PARAPLEGIA AND SPINAL CORD SYNDROMES Dr. M. Sofi MD;FRCP(London); FRCPEdin; FRCSEdin

PARAPLEGIA AND SPINAL CORD SYNDROMES

Spinal cord: Overview Information highway between brain and body Extends through vertebral canal from foramen magnum to L1 Each pair of spinal nerves receives sensory information and issues motor signals to muscles and glands Spinal cord is a component of the CNS while the spinal nerves are part of the peripheral Nervous System

Functions of the Spinal Cord The spinal cord has two major functions: Carrying information: The spinal cord has three major functions: Conduit for motor information, which travels down the spinal cord Conduit for sensory information in the reverse direction, and finally as a Center for coordinating certain reflexes Coordinating reflexes: Coordinates reflexes without the involvement of the brain. Reflex actions are automatic, unlearned, involuntary, and inborn responses. These actions are sudden in nature and have a purpose of protecting the individual or his organs from sudden danger

Lateral Coticospinal Tract Anterior Corticospinal Tract Somato-sensory organization Pyramidal tracts Descending Tracts Lateral Coticospinal Tract Anterior Corticospinal Tract Extra-pyramidal Tracts Rubrospinal Reticulaospinal Olivospinal Vestibulospinal

Somato-sensory Organization Sensory & Ascending Pathways Ascending tracts Dorsal Column Medial Lemniscus Gracile fasciculus Cuneate fasciculus Spinocerebellar Tracts Posterior spinocerebellar Anterior spinocerebellar Anterolateral System Lateral spinothalmic tract Anterior spinothalmic tract Spino-olivary tract

BLOOD SUPPLY SPINAL CORD

Paraplegia & Spinal cord syndromes Spinal shock is a loss of sensation accompanied by motor paralysis with initial loss but gradual recovery of reflexes, following a spinal cord injury (SCI) – most often a complete transaction. Reflexes in the spinal cord caudal to the SCI are depressed hyporeflexia/areflexia), while those rostral to the SCI remain unaffected. ‘Shock' in spinal shock does not refer to circulatory collapse, and should not be confused with neurogenic shock. Phase Time Physical exam finding Underlying physiological event 1 0-1d Areflexia/Hyporeflexia Loss of descending facilitation 2 1-3d Initial reflex return Denervation supersensitivity 3 1-4w Hyperreflexia (initial) Axon-supported synapse growth 4 1-12m Hyperreflexia, Spasticity Soma-supported synapse growth

Classification of etiology COMPRESSIVE MYELOPATHY Paraplegia & Spinal cord syndromes Classification of etiology COMPRESSIVE MYELOPATHY EXTRAMEDULLARY INTRAMEDULLARY Syringomyelia, Ependymymoa, Glioma, Astrocytoma EXTRADURAL INTRADURAL DISC VERTEBRAL Meningoma, Neurofibroma, Arachnoditis

COMPRESSIVE MYELOPATHY Paraplegia & Spinal cord syndromes COMPRESSIVE MYELOPATHY Intramedullary 5% Extramedullary 95% Syringomyelia Glioma Ependymoma Intradural 15% Extradural 80% Meningoma Neurofibroma Patchy Arachnoditis AV malformation Neoplasms Pott’s spine IVDP Epidural abscess Trauma

Classification of etiology Non-compressive myelopathies Paraplegia & Spinal cord syndromes Classification of etiology Non-compressive myelopathies NONINLAMMATORY INFAMMATORY INFECTIOUS: VIRAL, BACTERIAL FUNGAL PARASTIC AUTOIMMUNE: SLE, SJOGREN, SARCOIDOSIS, BECHET S, MCTD DEMYELINATING: MS,NMO, ADEM, POST VIRAL POST VACCINIAL PARANEOPLASTIC INHERITED: HSP, INHERITED METABOLIC DISORDERS METABOLIC: VIT B12,COPPER,FOLATE, AIDS ASSOCIATED, VIT E DEFICIENCY TOXIC: CASSAVA, LATHYRISM,FLUOROSIS, SMON, NITROUS OXIDE VASCULAR: ANT SPINAL ARTERY THROMBOSIS, AVM, DURAL AV FISTULA

Paraplegia & Spinal cord syndromes Differences between extradural and intradural lesions Extradural Mnemonic – (3 Ps) Pain present - (root pain & spinal tenderness) Pyramidal involvement – early Protein in CSF high Intradural Dissociated anesthesia Bladder involvement early Not so high protein Symmetrical involvement Trophic ulcers common Determining level of lesion in cord compression Sensory level Motor level Reflex level Root pain – dermatome Type of bladder involvement Sensory level – below that level, sensory impairment of loss Motor level – Beevor’s sign indicates T10 lesion Reflex level – Inverted supinator C5 lesion

Clinical approach to Spinal cord syndromes What is the onset of paraplegia Is it acute within minutes or hours? Sub-acute within days or weeks? Is it chronic within months or years? Was there a history of trauma? Fall from a Height? Road traffic accident? Direct injury to spine?

Any wasting or fasciculation? Clinical approach to Spinal cord syndromes Symmetry of symptoms? Is motor weakness symmetrical? Is sensory symptoms symmetrical? Or they are asymmetrical? Any wasting or fasciculation? Anywhere in the body? Small muscles of the hand? Thigh and gluteal muscles?

