1.diabetes Mellitus

SPINAL CORD DISEASES
drdanielgk@gmail.com 1
Spinal cord anatomy
• A thin tubular extension of CNS within the bony spinal
canal.
• from the level of cranial border of Atlas (continuous
with medulla) lower border of the L1 vertebrae
• Average length-45cm.
• 31 pairs of nerves originate from it (8 cervical, 12
thoracic, 5 lumbar, 5 sacral, 1coccygeal)
Relationship of spinal cord to vertebral
level
• Growth rate of the spinal cord lags behind that of the

vertebral column
• The lower spinal nerves take a longer downward course
to exit via the respective interverte. Foramina.
Vertebrae Spinal cord segments
Upper Cervical Corresponds
vertebrae
Lower Cervical Add 1
vertebrae
Thoracic vertebrae 1 – Add 2
6
Thoracic vertebrae 7 – Add 3
10
Thoracic vertebrae 11 Overlies L3
Thoracic vertebrae 12 Overlies S1
1st lumbar arch Overlies sacral &
coccygeal segments
Cross-sectional Anatomy of the spinal cord
(1) Pia Mater

(2) Arachnoid
(3) Dura Mater
(4) Subarachnoid Space Containing CSF
(5) Subdural Space
(6) Epidural Space (Contains Adipose Tissue)
Lateral spinothalamic tract:
 Pain & temperature

 cross midline at a few segments higher
Anterior spinothalamic tract

 Pressure & crude touch
Dorsal column system

 Proprioception, light touch & vibratory senses
..
.
Descending Tracts
• 5 descending systems:
1 Corticospinal tract (Pyramidal tract).
2. Medial reticulospinal tract
3 Vestibulospinal tract
4. Corticorubrospinal tract
5. Lateral reticulospinal tracts
.
Corticospinal Tract
 Distal limb movements
Primary motor cortex, lateral premotor cortex


Corona radiata

Posterior limb of internal capsule

Ventral portion of midbrain & pons

Ventral portion of medulla

At caudal portion of medulla
90%
10%
Decussate
Not
decussate
Lateral corticospinal tract
Anterior (Ventral)
corticospinal tract
Decussate & terminate in lamina VIII in
cervical & upper thoracic region
Spinal cord
Spinal Cord – Functional Anatomy
Out of 10 or more Long Fibre Spinal Tracts coursing longitudinally in the
spinal cord, only 3 (shown below in Red, Blue and Green) are of prime
importance in clinical neurology practice:
Courtesy of Medical College, University of Florida.
1. Spinothalamic Tracts (Red) = Pain, Temperature, Crude Touch. 2.

Posterior Column Tracts (Green) = Position, Vibration, Discriminative
Touch. 3. Corticospinal Tracts (Blue) = Motor efferent (Descending) Fibres.
Spinal Cord – Vital Functions
• Respiration (mainly C4).
• Autonomic functions (Blood Pressure
and Heart rate).
• Brachial plexus = Upper limbs.
• Thoracic segments = Inter-costal nerves.
• Lumbosacral plexus = Lower limbs.
• Segmental sensations.
• Segmental autonomic nervous supply
(e.g. Sweating).
• Reflex control (e.g. withdrawal).
• Gait control (Walking).
• Bowel (regulation).
• Bladder (control).
• Sexual functions (Sympathetic and
Parasympathetic neurovascular inputs). Courtesy of MD Images.
Spinal Cord – Autonomic Nervous System
Courtesy of MD Images.
Spinal Cord – Key Symptoms
• Paralysis:
- Onset = Acute, Sub-Acute, Gradual, Chronic,
.
- Progress = Rapid, Slow, None, Improvement, Recovery,
- Proximal (Myelopathy), Distal, Global weakness,
- Fluctuation = Syringomyelia, Lipoma, Disc disease,
- Unilateral (Brown-Sequard) or Bilateral.
• Increased Tone & Reflexes (signs of UMN lesion) versus diminished

or absent reflexes, normal or decreased tone and presence of
Fasiculations (signs of LMN lesions).
• Pattern of Sensory Loss:
– Descending or Ascending
– Sensory level (localising value). Spinothalamic, Dorsal
Column, Dissociated or Segmental
– Brown-Sequard syndrome.
• Sphincter Involvement:
– Early incontinence occurring with relatively late
corticospinal weakness (Intramedullary lesion).
• Fluctuation of (motor & sensory) symptoms suggest:
1. Syringomyelia
2. Foramen Magnum pathology
3. Spinal Cord Lipoma (commonly Lumbo-Sacral in location).
Spinal Cord – Patterns of LMN Diseases
http://www.neuroanatomy.wisc.edu.
Four anatomic stations underlying lower motor neuron (LMN) weakness:
1. Anterior (ventral) Horn Cell,
2. Peripheral Nerve (Ventral & Dorsal Roots = Radiculopathy or Nerve = Neuropathy),
3. Neuromuscular Junction,
4. Muscle (Myopathy), drdanielgk@gmail.com * LMN = Lower Motor Neruon.

