CENTRAL NERVOUS SYSTEM spinal cord and brain SPINAL CORD ...
Spinal Cord Syn
-
Upload
mohammad-sadiq-azam -
Category
Documents
-
view
20 -
download
0
Transcript of Spinal Cord Syn
In the Name of God, Most Gracious, Most Merciful
SPINAL CORD
SYNDROMES
- Dr. Mohammed Sadiq Azam
II yr. Postgraduate
MD Internal Medicine
Deccan College of Medical Sciences
CLASSIFICATION
COMPLETE
INCOMPLETE
Trauma
Metastatic carcinoma
Multiple sclerosis
Spinal epidural haematoma
Autoimmune disorders
Post vaccinial syndromes.
COMPLETE CORD SYNDROMES
• All ascending tracts from
below and descending tracts
from above are interrupted.
• Affects motor, sensory and
autonomic functions.
COMPLETE CORD TRANSECTION
SENSORY:
All sensations are affected.
Pin prick test is very valuable.
Sensory level is usually 2 segments below the level of
lesion.
Segmental paraesthesia occur at the level of lesion.
COMPLETE CORD TRANSECTION
MOTOR:
Paraplegia due to corticospinal tract involvement.
First spinal shock-followed by hypertonic
hyperreflexic paraplegia.
Loss of abdominal and cremastric reflexes.
At the level of lesion LMN signs occur.
COMPLETE CORD TRANSECTION
AUTONOMIC:
Urinary retention and constipation.
Anhidrosis, trophic skin changes, vasomotor instability
below the level of lesion.
Sexual dysfunction can occur.
COMPLETE CORD TRANSECTION
Brown Sequard syndrome
Central cord syndrome
Anterior cord syndrome
Posterior cord syndrome
Conus medullaris syndrome
Cauda equina syndrome
INCOMPLETE CORD SYNDROMES
BROWN SEQUARD SYNDROME
= Hemi-section of the spinal cord
Caused by extramedullary lesions
Usually caused by penetrating trauma or tumour.
SENSORY:
Ipsilateral loss of proprioception due to
posterior column involvement.
Contralateral loss of pain and temperature
due to involvement of lateral spinothalamic tract.
BROWN SEQUARD SYNDROME
MOTOR:
Ipsilateral spastic weakness due to
descending corticospinal tract involvement
LMN signs at the level of lesion.
BROWN SEQUARD SYNDROME
CENTRAL CORD SYNDROME
CENTRAL CORD SYNDROME
Commonest cause is Syringomyelia.
Other causes:
◦ Hyperextension injuries of neck
◦ Intramedullary tumours
◦ Trauma
◦ Associated with Arnold Chiari type 1 and 2, Dandy walker
malformation
CENTRAL CORD SYNDROME
SENSORY:
Pain and temperature are affected.
Touch and proprioception are preserved.
Dissociative anaesthesia.
Shawl like (= Cape like) distribution of sensory loss.
MOTOR:
Upper limb weakness > Lower limb
CENTRAL CORD SYNDROME
OTHER FEATURES :
Horner’s syndrome
Kyphoscoliosis
Sacral sparing
Neuropathic arthropathy of shoulder and
elbow joint
Prognosis is fair.
SYRINGOMYELIA
Commonest causes include diabetes mellitus &
neurosyphilis.
Usually occurs 10 to 20 yrs after disease onset.
POSTERIOR CORD SYNDROME
SENSORY :
Impaired position and vibration sense in LL
Tactile and postural hallucinations can occur.
Numbness or paresthesia are frequent complaints..
Sensory ataxia.
Positive rhomberg sign.
Positive sink sign
Positive lhermittes sign.
POSTERIOR CORD SYNDROME
SENSORY (contd):
Abadie’s sign (of tabes dorsalis) positive
Urinary incontinence
Absent knee and ankle jerk (Areflexia, Hypotonia)
Charcot’s joint
Miotic and irregular pupil not reacting to light
Argyl Robertson Pupil
POSTERIOR CORD SYNDROME
CAUSES :
Vitamin B12 deficiency
AIDS
HTLV associated myelopathy
Cervical spondylosis
POSTERIO LATERAL COLUMN DISEASE
FEATURES :
Paresthesia in feet
Loss of proprioception and vibration in legs
Sensory ataxia
Positive Rhomberg sign
Bladder atony
Corticospinal tract involvement:
◦ Spasticity
◦ Hyperreflexia
◦ Bilateral Babinski sign - Positive
POSTERIO LATERAL COLUMN DISEASE
AIDS:
◦ Associated dementia and spastic bladder is present
HTLV associated myelopathy:
◦ Slowly progressive paraparesis
◦ Increase in CSF IgG with antibodies to HTLV 1
POSTERIO LATERAL COLUMN DISEASE
Due to acute disc herniation or ischemia from anterior
spinal artery occlusion.
Usually caused by hyperflexion injuries
Area supplied by anterior spinal artery is affected
ANTERIOR CORD SYNDROME
Sudden onset of paralysis
(quadriparesis/paraparesis)
below the level of lesion.
Pain and temperature loss.
Dorsal column is
preserved.
Prognosis is poor.
ANTERIOR CORD SYNDROME
ANTERIOR SPINAL ARTERY SYNDROME
ANTERIOR SPINAL ARTERY SYNDROME
Commonest of the vascular syndromes of the cord.
Spinal cord infarction usually occurs in T1 to T4 segment & L1.
Occurs due to aortic dissection, atherosclerosis of aorta, SLE,
AIDS, AV malformation
Rarely due to dissection of the anterior spinal artery or systemic
arteritis. Syphilitic arteritis is now rare.
