1. 1 DISEASES OF THE SPINAL CORD Dr. Khairul P Surbakti, SpS

2. 2 DISEASES OF SPINAL CORD Related to special physiologic and anatomic Related to special physiologic and anatomic Including: Including: 1. Complete sensory motor myelopathy 2. Combined painful radicular & transverse cord syndromes 3. Hemicord (Brown-Squard syndromes) 4. Ventral cord syndromes, sparing posterior column function column function 5. High cervical-foramen magnum syndromes 6. Central cord or syringomyelic syndromes 7. Syndrome of conus medullaris 8. Syndromes of cauda equina

3. 3 The syndrome of acute paraplegia due to complete transverse lesion of the spinal cord (Transverse myelopathy) The syndrome of acute paraplegia due to complete transverse lesion of the spinal cord (Transverse myelopathy) 1. Trauma to the spine and Spinal cord Clinical Effects of spinal cord injury a. All involuntary movements in parts of the body below the lesion is immediately and permanently below the lesion is immediately and permanently lost lost b. All sensation from the lower parts is abolished c. Reflex functions in all segments of the isolated spinal cord are suspended spinal cord are suspended

4. 4 Spinal shock Spinal shock - Involves tendon as well as autonomic reflex - Duration : 1 to 6 weeks as, but sometimes longer longer - Riddoch : spinal cord transection - spinal shock & areflexia - heightened reflex activity - Less complete lesions  little or no spinal shocks

5. 5 Stage of Spinal shock or Areflexia Stage of Spinal shock or Areflexia - Loss of motor function: Cervical cord  Tetraplegia Thoracic cord  Paraplegia - Immediate atonic paralysis of bladder and bowel - Gastric atony - Loss of sensation below a level corresponding to the spinal cord lesion cord lesion - Muscular flaccidity - Almost complete suppression of all spinal segmental reflex activity below the lesion reflex activity below the lesion

6. 6 - Impaired of autonomic control in the segments below the lesion the lesion - Abolished of vasomotor tone, sweating, and piloerection in the lower parts of the body temporarily piloerection in the lower parts of the body temporarily - Systemic hypotension - The lower extremities lose heat - The skin becomes dry and pale - The spinchters of bladder and the rectum remain contracted to some degree due to loss of inhibitory contracted to some degree due to loss of inhibitory influences of higher CNS centers, but detrussor of the influences of higher CNS centers, but detrussor of the bladder and smooth muscle of the rectum  atonic bladder and smooth muscle of the rectum  atonic

7. 7 - Overflow incontinence - Passive distension of the bowel - Retention of feces - Absence of peristaltic (paralytic ileus) - Genital reflexes are abolished or profoundly depressed

8. 8 Stage of Heightened Reflex activity Stage of Heightened Reflex activity - The more familiar neurologic state that emerges within several weeks or months after spinal injury within several weeks or months after spinal injury - Heightened flexion reflexes - Babinski sign (+) - The Achilles and patellar reflexes return - Retention of urine becomes less complete - Reflex defecation also begins

9. 9 TRANSIENT CORD INJURY ( SPINAL CORD CONCUSSION)  Transient loss of motor and /or sensory functions of the spinal cord that recovers within minutes or hours but sometimes persist for a day or several days The syndromes including: - bibrachial weakness - quadriparesis ( occasionally hemiparesis ) - paresthesia or dysesthesias in a similar distribution to the weakness or sensory symptom alone the weakness or sensory symptom alone

10. 10 Central cord syndrome (Schneider syndrome) and Cruciate Paralysis - The loss of motor function is more severe in the upper limb than lower limbs and particularly severe in upper limb than lower limbs and particularly severe in the hands the hands - Bladder dysfunction with urinary retention - Sensory loss is often slight (hyperpathia over shoulder and arms may be the only sensory abnormality and arms may be the only sensory abnormality - Damage of the centrally ituated gray matter  atrophic, areflexic paralysis, segmental loss of pain,

11. 11 Causes : Causes : - Retroflexion injury of the head and neck - Hematomyelia - Necrotizing myelitis - Fibrocartilagenous embolism - Infarction due to dissection - Compression of the vertebral artery in the medullary- cervical region cervical region

12. 12 Examination and Management of the spine injured patient Examination and Management of the spine injured patient - The level of the spinal cord and vertebral lesions can be determined from clinical findings - Diaphragmatic paralysis : lesion of the upper three cervical segments - Complete paralysis of arm and legs : fractures or dislocation C4 to C5 vertebrae

13. 13 The level of sensory loss on the trunk  determined by perception of pinprick  an accurate guide to the level of the lesion The level of sensory loss on the trunk  determined by perception of pinprick  an accurate guide to the level of the lesion If any movement or sensation is elicitable during te first 48 to 72 hours  the prognosis is more favorable If any movement or sensation is elicitable during te first 48 to 72 hours  the prognosis is more favorable If the spine can be examined safely  inspection of angulation/irregularity, signs of bony injury If the spine can be examined safely  inspection of angulation/irregularity, signs of bony injury In all cases of suspected spinal injury  the immediate In all cases of suspected spinal injury  the immediate concern is that the movement (especially flexion) of the cervical spine be avoided.

