1. 25.05.2009 Dr.H.N.Sarker Compressive and non compressive spinal cord syndrome Dr. H.N. Sarker MBBS, FCPS (Medicine), MACP(USA), MRCP(UK), MRCPS(GLASGO),FRCP(Edin) Associate Professor Medicine SBMC, Barisal

2. 25.05.2009 Dr.H.N.Sarker INTRODUCTION Spinal cord is a long, thin tubular structure of central nervous system which extends from foramen magnum to lower border of first lumbar vertebra. It is covered by three meninges – Dura, arachnoid, and pia matters. Spinal cord is a long, thin tubular structure of central nervous system which extends from foramen magnum to lower border of first lumbar vertebra. It is covered by three meninges – Dura, arachnoid, and pia matters.

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4. 25.05.2009 Dr.H.N.Sarker INTRODUCTION…. Spinal cord consists of 31 spinal segments from which corresponding pair of spinal nerve arise. Since the spinal cord is shorter than vertebral canal, spinal segment does not correspond with vertebra. Spinal cord consists of 31 spinal segments from which corresponding pair of spinal nerve arise. Since the spinal cord is shorter than vertebral canal, spinal segment does not correspond with vertebra.

5. 25.05.2009 Dr.H.N.Sarker INTRODUCTION There are two enlargements in spinal cord – There are two enlargements in spinal cord –  cervical (C4-T1) from which nerves supplying the upper limbs arise  lumbar (L1-S3) from which nerves supplying lower limbs arise.

6. 25.05.2009 Dr.H.N.Sarker Blood Supply Spinal cord is supplied by Spinal cord is supplied by a single anterior spinal artery – which supplies anterior two thirds of spinal cord a single anterior spinal artery – which supplies anterior two thirds of spinal cord Two posterior spinal arteries- which, supplemented by segmental arteries supply posterior one third of the cord. Two posterior spinal arteries- which, supplemented by segmental arteries supply posterior one third of the cord.

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8. 25.05.2009 Dr.H.N.Sarker Neuroanatomy Any lesion of the spinal cord produces effects involving the spinal segment(s) and long tract(s) of the spinal cord. So, to understand the effect of any lesion you should clearly understand anatomical arrangement of the spinal segment and long tracts. Any lesion of the spinal cord produces effects involving the spinal segment(s) and long tract(s) of the spinal cord. So, to understand the effect of any lesion you should clearly understand anatomical arrangement of the spinal segment and long tracts.

9. 25.05.2009 Dr.H.N.Sarker Neuroanatomy Each segment consists of Each segment consists of central gray matter central gray matter peripheral white matter peripheral white matter

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11. 25.05.2009 Dr.H.N.Sarker Neuroanatomy Central gray matter: Composed of nerve cells which are arranged as Central gray matter: Composed of nerve cells which are arranged as anterior horn cell- lower motor neuron anterior horn cell- lower motor neuron Posterior horn cell- Posterior horn cell-  Sensory neuron  Second order neuron  Fibre from this neurons crosses within the segment to the opposite side to form lateral spinothalamic tract. First order neuron lies in dorsal root ganglion of spinal cord.

12. 25.05.2009 Dr.H.N.Sarker Neuroanatomy Peripheral white matter: Peripheral white matter: It contains bundles of fibres that are called tracts. It contains bundles of fibres that are called tracts.

13. 25.05.2009 Dr.H.N.Sarker Neuroanatomy Long tracts: Long tracts: There are at least 10 tracts in spinal cord; But we are interested in only three long tracts- corticospinal tract, spinothalamic tract and dorsal column which subserves most of the functions. There are at least 10 tracts in spinal cord; But we are interested in only three long tracts- corticospinal tract, spinothalamic tract and dorsal column which subserves most of the functions.

14. 25.05.2009 Dr.H.N.Sarker Neuroanatomy Corticospinal tract: Corticospinal tract: It produces ipsilateral upper motor neuron lesion as the fibres of the tract crosses at medullae oblongata. It produces ipsilateral upper motor neuron lesion as the fibres of the tract crosses at medullae oblongata.

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16. 25.05.2009 Dr.H.N.Sarker Neuroanatomy Spinothalamic tract: Spinothalamic tract: It contains fibers for pain, crude touch and temperature. Since fibers of 2nd order neuron crosses within the segment to opposite side, any lesion of the tract leads to loss of pain and temperature sensation of opposite site of the body below the lesion. It contains fibers for pain, crude touch and temperature. Since fibers of 2nd order neuron crosses within the segment to opposite side, any lesion of the tract leads to loss of pain and temperature sensation of opposite site of the body below the lesion.

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18. 25.05.2009 Dr.H.N.Sarker Neuroanatomy Dorsal column: Dorsal column: It carries sense of position and vibration and fine touch. As the fibres croses midline at medullae oblongata, so lesion in the tract produce ipsilateral loss of sense of position and vibration and fine touch. It carries sense of position and vibration and fine touch. As the fibres croses midline at medullae oblongata, so lesion in the tract produce ipsilateral loss of sense of position and vibration and fine touch.

19. 25.05.2009 Dr.H.N.Sarker Compressive Spinal cord lesion: Common causes SiteFrequencyCauses Vertebral80% Trauma (extradural) Intervertebral disc prolapse Metastatic carcinoma (e.g. breast, prostate, bronchus) Myeloma Tuberculosis Meninges (intradural extramedullary 15% Tumours (e.g. meningioma, neurofibroma, ependymoma, metastasis, lymphoma, leukaemia) Spinal cord (intradural intramedullary 5% Epidural abscess Tumours (e.g. glioma, ependymoma, metastasis

20. 25.05.2009 Dr.H.N.Sarker Compressive Spinal cord lesion Clinical features: Clinical features: Onset is usually slow (over weeks) but can be acute as a result of trauma or metastases. Onset is usually slow (over weeks) but can be acute as a result of trauma or metastases.

