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dr. Ashari Bahar, M.Kes, Sp.

S, FINS
Department of Neurology
University of Hasanuddin
Makassar 2014

L/O/G/O
Ringkasan

• 1.Brown Sequard Syndrome


• 2. Anterior Syndrome
• 3.Central Cord Syndrome
• 4. Posterior Cord Syndrome
• 5. Syringo Myelia
• 6. Cauda Equina Syndrome
• 7. Conus Medullaris Syndrome
• 8.
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Main Spinal Cord Syndromes
Transverse Myelopathy (complete or partial)

Hemisection (Brown-Sequard Syndrome)

Ventral or Anterior Cord Syndrome

Central Cord Syndrome (Syringomyelia)

Posterior Spinal Cord Syndrome

Syndrome of the Conus Medullaris

Syndrome of the Cauda equina

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Contents

1 Basic Features of Spinal Cord Disease

2 Main Spinal Cord Syndromes

3 Etiology of Spinal Cord Disease

4 Examination of Spinal Cord Disease

5 Management of Spinal Cord Disease

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Important Dermatomal Landmarks
• C2 - posterior half of the skull cap
• C3 - area correlating to a high turtle neck shirt
• C4 - area correlating to a low-collar shirt
• C6 - (radial nerve) 1st digit (thumb)
• C7 - (median nerve) 2nd and 3rd digit
• C8 - (ulnar nerve) 4th and 5th digit, also the funny
bone
• T4 - nipples.
• T5 - Inframammary fold.
• T6/T7 - xiphoid process.
• T10 - umbilicus (important for early appendicitis pain)
• T12 - pubic bone area.
• L1 - inguinal ligament
• L4 - includes the knee caps
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Upper vs. Lower Motor Neuron

• Upper motor neuron lesion


– Motor cortex internal capsule brainstem
spinal cord
• Lower motor neuron lesion
– Anterior horn cell nerve root plexus
peripheral nerve neuromuscular junction
muscle

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Upper Motor Neuron (UMN) vs. Lower Motor Neuron (LMN) Syndrome

UMN syndrome LMN Syndrome

Type of Paralysis Spastic Paresis Flaccid Paralysis

Atrophy No (Disuse) Atrophy Severe Atrophy

Deep Tendon Reflex Increase Absent DTR

Pathological Reflex Positive Babinski Sign Absent

Superficial Reflex Absent Present

Fasciculation and Absent Could be


Fibrillation Present

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Basic Features of Spinal Cord Disease

• UMN findings below the lesion


– Hyperreflexia and Babinski’s
• Sensory and motor involvement that
localizes to a spinal cord level
• Bowel and Bladder dysfunction common
• Remember that the spinal cord ends at
about T12-L1

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Types of Spinal Cord Paralysis

• Depending on the location and the extent of the


injury different forms of paralysis can occur.
• Monoplegia- paralysis of one limb
• Diplegia- paralysis of both upper or lower limbs
• Paraplegia- paralysis of both lower limbs
• Hemiplegia- paralysis of upper limb, torso and
lower leg on one side of the body
• Quadraplegia- paralysis of all four limbs

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Spinal Cord Paralysis Levels
C1-C3
• All daily functions must be totally assisted
• Breathing is dependant on a ventilator
• Motorised wheelchair controlled by sip and puff or chin movements
is required
C4
• Same as C1-C3 except breathing can be done without a ventilator
C5
• Good head, neck, shoulder movements, as well as elbow flexion
• Electric wheelchair, or manual for short distances
C6
• Wrist extension movements are good
• Assistance needed for dressing, and transitions from bed to chair
and car may also need assistance
C7-C8
• All hand movements
• Ability to dress, eat, drive, do transfers, and do upper body washes

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Spinal Cord Paralysis Levels
T1-T4 (paraplegia)
• Normal communication skills
• Help may only be needed for heavy household work or
loading wheelchair into car
T5-T9
• Manual wheelchair for everyday living
• Independent for personal care
T10-L1
• Partial paralysis of lower body
L2-S5
• Some knee, hip and foot movements with possible slow
difficult walking with assistance or aids
• Only heavy home maintenance and hard cleaning will
need assistance

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Complete and Incomplete
Spinal Cord Syndromes can be classified into
either complete or incomplete categories
• Complete – characterized as complete loss of
motor and sensory function below the level of
the traumatic lesion

• Incomplete – characterized by variable


neurological findings with partial loss of sensory
and/or motor function below the lesion

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Spinal Shock
• An immediate loss of reflex function, called
areflexia, below the level of injury
• Signs:
– Slow heart rate
– Low blood pressure
– Flaccid paralysis of skeletal muscles
– Loss of somatic sensations
– Urinary bladder dysfunction
• Spinal shock may begin within an hour after
injury and last from several minutes to several
months, after which reflex activity gradually
returns