14. 14 The patient should be placed supine on a firm, flat surface, keep the head and neck immobile The patient should be placed supine on a firm, flat surface, keep the head and neck immobile A neurologic examination wit detailed recording of motor, sensory, and spinchter function is necessary to follow the clinical progress of SCI A neurologic examination wit detailed recording of motor, sensory, and spinchter function is necessary to follow the clinical progress of SCI Common practice to define the injury: Common practice to define the injury: 1. Complete : motor and sensory loss below lesion 2. Incomplete : some sensory preservation below the zone of injury zone of injury 3. Incomplete : motor and sensory sparing, but the patient is nonfunctional is nonfunctional

15. 15 4. Incomplete : motor and sensory sparing and the patient is functional (stands and walks) patient is functional (stands and walks) 5. Complete functional recovery : reflex may be abnormal abnormal Group 2, 3, and 4 have a more favorable prognosis for recovery than does group 1

16. 16 Radiologic examination: Radiologic examination: - alignment of vertebrae and pedicles - fractures of pedicle or vertebral body - compression of spinal cord or cauda equina due to malalignment, bone debris in the spinal canal, the presence of tissue damage within cord The MRI is ideally suited to display these process, but if it is not available myelography with CT scanning is an alternative The MRI is ideally suited to display these process, but if it is not available myelography with CT scanning is an alternative

17. 17 Once the degree of injury to spine and cord have been assessed  Administer of metylprednisolone in high Once the degree of injury to spine and cord have been assessed  Administer of metylprednisolone in high dosage ( bolus of 30 mg/kg followed by 5.4 mg/kg every hour), beginning within 8 h of the injury and continued for 23 h. The greatest risk to the patient with spinal cord injury is The greatest risk to the patient with spinal cord injury is the first 10 days : gastric dilatation, ileus, shock, infection The mortality rate falls rapidly after 3 months The mortality rate falls rapidly after 3 months

18. 18 Aftercare of patient with paraplegia : Aftercare of patient with paraplegia : - psychologic support - management of bladder and bowel dirturbances - care of skin - prevention of pulmonary embolism - maintenance of nutrition - decubitus ulcers can be prevented by frequent turning to avoid pressure necrosis to avoid pressure necrosis - use of special mattresses - morning suppositories - physical therapy

19. 19 MYELITIS = infective and non infective inflammatory process of the spinal cord. the spinal cord. If it is confined to gray matter  poliomyelitis white matter  leukomyelitis white matter  leukomyelitis If approximately the whole cross-sectional area of the cord is involved  transverse myelitis

20. 20 The evolution of myelitic symptoms : The evolution of myelitic symptoms : - Acute  more or les within days - Sub acute  2 to 6 weeks - Chronic  more than 6 weeks CLASIFICATION OF INFLAMMATORY DISEASE CLASIFICATION OF INFLAMMATORY DISEASE OF THE SPINAL CORD I. Viral myelitis A. Enteroviruses ( groups A and B Coxsackie virus, A. Enteroviruses ( groups A and B Coxsackie virus, poliomyelitis, others) poliomyelitis, others)

21. 21 B. Herpes zoster C. Myelitis of AIDS D. Epstein-Barr virus (EBV), cytomegalovirus (CMV), herpes simplex. (CMV), herpes simplex. E. Rabies F. Arboviruses-flaviviruses (Japanese, West Nile, etc.) etc.) G. HTLV-1 (tropical spastic parapareis) II. Myelitis secondary to bacterial, fungal, parasitic, and primary granulomatous diseases of the meninges primary granulomatous diseases of the meninges and spinal cord and spinal cord

22. 22 A. Mycoplasma pneumoniae B. Lyme disease C. Pyogenic myelitis 1. Acute epidural abscess and granuloma 1. Acute epidural abscess and granuloma 2. Abscess of spinal cord 2. Abscess of spinal cord D. Tuberculous myelitis 1. Pott disease with spinal cord compression 1. Pott disease with spinal cord compression 2. Tuberculous meningomyelitis 2. Tuberculous meningomyelitis 3. Tuberculoma of spinal cord 3. Tuberculoma of spinal cord

23. 23 E. Parasitic and fungal infections producing epidural granuloma, localized meningitis, or epidural granuloma, localized meningitis, or meningomyelitis and abscess, especially certain meningomyelitis and abscess, especially certain form of shistosomiasis form of shistosomiasis F. Syphilitic myelitis 1. Chronic meningoradiculitis (tabes dorsalis) 1. Chronic meningoradiculitis (tabes dorsalis) 2. Chronic meningomyelitis 2. Chronic meningomyelitis 3. Meningovascular syphilis 3. Meningovascular syphilis 4. Gummatous meningitis including chronic 4. Gummatous meningitis including chronic spinal pachymeningitis spinal pachymeningitis G. Sarcoid meningitis