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22. 25.05.2009 Dr.H.N.Sarker SYMPTOMS OF SPINAL CORD COMPRESSION Pain: Pain:  Localised over the spine or in a root distribution, which may be aggravated by coughing, sneezing or straining Sensory: Sensory:  Paraesthesia, numbness or cold sensations, especially in the lower limbs, which spread proximally, often to a level on the trunk

23. 25.05.2009 Dr.H.N.Sarker SYMPTOMS OF SPINAL CORD COMPRESSION Motor : Motor :  Weakness, heaviness or stiffness of the limbs, most commonly the legs Sphincters: Sphincters:  Urgency or hesitancy of micturition, leading eventually to retention.

24. 25.05.2009 Dr.H.N.Sarker SIGNS OF SPINAL CORD COMPRESSION Signs depends on site of lesion and completeness of involvement. Signs depends on site of lesion and completeness of involvement.

25. 25.05.2009 Dr.H.N.Sarker SIGNS OF SPINAL CORD COMPRESSION Cervical, above C5:  Upper motor neuron signs and sensory loss in all four limbs  Diaphragm weakness (phrenic nerve) Cervical, C5 to T1: Cervical, C5 to T1:  Lower motor neuron signs and segmental sensory loss in the arms;  upper motor neuron signs in the legs  Respiratory (intercostal) muscle weakness

26. 25.05.2009 Dr.H.N.Sarker SIGNS OF SPINAL CORD COMPRESSION Thoracic cord : Thoracic cord :  Spastic paraplegia with a sensory level on the trunk Conus medullaris: Conus medullaris:  Lesions at the end of the spinal cord cause sacral loss of sensation and extensor plantar responses

27. 25.05.2009 Dr.H.N.Sarker SIGNS OF SPINAL CORD COMPRESSION Cauda equina : Cauda equina :  Spinal cord ends at approximately the T12/L1 spinal level and spinal lesions below this level can only cause lower motor neuron signs by affecting the cauda equine.

28. 25.05.2009 Dr.H.N.Sarker Signs of partial transection of spinal cord (Brown- Sequard syndrome) Site of Lesion IpsilateralContralateral At the level Hyperaesthesia Below the level UMN lesion Loss of Propioception and vibration. Loss of pain and thermal sensation.

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30. 25.05.2009 Dr.H.N.Sarker Investigation Plain X-rays of spine Plain X-rays of spine MRI of spine or myelography MRI of spine or myelography Chest X-rays Chest X-rays CSF CSF Serum B12 Serum B12

31. 25.05.2009 Dr.H.N.Sarker Management General measures General measures  Care of skin:  Meticulous attention must be paid to cleanliness and to turning pt two hrly  Inspect pressure areas regularly  Use pressure mattress  Treat any pressure sore

32. 25.05.2009 Dr.H.N.Sarker Management General measures……. General measures…….  Care of Bladder: Self catheterization or reflex bladder emptying Self catheterization or reflex bladder emptying  Care of Bowel: Constipation and fecal impacation must be avoided. Constipation and fecal impacation must be avoided.

33. 25.05.2009 Dr.H.N.Sarker Management  General measures……  Care of paralysed limbs:  Passive physiotherapy to prevent contracture.  Severe spasticity may be helped by beclofen or diazepam.

34. 25.05.2009 Dr.H.N.Sarker Management  Specific measure:  Treatment of the underlying cause e.g. anti TB in pott’s disease.  Rehabilitation

35. 25.05.2009 Dr.H.N.Sarker Non compressive spinal cord syndrome causeconditions Hereditary Hereditary spastic paraplegia, Friedreich’s ataxia Infective/inflammatory Transverse myelitis, MS, Syphilis Vascular Anterior spinal artery infarct Spinal AVM Metabolic Vitamin B12 deficiency (subacute combined degeneration Degenerative Motor neuron disease, Syringomyelia

36. 25.05.2009 Dr.H.N.Sarker Acute Transverse Myelitis Acute Transverse Myelitis is an acute, often monophasic inflammatory demyelinating disease affecting the spinal cord over a variable number of segments. Acute Transverse Myelitis is an acute, often monophasic inflammatory demyelinating disease affecting the spinal cord over a variable number of segments.

37. 25.05.2009 Dr.H.N.Sarker Aetiology Multiple Sclerosis Multiple Sclerosis Post infectious e.g. CMV Post infectious e.g. CMV Post vaccination Post vaccination Trauma Trauma Surgery Surgery

38. 25.05.2009 Dr.H.N.Sarker Clinical Feature Any age Any age Subacute onset Subacute onset May be severe neck or back pain May be severe neck or back pain Spastic paraparesis Spastic paraparesis Definite sensory level Definite sensory level Sphincter involvement- Initially urinary retention later on incontinence Sphincter involvement- Initially urinary retention later on incontinence

39. 25.05.2009 Dr.H.N.Sarker Investigation MRI MRI CSF study CSF study

40. 25.05.2009 Dr.H.N.Sarker Management General measures General measures  As for a paralysed patient Specific measure: Specific measure:  High dose intravenous methyl prednisolone.

41. 25.05.2009 Dr.H.N.Sarker Prognosis Variable Variable One third recovered completely One third recovered completely One third remains with residual disability One third remains with residual disability One third bed ridden. One third bed ridden.

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