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

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

3. PROYEKSI DERMATOM DIPERMUKAAN KULIT

4. 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

5. Ascending Spinal Cord Tract

6. The Spinal Cord
vertebra
spinal cord
spinal nerve

8. 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)

9. 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

10. Nerve Pathways into the Spinal Cord
sensory pathway
motor pathway

11. Somatic Sensory Pathway

13. CORTICOSPINAL TRACTS

14. 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

15. 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

16. ▪ 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

17. 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

18. 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

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

22. Complete spinal cord transection (Transverse myelopathy)

23. 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

25. 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

26. 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

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

30. Posterior column disease

31. 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 (+)

32. 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

33. 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

35. Hemisection of the spinal cord ( Brown sequard syndrome)

36. 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

37. INNERVATION OF AUTONOMIC NERVOUS
SYSTEM

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