Paraplegia and
spinal cord leasions
Dr. Mageda Bashir
: Corticospinal (pyramidal) tracts
The corticospinal tracts originate in the neurons of
the cortex and terminate at the motor nuclei of the
cranial nerves and spinal cord anterior horn
cells.congregate in the internal capsule and cross in
the madulla, passing to the contralateral cord as
corticospinal tracts.A proportion of the corticospinal
outflow is uncrossed (anterior corticospinal tracts).
.The pyramidal system,disease causes UMN lesions
Spinal cord :it extend from C1, the junction with the
medulla, to the lower vertebral body ofL1. Blood
supply is from the anterior spinal artery and a plexus
on the Posterior cord. This network is supplied by the
vertebral arteries and by several branches from
.lumbar and intercostal vessels
: Posterior columns
Axons in the Posterior columns whose cell bodies are in the
ipsilateral gracile and cuneate nuclei in the medulla carry
sensory modalities of vibration, joint position light touch and
two _point discrimination. Axons from second_order neurons
then cross in the brainstem to form the medial lemniscus,
.passing to the thalamus
:Spinothalamic tracts
Axons carrying pain and temperature sensation, cross within
the cord, and pass in the Spinothalamic tracts to the thalamus
.and reticular formation
:Sensory cortex
Fibers from the thalamus pass to the parietal region
sensory cortex. Connections exist between the
.thalamus, sensory and motor cortex
Posterior column lesions :cause
Tingling, electric shock_like sensation,numbness,
.tight band_like sensations
Position sense, vibration sense light touch and
two_point discrimination are diminished below the
.lesion
Position sense loss produce a stamping gait (sensory
.ataxia)
: Spinothalamic tracts lesions
Cause contralateral loss of pain and temperature sensation
.with a clear level below the lesion (dissociated sensory loss)
The fibres of the Spinothalamic tracts from lower spinal
roots lie superficially and are damaged first by compressive
lesions from outside the cord (meningioma),the spinal level
asend as deeper fibres involved. Conversely,a central cord
.lesion (syrinx) affectes deeper fibres first
Loss of pain and temperature perceptions(painless burns)
.ulcers and neuropathic(charcot) joints ,
:Paraparesis
Spastic paraparesis indicates bilateral damage to
corticospinal pathways causing weakness and
spasticity. Cord compression or cord diseases are the
usual causes ;cerebral lesions occasionally produce
.paraparesis
: Spastic paraparesis
: Cause
Cord compression
Demyelination (ms)
Transverse myelitis
Syrigomyelia
Tropical spastic paraparesis
Heredity spastic paraparesis
Osteoarthritis of the cervical spine
Parasagittal meningioma
MND
Paraneoplastic disorders
Subacute combined degeneration of the cord
Spinal cord compression
Cause progressive Spastic paraparesis (quadriparesis)
with sensory loss below the level of compression.
Sphincter disturbance is common. Root pain at the
level of compression, exacerbated by coughing and
.straining
: Causes
: Spinal cord tumors
Extramedullary, e.g.meningioma or neurofibroma
Intramedullary, e.gependymoma or glioma
Vertebral body destruction by bone metastases. Disc prolapse
: Inflammatory
Epidural abscess
TB(pott's)
Granulomatous
Epidural hemorrhage /hematoma
:Features
Back pain earliest and most common symptom, worse on lying _
.down and coughing
Lower limb weakness, arm weakness (cervical lesion) _
.sensory loss and numbness_
: neurological signs depend on the level of the lesion _
.Above L1 result in UMN signs in legs and sensory level
.Below L1 result in LMN signs in the legs and perianal numbness
normal findings above the level of the lesion, LMN signs at the _
.level and UMN signs below the level
.bladder and anal sphincter involvement is late _
: Investigation
CBC, ESR, B12, syphilis serology, RFT, LFT, PSA,
.electrophoresis
.MRI of vertebral colum is definitive investigation
.CXR(ca, TB)
.Biopsy to identify the nature of the mass
: Management
.High dose dexamethasone
Urgent oncological assessment for radiotherapy or
.surgery
Transverse myelitis
Is an acute Inflammatory disorder affecting the spinal cord with swelling
and loss of function. Typically one or two spinal segment are affected
with or all of the cord area at that level (Transverse :whole cross_section
.at the affected level)
:Sign
develop over hours to day usually bilateral , recovery over week to(
) months
.Midline or dermatomal neuropathic pain
.Urinary incontinence or retention
.Bowel incontinence or constipation
.Sexual dysfunction
: Causes
Para_infectious autoimmune Inflammatory response :most
.commmon cause and follow viral or immunization
.Systemic Inflammatory disorder e.g SLE, sjogrn's, sarcoidosis
: Infections
viral :varicella zoster, EBV, HIV, HTLV_1and 2(tropical spastic