19
Arterial supply
• Anterior spinal artery
supply ant 2/3 the spinal cord &ventral
surface of medulla
• Two posterior spinal arteries
supply the posterior one-third of the
spinal cord.
• Radiculomedullary arteries
6 to 10 join the ASA
10 to 20 join the PSA
Arterial supply to the spinal cord
Spinal Cord – Disease Classification
• Vascular – Infarction, AV Malformations, Haemorrhage, Fibro-
cartilaginous embolism..
• Infectious (Abscess) – Viral, Bacterial, Fungal, TB, Brucella,

Parasitic..
• Immune-Mediated – Mixed Connective Tissue Disease, Anti-

Phospholipid & Anti-Ro (SSA) causing Recurrent Transverse
Myelitis, as well as SLE & Rheumatoid Arthritis..
• Demyelinating – Primary (Multiple Sclerosis, Devic’s Disease),

Secondary (ADEM)..
• Granulomatous – Sarcoidosis
• Neoplastic (Tumours) – Primary or Metastatic – Extradural, Extra or
Intra-medullary..
• Genetic – Hereditary & Familial Spastic Paraplegias, Friedreich
Ataxia
• Developmental – Meningomyelocele, Tethered Cord, Lumbosacral
Lipomas..
• Metabolic – Deficiency (B12) and Toxic (Cassava)..
• Traumatic (Injury) – e.g. Fracture dislocation: RTA, Sports, Domestic
falls, Violence..
• Degenerative – Prolapsed inter-vertebral Disc, Osteophyte
formation..
• Miscellaneous – Iatrogenic, Paraneoplastic,
Lesions of .
the spinal cord
Complete SC transection (transverse myelopathy)
• All ascending & descending tracts are interrupted

• Sensory
– loss of all sensation below the level of lesion
Localization
– sensory level
– radicular pain
– vertebral tenderness
Complete SC transection (transverse myelopathy)
• Motor
– weakness below the lesion
– LMN at the level
– UMN below the level
• In spinal shock LMN weakness is seen
• Autonomic
– Bladder, bowel and sexual dysfunction
– Anhidrosis, trophic skin, impaired T0 control
Hemisection of the Spinal Cord /Unilateral Lesions/
(Brown- sequard syndrome)
Brown- sequard syndrome
• Ipsilateral spastic weakness(corticosp.tr.
Damage)
• Segmental LMNS and sensory signs.(ant.horn
cell damage)
• Loss of pain and temp. Sensation contra lateral
to hemi section
• Ipsilateral propioceptive fn loss
• Eg. Extramedullary lesions
CENTERAL CORD SYNDROME
common causes are syringomyelia, intramedullary cord
tumors
• damage starts centrally and extend centrifugally
• Initially
• decussating spinothalamic tract
– touch, position and vibration intact
– dissociation of sensory loss.
• Forward extension -anterior horn cell with segmental sign .
• Lateral extension:
– ipsilateral Horner syndrome
– spastic paralysis below the level of the lesion.
• Dorsal extension
– position and vibration loss
• With extreme ventrolateral extension
– pain and temperature loss below the level of the lesion
with sacral sparing
Posterolateral Column Syndrome
causes of posterolateral column damage:

• SCDS(Vit B12 Def.)
• Vacuolar myelopathy associated with AIDS
• Tropical spastic paraparesis
• Extrinsic cord compression e.g. cervical spondylosis
 Dorsal column dysfn,sensory ataxia with positive Romberg sign&spasticity
 Pain &temperature remain intact
Posterior Cord Lesions /syndrome
• The posterior columns are selectively damaged by tabes dorsalis

(tabetic neurosyphilis).
• impaired vibration and position sense and decreased tactile
localization below that level
• disturbances in the knowledge of extremity movement and
position (temporal and spatial disturbances)
Posterior Cord Lesions /syndrome
• sensory ataxia, noted first at night or in the dark, and a
positive Romberg sign.
• The gait is ataxic – it is more pronounced in darkness or
with eye closure
• Often pt fall forward immediately following eye closure
(+ve Sink sign)
• Affected limb is hypotonic but not weak.
• Absent ankle & patellar reflexes
• In cervical region  neck flexion may elicit a sudden
“electriclike” sensation down the back or into the arms
(Lherrmitie’s sign or “barber’s chair” syndrome).
• Other Causes , compressive cervical ds, MS
Anterior Horn cell syndrome
• Diffuse anterior horn cell damage  diffuse muscle

weakness, atrophy, and fasciculations –in muscles of the
trunk & extremities
• Muscle tone usually reduced & DTR may be depressed or
absent
• Sensory changes are absent b/se the sensory tracts remain
unaffected
Anterior Horn cell syndrome
•E.g. of spinal muscle atrophies

