiari malformation

B.

With other obstructive lesions of the foramen magnum

Type II. Syringomyelia without obstruction of the foramen magnum

(developmental type)
Type III. Syringomyelia with other diseases of the spinal cord (acquired types)
A. Spinal cord tumors (usually Intramedullary)
B. Traumatic myelopathy
C. Spinal arachnoiditis and pachymeningitis
D. Secondary myelomalacia from cord compression (tumor, spondylosis),
infarction, hematomyelia
Type IV. Pure hydromyelia (developmental dilatation of the central canal), with
or without hydrocephalus

3-Subacute Combined
Degeneration
Subacute paresthesias in the hands and feet
A progressive spastic and ataxic weakness

Loss of vibration and position sensation

Loss of reflexes due to an associated peripheral

neuropathy in a patient who also has Babinski signs,
is an important diagnostic clue
Optic atrophy and irritability or other mental changes
in advanced cases
Myelopathy is diffuse rather than focal
signs are generally symmetric
predominant involvement of the posterior and lateral
tracts

Romberg's sign

 DX confirmed by the finding of

1. macrocytic red blood cells
2. serum B12 concentration
3. elevated serum levels of homocysteine and

methylmalonic acid
4. positive Schilling test

Treatment
vitamin B12, beginning with 1000 g IM
repeated at regular intervals or by

subsequent oral treatment

Vascular Malformations of the Cord

and Dura

uncommon
middle-aged men
located posteriorly along the surface of the cord

or within the dura

Pain over the dorsal spine, dysesthesias, or
radicular pain
intermittent claudication
Spinal bruits are infrequent
should be sought at rest and after exercise in
suspected cases
progressive myelopathy that worsens slowly or
intermittently
A saltatory progression is most common and is
the result of local ischemia and edema from
venous congestion.

Tropical Spastic
Paraparesis
Caused by Human T-Cell Lymphotropic Virus Type I
cytotoxic

The posterior columns and corticospinal tracts are the main

sites of disease,
most evident in the thoracic cord
slowly progressive paraparesis with increased tendon reflexes
and Babinski signs
most patients are unable to walk within 10 years of onset
disorder of sphincteric control is usually an early feature
but symmetric paresthesias, reduced vibratory and position
senses, and ataxia follow over several months or years
often lack a well-defined sensory level
upper extremities usually spared (except for lively tendon
reflexes)

 CSF contains
small numbers of lymphocytes of the T type (10 to

50/mm3),
normal concentrations of protein and glucose
an increased content of immunoglobulin (Ig) G with
antibodies to HTLV-I
diagnosis is confirmed by the detection in the serum
of the antibodies to the virus
MRI :
Thinness of the spinal cord
subcortical cerebral white matter lesions may be
seen as well
no effective treatment

symptomatic therapy for spasticity and bladder symptoms

Vacuolar Myelopathy with

AIDS
20 of 89 successive cases of AIDS on whom a

postmortem examination was performed had it

The white matter of the spinal cord is
vacuolated, most severely in thoracic segments
posterior and lateral columns are affected
the lesions in the spinal cord resemble those of
subacute combined degeneration
levels of vitamin B12 and folic acid have been
normal
symptoms and signs obscured by
a neuropathy or
one or more of the cerebral disorders that complicate

AIDS

 Hemi- or quadriparesis, often asymmetrical

Develop over a period of weeks

sensory and sphincteric disorder

A sensory ataxia has also been a common early feature

CSF
a small number of lymphocytes,
a slight elevation of protein
occasionally bizarre giant cells

Similar vacuolar lesions may be seen in the brain in

some cases
antiretroviral drugs have little effect on the myelopathy
symptomatic treatment of spasticity

Familial Spastic Paraplegia

onset may be as early as the first year of life or as late

as middle adulthood
imperceptibly progressive spasticity and weakness in
the legs,
usually symmetrical
Sensory symptoms and signs are absent or mild
sphincter disturbances may be present
IN some families additional neurologic signs are
prominent, including
nystagmus, ataxia, or optic atrophy
Only symptomatic therapies for the spasticity are
currently available

 konzo

MANAGEMENT
Management of SC problems must

be cautious and fast because

reversal of paraparesis is TIMELOCKED .
Paraplegia beyond a certain interval
may remain complete, with no
prospect of future ambulation or
bladder bowel control.
So again expedited evaluation and
act is required

 Unacceptable delay in diagnosis

,refferal,and investigation shouldnt

occur.
If traumatic or other they should
immediately be transferred to
institutions providing the service.
Specific diagnosis needs specific
treatment.

 Postoperative care, rehabilitation are

very important aspects of managing

patients with spinal cord lesions.

 THANKS!