Spinal Cord Compression
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Transcript of Spinal Cord Compression
Spinal Cord Compression
Postgraduate seminarNeurology UnitBy: Chidimma A Onwurah
Outline
Introduction Anatomy Aetiology Epidemiology Clinical features Investigations Management Conclusion
Spinal Cord Function
Transmits neural signals and contains neural circuits that control reflexes
Four major functions: Motor Sensory Reflex Autonomic function
Anatomy
Anatomy • Spinal cord terminates
at L1-L2• Covered by 3
connective tissue: Dura, Pia & Arachnoid
• Dural sac ends at S2
• Terminology– Conus medullaris: most
distal bulbous part– Filum termiale: tapering
part of conus medullaris (mostly fibrous tissue)
– Cauda equina: distal collection of nerve roots
3 layers of spinal coverings Pia mater
Arachnoid mater
Dura mater
Gray matter of spinal cord
Cell bodies of neurons which receive efferent information from the brain and send it to skeletal myocytes (somatic motor innervation)
Cell bodies of neurons which receive efferent information from the brain and send it to smooth myocytes, cardiac myocytes, and glands (autonomic motor innervation)
Cell bodies of neurons which receive afferent information from spinal nerves and send it toward the brain
White matter Carries afferent information into dorsal horn of gray matter
Carries efferent information away from ventral horn of gray matter
Corticospinal tract
Spinothalamic tract and dorsal column lemniscal pathway
Arterial supply to the spinal cord Intraspinal Arteries
Anterior spinal artery▪ Supply the ventral gray and white matter, except the dorsal
horns and dorsal white matter Posterior spinal arteries
▪ Supply the dorsal horns and dorsal white matter Extraspinal Arteries
Radicular arteries
Causes of Spinal Cord Compression
EXTRADURAL Vertebral: epidural abscess /Infection-
TB & bacterial; vertebral collapse, disc prolapse, spondylosis, spondylolisthesis, Paget’s dx, neoplasm (10 & 20)
Non- vertebral: Hodgkin’s leukemic infiltration or metastases, abscess, cyst
Contd INTRADURAL A] Extramedullary
▪ Neoplasm, nerve sheath tumours (schwannomas and neurofibromas ) meningioma; arachnoiditis; arachnoid cyst
B] Intramedullary ▪ Neoplasm, astrocytomas, ependymomas,
hemangioblastomas (primary spinal tumours); cyst/syringomyelia; haematomyelia [AVMalformation] and venous angiomas
Epidemiology
USA: spinal stenosis (54%), tumors (26%), ischemia (8%), infection (7%)
Gupta et al in India(2005-2008): spinal tumors (27%), TB spine (25%), transverse myelitis (22%)
Ogunniyi et al in Ibadan (1988-1993): spondylotic myelopathy (30%), TB spine (25%), neoplastic (12%)
History (SCCx) Onset Deficits
Motor Sensory
Progression Time to maximum disability Changes in deficits Sphincter dysfunction Autonomic changes Preceding illness Systemic complaints
Clinical findings UMN: preserved muscle bulk or atrophy of
disuse, no fibrillation/ fasciculation, hypertonia, brisk DTR, extensor plantar response, absent abdominal reflex
These occur late with intramedullary lesions but early with extramedullary lesion.