- infantile progressive spinal muscular atrophy of
Werdnig-Hoffman
- intermediate spinal muscular atrophy or type II
spinal muscular atrophy
- juvenile progressive spinal muscular atrophy or
Kugelberg-Welander disease
- progressive spinal muscular atrophy in motor
neuron disease
Combined ant. Horn cell &pyramidal tract disease
• ALS
• Diffuse LMN signs superimposed on UMN
signs
• Sensory changes are absent
• Bulbar and pseudo bulbar impairment
• Urinary and rectal sphincters unaffected
Vascular syndrome of the spinal cord
• Spinal cord infarction very rare compared to

cerebral infarction
• Most spinal cord infarction –from inv’t of the
territory of ASA
Anterior spinal artery syndrome:
• Abrupt onset & often associated with radicular or

“girdle” pain
• Deficit in pin prick, light touch, temperature sensations
–starting one or 2 segments below the level of the
lesion  lateral spinothalamic tracts bilaterally
• Deficit in light touch below the level of the lesion 
ventral spinothalamic tracts bilaterally
• Loss of motor function (flaccid tetraplegia or
paraplegia) –within minutes to hrs below the lesion 
bilateral corticospinal tract
• Impaired bladder & bowel control
 T1 to T4 segments & The L1 segment; common sites
Extamedullary vs. intramedullary
Symptoms & signs Intramedullary Extramedullary

Radicular pain Unusual Common, early
Vertebral pain Unusual Common
Funicular (central) pain Common Less Common
UMN signs late Yes, early

LMN signs e.g. anterior horn Prominent & diffuse Unusual, if present
cells segmental
Parasthesias progression Descending progression Ascending progression
Sphincter abnormalities e.g. Early with caudal Late
bladder inv’t lesions (conus –cauda
equina)
II/ Localization SC lesions at
different levels
A) Foramen magnum syndrome
– tumors, syringobulbia, joint subluxation
– Hemiplegia cruciata
– Sub occipital pain , neck stiffness
B) Cervical cord
C1- C4:
– may also involve CN XI
– weakness of sternocleidomastoid and trapezium
– Spastic quadriparesis with diaphragmatic
paralysis.
C5-C6:
– LMN at segmental level and UMN below the lesion
– LMN sign at deltoid, biceps, brachioradialis
– spastic paraparesis of the lower extremity
– Biceps and brachioradialis reflex absent or
diminished
– triceps and finger flexors reflex exaggerated
C7:
– paresis involve flexors and extensors of the wrists and fingers
– Biceps and brachioradialis reflex preserved (C5- C6)
– Finger flexor reflex (C8- T1) - exaggerated.
C8 and T1:
– weakness of the small hand muscles
– spastic Paraparesis
– C8 lesion -triceps and fingers flexor reflex decreased
– T1 lesion -triceps reflex preserved
– Horner syndrome
C) Thoracic cord
 Root pain and paraesthesia
 Paraplegia
 sensory loss below a thoracic level
 segmental LMN sign is difficult to detect clinically.
D) Lumbar cord
L2- L4:
 paralyze flexion and adduction of the thigh &
extension of the knee
 absent knee reflex
 exaggerated ankle jerk.
L5-S1:
 paralyze movement of foot and ankle, flexion at the knee ,
and extension of the thigh
 Absent ankle jerk (S1).
E) Sacral cord/conus medullaris
– Bilateral saddle anesthesia (S3- S5)
– Prominent bladder and bowel dysfunction
– Impotence
– Bulbocavernosus(S2 – S4) and anal ( S4- S5)
reflexes are absent
– Muscle strength largely preserved
F) Caudal equina syndrome
– Early radicular pain
– Asymmetric flaccid paralysis and sensory finding
– Ankle reflex absent
– Sphincter abnormality late
.
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1.diabetes Mellitus

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SPINAL CORD DISEASES

• Growth rate of the spinal cord lags behind that of the

(1) Pia Mater

 Pain & temperature

Anterior spinothalamic tract

Dorsal column system

Primary motor cortex, lateral premotor cortex

Courtesy of Medical College, University of Florida.

1. Spinothalamic Tracts (Red) = Pain, Temperature, Crude Touch. 2.

• Increased Tone & Reflexes (signs of UMN lesion) versus diminished

1. Anterior (ventral) Horn Cell,

2. Peripheral Nerve (Ventral & Dorsal Roots = Radiculopathy or Nerve = Neuropathy),

4. Muscle (Myopathy), drdanielgk@gmail.com * LMN = Lower Motor Neruon.

• Infectious (Abscess) – Viral, Bacterial, Fungal, TB, Brucella,

• Immune-Mediated – Mixed Connective Tissue Disease, Anti-

• Demyelinating – Primary (Multiple Sclerosis, Devic’s Disease),

• All ascending & descending tracts are interrupted

causes of posterolateral column damage:

• The posterior columns are selectively damaged by tabes dorsalis

• Diffuse anterior horn cell damage  diffuse muscle

•E.g. of spinal muscle atrophies

• Spinal cord infarction very rare compared to

• Abrupt onset & often associated with radicular or

Symptoms & signs Intramedullary Extramedullary

UMN signs late Yes, early

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