.paraparesis)HSV, CMV, influenza, echovirus
.Bacterial :syphilis, Lyme, TB
.Flatworm e. g schistosomiasis
.First symptom of MS or NMO
: Investigation
MRI to determine the presence of myelitis, which
enhances with gadolinium, and rule out the presence
.of structural lesions
: Treatment
.Corticosteroids are first line, high dose intravenously
.Plasma exchange to those who fail to respond
Long term immunosuppression for demyelinating
.disease
Neuromyelitis
optica(Devic's syndrome)
Is Inflammatory relapsing demyelinating disorder
previously though to be a variant of MS. It
characterized by long segments Transverse myelitis
.(more than 3)and bilateral or recurrent optic neuritis
: Investigation
Serum antibodies to aquaporin_4 water channels are
diagnostic
: Treatment
.Steroids and immunosuppressive drugs
Syrigomyelia
A syrinx is a tubular cavity in or close to the central
.canal of the cervical cord
.age of onset: 30yrs •
Symptoms may be static for years, but then worsen •
fast—eg on coughing or sneezing, as pressure
causes extension, eg into the brainstem
.(syringobulbia)
:Causes
blocked CSF circulation (without 4th ventricular communication), eg
Arnold–Chiari malformation (cerebellum herniates through foramen
.magnum)
basal arachnoiditis (after infection, irradiation, subarachnoid haemorrhage)
basilar invagination(in which the top of the odontoid process of C2
migrates upwards, causing foramen magnum stenosis ± medulla oblongata
compression)
.masses (cysts, rheumatoid pannus, encephalocoele, tumours)
Less commonly, a syrinx may develop after myelitis, cord trauma, or
rupture of an AV malformation, or within spinal tumours (ependymoma or
haemangioblastoma) due to fluid secreted from neoplastic cells or
.haemorrhage
:Signs
Dissociated sensory loss (absent pain and T° sensation, with preserved light
touch, vibration, and joint-position sense) due to pressure from the syrinx on
the decussating anterlateral pathway reflecting the location of the syrinx (eg
for typical cervical syrinx then sensory loss is over trunk and arms)
wasting/weakness of hands + claw-hand (then arms, shoulders respi ratory
.muscles)
.Horner’s syndrome (can be bilateral and therefore more difficult to spot)
UMN leg signs
body asymmetry, limb hemihypertrophy, or unilateral odo- or
chiromegaly(enlarged hand or foot)from release of trophic factors via anterior
.horn cells
.Charcot’s joints in the shoulder/wrist due to lost joint pro prio ception
Syrengobulbia
Nyst agmus, tongue ).Brain stem involvement(
atrophy, dysphagia, pharyngeal/palatal
.weakness, Vth nerve sensory loss
Imaging:MRI
: Surgery
Don’t wait for gross deterioration to occur.
Decompression at the foramen magnum may be
tried in Chiari malformations to promote free flow of
CSF, and so prevent syrinx
.dilatation. Surgery may reduce pain and progressoin
Subacute combined
degeneration of the cord
Combined cord and peripheral nerve damage is a sequel of the
addisonian pernicious anemia
:C/F
.Numbness and tingling of the fingers and toes
Distal sensory loss (Posterior column)
.Absent ankle jerk, exaggerated knee jerk and extensor plantars
.Lhermitte's phenomenon
.Optic atrophy and retinal haemorrhage
Sphincter disturbance
.Weakness and dementia
: Investigation
Vitamin B12, methylmalonic acid and homocysteine
.level
.Macrocytosis,megaloblastic marrow
: Management
Parenteral B12
Brown_sequard's syndrome
.Thoracic spinal cord leasion produced by a hemisection of the cord
: Cause
Trauma, tumors, MS
: Features
: Ipsilateral
.loss of proprioception and vibration below the level of the lesion
Flaccid paresis at the level of the lesion and, spastic paralysis below
.the level
Babinski sign
: Contralateral
.Loss of pain and temperature sensation in one or two level
Anterior spinal artery
thrombosis
.It supplies the anterior 2/3 of the cord
Affects (corticospinal and Spinothalamic tracts)
Cause : aortic atherosclerosis, dissection, trauma,
vasculitis, emboli, severe hypotension
: Features
Sudden paralysis
Pain and temperature sensation are lost
.Vibration and joint _position sense are normal
Cauda equina syndrome
The lumbosacral roots, from L1 to S5 are bilaterally damaged,
.symmetrically or asymmetrically
: Cause
Herniation of lumber disc, tumors, trauma, Epidural abscess, akylosing,
.Paget, spinal stenosis
: Features
: Radiculpathy and LMNL
Flaccid paraplegia
Areflexia,sensory level, flexor plant or, bladder retention and overflow
incontinence
Saddle and perianal anaesthia(pins and needles in groin and inner thighs)
.S3_S5 roots
MRI
Conus medularis syndrome
Causesd by compression of the T12_L2 cord and
.nerve roots,mix UMN and LMN lesions
Bilateral distal weakness with hypertonia,
hyperrflaxia, fascicuation
Perianal sensory loss
.Urinary retention and atonic anal sphincter early
Marked low back pain and importance