LMN: wasting, fibrillation/fasciculation, hypotonia, hyporeflexia, flexor plantar response
Inverted supinator jerk : C5/C6 lesion
Lasegue’s sign – lifting a straight lower limb causes pain.Shows a herniated disc
Shober’s sign- <5cm increase in distance between standing and bending to touch the toes when marks are placed 10cm above and 5 cm below the L5 vertebraPositive in ankylosing spondylosis
Syringomyelia
Fluid filled cavitation in the center of the cord
May be late sequelae of trauma Most common site is the cervical cord
Loss of pain and temperature Cape sensory loss Weakness of muscles in arms with atrophy and
hyporeflexia Later- leg weakness, spasticity with brisk
reflexes
Syringomyelia Can be associated with
Arnold Chiari malformation, spinal arachnoiditis, scoliosis, spinal vertebrae misalignment, spinal tumors, spina bifida, meningitis
Other central cord lesions: Hydromyelia, HematomyeliaIntramedullary tumors
Cervical spondylosis with myelopathy Most common form of myelopathy Degenerative disease of the spine
usually at mid and lower cervical spine vertebrae Narrowing of spinal canal and vertebral
foramina Progressive injury of the spinal cord and
spinal roots Prevalence of cervical degenerative
disease reaches 95 % at the age of 65 years
Pathology Fraying of annulus fibrosus Extension of disc material in the
spinal canal Bulging of annulus fibrosus Osteophytes Hypertrophied longitudinal ligaments
and ligamentum flavum Compression of posterior roots may
lead to degeneration in posterior columns
Compression of spinal cord may produce demyelination or focal necrosis
Pathogenesis
No clear explanation Compression High mobility of lower cervical vertebrae Diminished AP diameter of the spinal
canal Compression of spinal arteries and
ischemia Trauma from sudden extreme extension
Clinical features Radiculopathy Spondylotic Myelopathy Myeloradiculopathy Rotational vertebral artery occlusion,
Vertebro-basillar insufficiency Lhermitte’s Spurling’s- turning the patients head to the
affected side and flexing the neck leads to pain along the affected nerve/dermatome.
Intermittent neurogenic claudication
Bladder disturbance Fingers may feel swollen or clumsy Weakness of small muscles of the hand Clumsiness Weakness of the legs
Spasticity is more than weakness Quadriparesis
Muscle stretch reflexes Loss of biceps reflex, but exaggerated triceps
reflex Extensor plantar reflex
Sensory Changes Impaired vibration sense, joint position sense Romberg sign may be present Sensory gait ataxia in some subjects
Radiculopathy Symptoms usually begin on waking Symptoms worsen with Valsalva activities Motor and reflex changes
▪ C5/C6 disc herniation compresses C6 root▪ C6/C7 disc herniation compresses C7 root
Brown-sequard syndrome/lateral cord syndrome
Cord hemisection
Trauma or tumour De-myelination Burst fracture
Sign and symptoms Weakness on side of
lesion Dissociated sensory loss
▪ Contralateral loss of pain and temperature to lesion, 1 or 2 levels below;
▪ Ipsilateral propioceptive loss 1-2 segments below
Brown Sequard syndrome
Posterior cord syndrome Causes:
Cervical spondylosis, Multiple sclerosis Demyelination Spinal cord tumor Atlanto-axial subluxation Sub-acute combined degeneration
Signs Sensory ataxia (propioceptive loss) Urinary incontinence Lhermitte signs
Vascular disease of cord Arteriovascular malformation and
venous angiomas Occur primarily in the thoracic cord May present as acute, subacute or
chronic compressive lesion Can cause recurrent symptoms Associated with pain and bloody CSF if
they bleed.
Complete cord
Trauma- commonest cause Features:
Loss of sensory Loss of motor Loss of autonomic All below the level of lesion
Conus medullaris syndrome
•D12 burst fracturecompresses theconus.•All lumbar and sacralsegments canbe compressed
Conus medullaris syndrome
Early disturbance of bladder and bowel control, urine retention, constipation
Erectile impotence Symmetrical saddle anesthesia Pain is not common, but may occur
late
CAUDA EQUINA SYNDROME
•Acute central disc prolapse L4/5. •Medially placed sacral roots sustainmaximumcompression
Cauda equina syndrome
Early radicular pain in the distribution of lumbosacral roots, usually asymmetric
Pain May be unilateral Worse when lying down
Flaccid paresis - glutei, posterior thigh muscles, anterolateral leg muscles, and foot
Asymmetric saddle anesthesia Loss of ankle jerk Sphincter disturbance uncommon
Conus Medullaris vs. Cauda Equina lesionFindings CONUS
MEDULLACAUDA EQUINA
Motor Symmetric Asymmetric Sensory loss Saddle Saddle Pain Uncommon Common Reflexes Increased Decreased Bowel/bladder Common Uncommon
Spinal Tuberculosis Dorsolumbar region is the most frequently involved
with D.11 vertebra being most often affected Radiological features:
disc space narrowing only kissing lesions; half-moon wedge collapse of vertebra; vertebra plana; lesions localised in the vertebral body and/or its
appendages para-spinal abscesses; complete destruction of vertebral body.