Clinical approach to Spinal cord syndromes Is there a history of root pains? Is it unilateral or bilateral? Does it radiate to Limbs? Does it aggravate with coughing? Any pyramidal tract involvement? Buckling of knees while walking? Slipping of foot Wear? Tipping on small Objects?

History of vaccinations? Clinical approach to Spinal cord syndromes History of vaccinations? Anti Rabies Vaccination? Polio vaccination? Others? History of increased ICT Fever and headache? Projectile vomiting? Seizures or loss of consciousness?

Clinical approach to Spinal cord syndromes What is the mode of onset of paraplegia Acute within days Transverse myelitis Anterior spinal artery syndrome Traumatic paraplegia Sub-acute 2- 6 weeks Pott’s paraplegia Spinal epidural abscess Spinal cord tumors Chronic ˃ 6weeks Familial spastic paraplegia Amyotrophic lateral sclerosis Cranio-vertebral junction anomalies

Lesion of the right dorsal column at L1 produces what impairment? Damage to the right dorsal column at L1 causes the absence of light touch, vibration, and position sensation in the right leg. Only fasciculus gracilis exists below T6.

Right Dorsal Column Lesion Common causes include MS, pene-trating injuries, and compression from tumors. DRG R L L1 Dorsal column lesion Ipsilateral loss of light touch, vibration, and position sense generalized below the lesion level Below T6 only the fasciculus gracilis is present.

R L Lesion of the right fasciculus cuneatus at C3 produces what impairment? Damage to the right fasciculus cuneatus at C3 causes the absence of light touch, vibration, and position sensation in the right arm and upper trunk.

Right Fasciculus Cuneatus Lesion Common causes include MS, penetrating injuries, and compression from tumors. DRG R L C3 Fasciculus cuneatus lesion Ipsilateral loss of light touch, vibration, and position sense In the right arm and upper trunk

Right Lateral Corticospinal Tract Lesion UMN Common causes include penetrating injuries, lateral compression from tumors, and MS. R L L1 Lateral corticospinal tract lesion Ipsilateral upper motor neurons signs generalized below the lesion level UMN signs Weakness (Spastic paralysis) Hyperreflexia (+ Babinski, clonus) Hypertonia

Lesion of the right lateral spinothalamic tract at L1 produces what impairment? Damage to the right lateral spinothalamic tract at L1 causes the absence of pain and temperature sensation in the left leg.

Right Lateral Spinothalamic Tract Lesion Common causes include MS, Penetrating injuries, compress-ion from tumors. R L L1 Lateral spinothalamic tract lesion Contralateral loss of pain and temperature sense

Lesion of the anterior gray and white commissures (central cord syndrome) at C5-C6 produces what impairment? L R Damage to the anterior gray and white commissures at C5-C6 causes the absence of pain and temperature sensation in the C5 and C6 dermatomes in both upper extremities.

Central Cord Syndrome Common causes include post-traumatic contusion syringo-myelia, and intrinsic spinal cord tumors. R L C5-C6 Lateral SpinothalamicTract Impaired pain and temperature sensation, C5-C6 dermatomes, bilaterally

Postraumatic central cord syndrome MRI of the cervical spine focal posterior disc protrusion at C3/4 level causing spinal stenosis obliterating CSF space and impressing onto the spinal cord. There is increased intramedullary T2 signal without abnormal T1 signal noted

Complete transection of the right half the spinal cord (Hemicord or Brown-Sequard syndrome) at L1 produces what impairments? R L Damage to the right dorsal columns at L1 causes the absence of light touch, vibration, and position sense in the right leg. Damage to the lateral corticospinal tract causes upper motor neuron signs in the right leg (Monoplegia), and damage to the lateral spinothalamic tract causes the absence of pain and temperature sensation in the left leg.

Hemicord Lesion (Brown-Sequard Syndrome) UMN DRG R L DRG L1 Dorsal column lesion Ipsilateral loss of light touch, vibration, and position sense Lateral corticospinal tract lesion Ipsilateral upper motor neurons signs Lateral spinothalamic tract lesion Contralateral loss of pain and temperature sense Hemicord lesion

Hemicord Lesion (Brown-Sequard Syndrome) Cervical spine MRI showing a T2 hyperintense enhancing lesion at C2-3

Transverse Cord Lesion Common causes include trauma, tumors, transverse myelitis, and MS. R L Transverse cord lesion Dorsal column lesion Bilateral loss of light touch, vibration, and position sense Lateral corticospinal tract lesion Bilateral upper motor neurons signs Lateral spinothalamic tract lesion Bilateral loss of pain and temperature sense

Anterior Cord Syndrome UMN UMN Common causes include anterior spinal artery infarct, trauma, and MS. DRG DRG R L Anterior cord lesion Lateral corticospinal tract lesion Ipsilateral upper motor neurons signs Lateral spinothalamic tract lesion Contralateral loss of pain and temperature sense

Anterior Cord Syndrome Hyperintense intramedullary lesion in T2 weighted image at the level C3-C7 (arrows), indicating acute cervical spinal cord infarction resulting from anterior spinal artery thrombosis MR sagittal T2: myelomalacia cavity C3-C7 in control after a month.

Posterior Cord Syndrome Common causes include trauma, compression from posteriorly located tumors, and MS. DRG DRG R L Dorsal column lesion (bilateral) Bilateral loss of light touch, vibration, and position sense, generalized below lesion level

Posterior Cord Syndrome

Parasagittal meningioma CT brain: acute left parafalcine subdural hematoma  extending into tentorium cerebella. Superior sagittal sinus thrombosis

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