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

2. PARAPLEGIA AND SPINAL CORD SYNDROMES

4. 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

5. 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

6. 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

7. 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

8. BLOOD SUPPLY SPINAL CORD

9. 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

10. 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

12. 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

13. 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

14. 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

15. 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?

16. 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?

17. 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?

18. 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?

19. 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 weeks
Pott’s paraplegia
Spinal epidural abscess
Spinal cord tumors
Chronic ˃ 6weeks
Familial spastic paraplegia
Amyotrophic lateral sclerosis
Cranio-vertebral junction anomalies

20. 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.

21. 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.

22. 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.

23. 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

24. 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

25. 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.

26. 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

27. 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.

28. 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

29. 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

30. 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.

31. 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

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

33. 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

34. 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

35. 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.

36. 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

37. Posterior Cord Syndrome

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

39. THANK YOU