Conus medullaris is frequently involved.
Neck pain of sudden onset is a common feature.
Also called as “Beck’s syndrome”.
ANTERIOR SPINAL ARTERY SYNDROME
SENSORY :
Loss of pain and temperature.
Preservation of position and vibration.
MOTOR :
Sudden onset flaccid and areflexic paraplegia.
AUTONOMIC :
Urinary incontinence +
ANTERIOR SPINAL ARTERY SYNDROME
UNCOMMON
Loss of proprioception and vibratory sense.
Pain and temperature is preserved.
Absence of motor deficit.
POSTERIOR SPINAL ARTERY SYNDROME
CAUSED BY SPINAL MUSCULAR ATROPHY
◦ Spinal muscular atrophy (SMA) is an autosomal recessive
disorder that causes decreased survival of the anterior horn
cells – motor neurons – that innervate voluntary muscles,
resulting in progressive muscle atrophy and weakness.
◦ Types I to IV
◦ Eponyms: Werdnig-Hoffman disease, Kugelberg-Welander
disease, SMA, Anterior horn cell disease
ANTERIOR HORN CELL SYNDROMES
MOTOR :
Weakness, atrophy and fasciculations.
Hypotonia, depressed reflexes.
Muscles of trunk and extremities are affected.
Sensory system is not affected.
ANTERIOR HORN CELL SYNDROMES
Occurs in amytrophic lateral sclerosis (ALS).
◦ Also called Lou Gehrig's disease.
◦ A form of Motor Neuron Disease caused by the degeneration of
upper and lower neurons, located in the ventral horn of
the spinal cord and the cortical neurons that provide
their efferent input.
Affects the anterior horn cells and corticospinal tract.
Both LMN and UMN signs occur.
ANTERIOR HORN CELL & PYRAMIDAL TRACT SYNDROME
MOTOR :
Ant horn cell related:
◦ Paresis, Atrophy and Fasciculations.
Corticospinal tract related:
◦ Paresis, Spasticity and Extensor plantar response.
ANTERIOR HORN CELL & PYRAMIDAL TRACT SYNDROME
It is usually unilateral with muscle weakness +
Reflexes are often exaggerated.
Bulbar and pseudo bulbar involvement occurs.
Sensory system is not affected.
Superficial reflex - Abdominal reflex is preserved.
ANTERIOR HORN CELL & PYRAMIDAL TRACT SYNDROME
CONUS MEDULLARIS & CAUDA EQUINA SYNDROMES
CM: Lies opposite to vertebral bodies of T12 and L1.
Contributes to 25% of spinal cord injuries.
Caused by flexion distraction injuries and burst
fractures.
Both UMN and LMN deficits occur.
Development of neurogenic bladder.
CONUS MEDULLARIS SYNDROME
CE: Begins at L2 disk space
distal to conus medullaris.
CE syndrome occurs due to:
◦ Acute disk herniation
◦ Epidural haematoma
◦ Tumour
CAUDA EQUINA SYNDROME
MOTOR :
Flaccid lower extremities.
Knee and ankle jerk absent.
SENSORY :
Asymmetrical sensory loss
Saddle anaesthesia
Loss of sensation around perineum, anus, genitals.
CAUDA EQUINA SYNDROME
AUTONOMIC:
Loss of bladder and bowel function.
Urinary retention.
CAUDA EQUINA SYNDROME
DDx: CONUS vs CAUDA
FEATURE CONUS MEDULARIS CAUDA EQUINA
PRESENTATION Sudden & Bilateral Gradual & Unilateral
REFLEXES Knee present, Ankle
–
(If the epiconus is
involved, patellar
reflex maybe absent
but bulbocavernosus
is spared)
Knee & Ankle –
Bulbocavernosus
reflex is absent in low
CE (sacral) lesions
RADICULAR PAIN Less severe More severe
LOW BACK ACHE More Less
Ref: http://www.emedicine.com/neuro/topic667.htm
FEATURE CONUS MEDULARIS
CAUDA EQUINA
SENSORY SYMPTOMS
Numbness tends to be more localized to perianal area; symmetrical and bilateral; sensory dissociation occurs.
Sensory loss of pin prick & temperature sensations (Tactile sensation is spared.)
Numbness tends to be more localized to saddle area; asymmetrical, maybe unilateral; no sensory dissociation; loss of sensation in specific dermatomes in lower extremities with numbness and paresthesia; possible numbness in pubic area, including glans penis or clitoris.
Ref: http://www.emedicine.com/neuro/topic667.htm
FEATURE CONUS MEDULARIS
CAUDA EQUINA
MOTOR SYMPTOMS
Typically symmetric, distal paresis of lower limbs that is less marked; fasciculations may be present.
Asymmetric areflexic paraplegia that is more marked; fasciculations rare; atrophy more common .
IMPOTENCE Frequent Less frequent; ED is commonerectile dysfunction that includes inability to have erection, inability to maintain erection, lack of sensation in pubic area (including glans penis or clitoris), and inability to ejaculate.
Ref: http://www.emedicine.com/neuro/topic667.htm
FEATURE CONUS
MEDULARIS
CAUDA EQUINA
SPHINCTER
DYSFUNCTION
Urinary retention and
atonic anal sphincter
cause overflow
urinary
incontinence and
fecal incontinence
Tend to present
early in course of
disease.
Urinary retention
Tends to present late in
course of disease
EMG Mostly normal
lower extremity
with external anal
sphincter invlmnt
Multiple root level
involvement; sphincters
may also be involved.
OUTCOME Less favourable More Favourable
Ref: http://www.emedicine.com/neuro/topic667.htm