1. Spinal Cord Compression Surgical Students’ Society of Melbourne Presentation Felicity Victoria Connon

2. Spinal Cord Compression Cervico-medullary junction  Conus medullaris +/- cauda equinae Lesions are: Extradural (80%) Intradural, extramedullary (15%) Intramedullary (5%) http://myradnotes.wordpress.com/category/tumor/http://indyspinemd.com/Images/normalAnat/coloredSpine.jpg

3. Causes of Spinal Cord Compression Acute Subacute Chronic LOCATION ExtraduralIntradural, Extramedullary Intramedullary AETIOLOGY TumourMetastases Myeloma, Leukaemia Lymphoma Chordoma 1° VB tumour Meningioma Schwannoma IC seeding (medulloblastoma, ependymoma) Glioma Metastases DegenerativeDisc prolapse OP/OA/spondylolithesis Ligamentum flava hypertrophy InfectionExtradural abscess VB (eg. TB) Abscess HaematomaExtradural haematoma (trauma) AVM Haematoma DevelopmentalArachnoid cyst Syrinx

4. Presentation - Pain Subacute  Chronic Pain Muscles Bone Segment/central Nerve root http://www.dheerajbojwani.com/images/spinal-nerve.jpghttp://www.patient.co.uk/images/OM1314b.jpg

5. Presentation – Altered Sensation and Power Brown-Sequard Syndrome/Hemisection Syringomyelia/Central cord Posterior Column Spinal Cord Lateral Compressive LesionCentral Cord Lesion Posterior Compressive Lesion Tracts Affected  Corticospinal  Dorsal column  Spinothalamic 1.Spinothalamic 2.Interomediolateral columns (autonomic) 3.Corticospinal Dorsal Column +/- Corticospinal & Autonomic Motor DeficitIpsilateral weakness LMN at level of lesion UMN below Bilateral weakness LMN at level of lesion UMN below Ipsilateral/Bilateral weakness LMN at level of lesion +/- UMN below Sensory DeficitIpsilateral loss of vibration, proprioception and fine touch Contralateral loss of pain and temperature Bilateral pain and temperature Cervical - Cape distribution extending downwards Sacral sparing Bilateral loss of vibration and proprioception Bladder and BowelUsually unaffectedLateLate incontinence

6. Presentation – Altered Sensation and Power CompleteAnterior SyndromeCauda Equinae Spinal Cord Anterior Compressive Lesion Tracts AffectedSpinothalamic Corticospinal Lumbar and Sacral nerve roots Motor DeficitBilateral weakness LMN at level of lesion UMN below Bilateral weakness LMN at level of lesion UMN below Ipsilateral or bilateral LMN Sensory DeficitAll modalities to level of lesion Bilateral loss of pain and temperature Lumbar nerve and S1 dermatome distribution (all modalities) S2-5 Saddle anaesthesia Bladder and Bowel1.Initiation 2.Retention 3.Incontinence Constipation +/- Priapism RetentionLoss of motor and sensory bladder control + detrusor paralysis (overflow incontinence) Impotence Faecal incontinence http://rezidentiat.3x.ro/eng/lombalgiaeng.files/image010.gif

7. Investigations MRI Definitive I x Spinal X-rays Erosion, destruction, collapse Scalloping,  IV space Myelography CT (intrathecal contrast) http://www.urmc.rochester.edu/smd/Rad/n eurocases/Case34/Fig3.jpg http://www.ortho.pe.kr/upload/ank_spond02.jpg

8. Management – Neurosurgical Emergency Conservative Rest Weight loss Epidural steroid injections Analgesia, anti- inflammatories Muscle relaxants Physiotherapy Specific Malignancy Extramedullary/Vertebral Laminectomy (post.) Vertebrectomy + fusion (ant.) XRT, chemo Intramedullary: Macroscopic excision XRT + Dexamethasone

9. Management Spinal canal stenosis Laminectomy Discectomy Foramenectomy ACDF Abscess Drainage +/- decompression Antibiotics AVM Dural: nidus excision or venous obliteration Intradural http://img.springerimages.com/Images/Springer/PUB=Springer-Verlag- Berlin- Heidelberg/JOU=00586/VOL=2009.18/ISU=S2/ART=2009_895/Media Objects/WATER_586_2009_895_Fig2_HTML.jpg

10. References Essential Neurosurgery, Kaye, 3 rd ed.,2005, Blackwell Publishing Neurology and Neurosurgery Illustrated, Lindsay & Bone, 4 th ed., 2004, Churchill Livingstone www.uptodate.com Treatment and prognosis of neoplastic epidural spinal cord compression, including cauda equinae. Schiff et al, 2010 Anatomy and localisation of spinal cord disorders, Eisen et al, 2010