Chronic Spinal Cord Injury (Lesi Medula Spinalis Khronis) Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

The Spinal Cord Cervical spinal erves Thoracic spinal nerves Conus medullaris Cauda equina Lumbar spinal nerves Sacral spinal nerves

PROYEKSI DERMATOM DIPERMUKAAN KULIT

Ascending Spinal Cord Tract Conducts sensory impulses upward through 3 successive chains of neurons 1st order neuron - cutaneous receptors of skin and proprioceptors  spinal cord or brain stem 2nd order neuron - to thalamus or cerebellum 3rd order neuron - to somatosensory cortex of cerebrum

Ascending Spinal Cord Tract

The Spinal Cord vertebra spinal cord spinal nerve

Cross Section of Spinal Cord White matter: Myelinated axons forming nerve tracts Fissure and sulcus Three columns: Ventral Dorsal Lateral Gray matter: Neuron cell cell bodies, dendrites, axons ‘Horns’: Posterior (dorsal) Anterior (ventral) Lateral Commissures: Gray: Central canal White (see later for white matter pathways)

The Nervous System The Spinal Cord-part of the CNS found within the Spinal column The spinal cord communicates with the sense organs and muscles below the level of the head Bell-Magendie Law-the entering dorsal roots carry sensory information and the exiting ventral roots carry motor information to the muscles and Glands Dorsal Root Ganglia-clusters of neurons outside the spinal cord

Nerve Pathways into the Spinal Cord sensory pathway motor pathway

Somatic Sensory Pathway

CORTICOSPINAL TRACTS

Symptoms and Signs Must be mastering in mind Start by understanding anatomy and physiology of the Nervous System Don’s forget the of CNS systematically - Anatomy of CNS - Physiology of CNS - Pathophysiology of the Disease - The steps to make the diagnosis

Sensory disturbances ▪ Soft touch, pain, temperature, position, vibration impaired below the level of lesion ▪ Band like radicular pain/segmental paraesthesia at the level of lesion ▪ localised vertebral spine pain- destructive lesions

▪ Extension of hip, knee occurs in high spinal & Incomplete lesion Motor disturbances ▪ Paraplegia/quadriplegia ▪ Acute-flaccid / Areflexic-spinal shock latter-hypertonic / hyper reflexic, loss of superficial reflexes, Babinski +, flexor/extensor spasm ▪ Extension of hip, knee occurs in high spinal & Incomplete lesion

Motor disturbances • Flexion of hip , knee occur in low spinal & complete lesion • At the level of lesion – paresis, atrophy, fasciculations,and areflexia(LMN signs) in a segmental distribution because of damage to the anterior horn cells and ventral roots

Autononomic disturbances initially atonic, latter spastic bladder, rectal sphincter disturbances orthostatic hypotension trophic skin changes anhydrosis impaired temperature control vasomotor instability sexual disturbances I/L horner syndrome

Causes of Chronic Lesion ° Tumour ° Multiple sclerosis ° Vascular disorders ° Spinal epidural hematoma/abscess ° Auto immune disease ° Herniated intervertebral disc ° Combine degeneration of B12 Deficiences

Complete spinal cord transection (Transverse myelopathy)

Complete spinal cord transection (Transverse myelopathy) All acsending tracts from below the level of the lesion and all descending tract from above the level of lesion interrupted. Motor, sensory, autonomic functions below the level of lesion disturbed Causes : ° tumour ° multiple sclerosis ° vascular disorders ° spinal epidural hematoma/ ° spinal epidural abscess ° herniated intervertebral disc ° auto immune disease

Central spinal cord lesion Spinal cord damage starts centrally and spreads centrifugally Decussating fibers of spinothalamic tract involved initially Thermo anaesthesia, analgesia in a ”vest like” or “suspended” bilateral distribution with preservation soft touch sensation and proprioception-- - dissociation of sensory loss

Central spinal cord lesion Forward extension of disease anterior horn cells involved segmental neurogenic atrophy, paresis, areflexia Lateral extension I/L Horner syndrome Kypho scoliosis Spastic paralysis Dorsal extension I/L Position sense, vibratory loss

Central spinal cord lesion Extreme venterolateral extension thermo anaesthesia, analgesia with sacral sparing Neuropathic arthropathy Pain

Posterior column disease

Posterior column disease Tabes dorsalis-tabetic neuro syphilis, progressive locomotor ataxia Impaired vibration and position sense, and decreased tactile localisation Lability of mechanical sensation threshold, tactile & postural hallucinations, persistence of mechano receptor sensation, disturbances in the knowledge of extremity movement and positions (temporal & spatial disturbances) Sensory ataxia in dark, Romberg (+)

Posterior column disease Ataxic / stomping/ double tapping gait Positive sink sign In tabes dorsalis lancinating pain, urinary incontinence, Negative patellar and ankle DTR, hypotonic limb, hyper extensible joints abdominal, laryngeal crises, impaired light touch perception, Argyll robertson pupil, optic atrophy, ptosis, ophthalmoplegia

Posterior column disease ○ Lhermitte sign or barber chair syndrome due to increased mechano sensitivity ○ Truncal and gait ataxia : also seen in mets causing cord compression ○ Impaired conduction in dorsal spino cere - bellar tract may be a primar manifestation of epidural spinal cord compression-lower extremity dysmetria and gait ataxia. ○ Pt usually have thoracic spine compression due to selective vulnerability of spinocere bellar tract in thoracic spine to compres - sive ischemia

Hemisection of the spinal cord ( Brown sequard syndrome)

Hemisection of the spinal cord ( Brown sequard syndrome) Loss of pain, temp C/L to the hemisection- interruption of crossed spino thalamic tract Loss of proprioception – interruption of ascending fibers of posterior column Spastic weakness due to interruption of descending cortico spinal tract Segmental LMN signs and sensory changes at the level of lesion due to damage of the roots and anterior horn cells at the level of lesion

INNERVATION OF AUTONOMIC NERVOUS SYSTEM

Thank you Brain For all you remember What you forgot was my fault