24. 24 III. Myelitis (myelopathy) of noninfectious inflammatory type inflammatory type A. Postinfectious and postvaccinal myelitis A. Postinfectious and postvaccinal myelitis B. Acute and chronic relapsing or progressive multiple sclerosis (MS) multiple sclerosis (MS) C. Subacute necrotizing myelitis and Devic disease D. Myelopathy with lupus or other forms of connective tissue disease and antipospholipid connective tissue disease and antipospholipid antibody antibody E. Paraneoplastic myelopathy and poliomyelitis

25. 25 TUBERCULOUS SPINAL OSTEOMYELITIS ( POTT’ DISEASE ) - Tuberculous osteitis of the spine with kyphosis (Pott disease) is well known in regions of endemic (Pott disease) is well known in regions of endemic tuberculosis tuberculosis - Children and young adults are most often affected - The osteomyelitis is the result of reactivation of tuberculosis at a site previously established by tuberculosis at a site previously established by hematogenous spread hematogenous spread

26. 26 An infectious endarteritis  bone necrosis and collapse An infectious endarteritis  bone necrosis and collapse of a thoracic or upper lumbar ( less often cervical ) vertebral body  angulated kyphotic deformity Symptoms : fever, night sweats, elevated sedimentation rate rate In some cases : spinal deformity  compresive myelo- pathy pathy Treatment :- external stabilization of the spine - long term antituberculous medication - long term antituberculous medication

27. 27 TUBERCULOUS MYELITIS - Pus or caseous granulation tissue may extrude from infected vertebra and gives rise to an epidural infected vertebra and gives rise to an epidural compression of the cord  Pott paraplegia compression of the cord  Pott paraplegia

28. 28 DEMYELINATIVE DISEASE ( ACUTE MULTIPLE SCLEROSIS ) - The most typical mode of clinical expression of demyelinative myelitis is with numbness that spread demyelinative myelitis is with numbness that spread over one or both sides of the body: over one or both sides of the body:  from the sacral segments to the feet  ant. Thighs  from the sacral segments to the feet  ant. Thighs  up over the trunk  coincident with asymmetric  up over the trunk  coincident with asymmetric weakness  then paralysis weakness  then paralysis - As this process becomes complete, bladder is affected

29. 29 Acute spinal MS is relatively painless and without fever Acute spinal MS is relatively painless and without fever the patient usually improves with variable residual signs Treatment : Treatment : - Corticosteroid  may lead to regression of symptoms sometimes with relapse when the medication is discontinued. - Plasma exchange - IVIG

30. 30 The combination of spinal cord necrosis and optic neuritis  Neuromyelitis optica (Devic’s disease)

31. 31 VASCULAR DIEASE OF THE PINAL CORD - In comparison with the brain, the spinal cord is an uncommon site of vascular disease - The spinal arteries tend not to be susceptible to atherosclerosis and emboli rarely lodge to atherosclerosis and emboli rarely lodge there. there.

32. 32 Vascular disorders of spinal cord : - infarction - dural fistula - bleeding - arteriovenous malformation

33. 33 INFARCTION OF THE SPINAL CORD INFARCTION OF THE SPINAL CORD ( MYELOMALACIA) ( MYELOMALACIA) HEMORRHAGE OF THE SPINAL CORD AND SPINAL CANAL (HEMATOMYELIA) HEMORRHAGE OF THE SPINAL CORD AND SPINAL CANAL (HEMATOMYELIA) VASCULAR MALFORMATIONS OF THE SPINAL CORD AND OVERLYING DURA VASCULAR MALFORMATIONS OF THE SPINAL CORD AND OVERLYING DURA

34. 34 SYRINGOMYELIA SYRINGOMYELIA SYRINX = “PIPE” OR “TUBE”  A CHRONIC PROGRESSIVE DEGENERATIVE OR DEVELOPMENTAL DISORDER OF THE SPINAL CORD CLINICALLY : PAINLESS WEAKNESS AND WASTING OF THE HAND AND ARMS PATHOLOGICALLY: CAVITATION OF THE CENTRAL PARTS OF SPINAL CORD

35. 35 USUALLY IN THE CERVICAL REGION BUT EXTENDING UPWARD IN SOME CASES INTO MEDULLA OBLONGATA AND PONS ( SYRINGOBULBIA ) OR DOWNWARD INTO THE THORACIC OR USUALLY IN THE CERVICAL REGION BUT EXTENDING UPWARD IN SOME CASES INTO MEDULLA OBLONGATA AND PONS ( SYRINGOBULBIA ) OR DOWNWARD INTO THE THORACIC OR EVEN THE LUMBAR SEGMENTS