Spinal tuberculosis
Other causes of spinal canal narrowing Ankylosing spondylitis Ossification of posterior longitudinal
ligament Paget disease Achondroplasia Platybasia and basilar invagination
Intra spinal tumors Most intraspinal tumours are benign Effects are usually due to compression
rather than infiltration Anatomical groups
Intramedullary▪ Primary▪ Metastasis
Extramedullary▪ Primary ▪ Metastasis
Primary neoplasms Intramedullary
▪ Astrocytomas, oligodendrogliomas, Ependymomas lipomas, teratomas
Extramedullary▪ Neurofibromas, more intradural than extradural ▪ Meningiomas, sarcomas, vascular tumours, chordomas
Secondary neoplasms Extramedullary
▪ Extradural▪ Carcinomas, lymphoma, myeloma
▪ Intradural▪ Usually lymphoma spreading to the meninges
Intramedullary▪ Bronchogenic carcinoma
Clinical features: tumors
Compression of spinal cord by tumor reduces the CSF space arround the cord
Loculation of CSF below the lesion Increase protein and xanthochromia
(Froin Syndrome
Intramedullary vs Extramedullary
Intramedullary Extramedullary
Poorly localized burning pain Prominent radicular pain
“sacral sparing” Early sacral sensory loss
Corticospinal tract signs appear later
Early spastic weakness in legs
Usually rapid progression (usually malignant lesion)
Usually slow progression (usually benign lesion)
Foramen magnum syndrome
Pain Suboccipital
Lhermitte symptoms Quadriparesis Neck stiffness Atrophy of the muscles of the hands and dorsal
neck muscles Lower cranial nerve palsies, IX – XII Horner’s syndrome Papilledema Downbeat nystagmus Cerebellar ataxia
Common Investigation
Spinal Xray- plain and contrast Spinal CT Spinal MRI Bone scan Tumor markers
Neurofibroma
Cervical astrocytoma
Lumbar spondylosis
Spinal meningioma
Cervical spondylosis
Treatment Goals: palliative, pain control,
preserve or restore ambulation & stability
Start definitive treatment ideally within 24 hours of Dx
Carefully plan surgery: consider fitness, prognosis, preferences
Urgent <24hours RT for definitive treatment if unsuitable for surgery
General management Bladder dysfunction – anticholinergics-
oxybutynin, α-adrenergic blockers-doxazocin, prazocin
Bowel dysfunction Decubitus ulcers Spasticity- baclofen, diazepam, dantrolene,
clonidine, tizanidine Deep vein thrombosis- antiembolism
stockings, pneumatic compression stocking, LMWH, IV heparin in acute DVT. INR 1.5-2.5, warfarin . Monitor PTTK,
Metastatic C management Analgesia: Conventional by WHO pain
relief ladder, ?specialist pain care Bisphosphonates: myeloma or breast Ca
and prostate if analgesia has failed; not for others
Corticosteroids: 16mg loading dexameth- 16mg/d, over 5-7/7 after RT or surgery- complications: sepsis, bowel perforation
Biopsy & stage (no., sites, extent)
Surgery
Vertebroplasty/kyphoplasty - consider if no malignant spinal cord compression or instability &:- mechanical pain resistant to analgesia- vertebral body collapse
Surgery: consider urgently if spinal instability, mechanical pain resistant to analgesia
External spinal support (halo, orthosis) if unsuitable for surgery
Radiotherapy Urgent (<24hrs) if definitive treatment or
unsuitable for surgery unless:- tetraplegia or paraplegia >24hrs and pain controlled; overall poor prognosis
Fractionated RT- definitive Tx if no neuro impairment, pain or instability
Post-operative RT offered when wound healed
TB: treatment/complications Treatment: AntiTB for 12 months,
Spinal support, decompression
Complications: Arachnoiditis, Froin syndrome, myelitis, Intraspinal granuloma, vasculitis with infarction,
Rehabilitation
Motorized wheel chair Pneumatic mattress Dedicated seats, toilets, walkways
Conclusion
Cord compression presents with a number of features attributable to the site of compression
The commonest cause is traumatic Non traumatic causes could be broadly
classified into extradural and intradural causes
Urgent diagnosis and treatment of acute SCCC is important to preserve neurologic function
Thank you