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Tempo of Spinal Cord Disease
Acute Subacute Chronic

Trauma X

Mass lesion X X

Infectious X X X

Inherited X

Vascular X X X

Autoimmune X X

Nutritional X
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Main Spinal Cord Syndromes
Transverse Myelopathy (complete or partial)

Hemisection (Brown-Sequard Syndrome)

Ventral or Anterior Cord Syndrome

Central Cord Syndrome (Syringomyelia)

Posterior Spinal Cord Syndrome

Syndrome of the Conus Medullaris

Syndrome of the Cauda equina

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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 :
 traumatic spine injuries
 tumour
 multiple sclerosis
 vascular disorders
 spinal epidural hematoma/abscess
 auto immune disease
 herniated intervertebral disc
 parainfectious/post vaccinal syndrome
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• 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
• 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
 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

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• 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

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Brown Sequard Syndrome
• Cord hemisection
• Trauma or tumor
• Dissociated sensory loss
– loss of pain and temperature contralateral to lesion,
one or 2 levels below
• crossing of spinothalamic tracts 1-2 segments
above where they enter
– loss of vibration/proprioception ipsilateral to the
lesion
• these pathways cross at the level of the brainstem
• Weakness and UMN findings ipsilateral to lesion
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Brown-Sequard syndrome
(spinal cord hemisection)
Major Symptoms
1. Ipsilateral UMN syndrome below the level of lesion
2. Ipsilateral LMN syndrome at the level of lesion
3. Ipsilateral loss of discriminative touch sensation and
conscious proprioception below the level of lesion
(posterior white column lesion)
4. Contralateral loss of pain and temperature sensation
below the level of lesion (spinothalamic tract lesion)

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Spinal Cord Syndrome

3' 3
1 1

3' 3
1' 1
4' 4
2' 2

5' 5
4 1
1' 3 3

Brown-Sequard Syndrome (Spinal Cord Hemisection)

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Anterior Spinal Cord Syndrome

• Usually results from compression of the artery


that runs along the front of the spinal cord
• Compression of SC may be from bone
fragments or a large disc herniation
• Patients with anterior spinal cord syndrome have
a variable amount of motor function below the
level of injury
• Sensation to pain and temperature are lost while
sensitivity to vibration and proprioception are
preserved

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Anterior horn cell syndrome
• Aterior horn cell, cranial
motor nuclei involved
• Autosomal recessive
spinomuscular atrophy
• Diffuse weakness and
atrophy, fasciculations of
trunk and extremities
• Muscle tone& DTR ↓
• Sensation intact

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Combined anterior horn cell and
pyramidal tract disease
• Progressive diffuse LMN
signs with UMN
dysfunction
• Striated muscles except
pelvic floor mucles
affected
• U/L, muscles of hands
and foot are involved
• Sparing rectal and
urethral sphincter
• Bulbar and pseudobulbar
inv super imposed

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Central Cord Syndrome

• Usually involves a cervical lesion


• May result from cervical hyperextension causing
ischemic injury to the central part of the cord
• Motor weakness is more present in the upper
limbs then the lower limbs
• Patient is more likely to lose pain and
temperature sensation than proprioception
• Patient may complain of a burning feeling in the
upper limbs
• More commonly seen in older patients with
cervical arthritis or narrowing of the spinal cord

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Syringomyelia
• Fluid filled cavitation in the center of the cord
• Cervical cord most common site
– Loss of pain and temperature related to the
crossing fibers occurs early
• cape like sensory loss
– Weakness of muscles in arms with atrophy and
hyporeflexia (AHC)
– Later - CST involvement with brisk reflexes in the
legs, spasticity, and weakness
• May occur as a late sequelae to trauma
• Can see in association with Arnold Chiari
malformation
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Syringomyelia, Hematomyelia
Lesion
- central canal of spinal cord
- gradually extended to peripheral part of the cord

Symptom
- initial symptom is bilateral loss of pain (compression of anterior white
commissure)
- variety of symptoms appear according to the lesion extended from
central canal

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Spinal Cord Syndrome

Syringomyelia - Initial Symptoms

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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 +
• Ataxic / stomping/ double tapping gait
• Positive sink sign
• In tabes dorsalis- lancinating pain, urinary incontinence, -ve patellar
and ankle DTR, hypotonic limb, hyper extensible joints
abdominal , laryngeal crises
Abadie’s sign , impaired light touch perception in hitzig zone
Argyll robertson pupil, optic atrophy, ptosis, ophthalmoplegia

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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 cerebellar tract
may be a primary
manifestation of epidural spinal
cord compression- lower
extremity dysmetria and gait
ataxia, pt usually have thoracic
spine compression due to
selective vulnerability of
spinocerebellar tract in
thoracic spine to compressive
ischemia

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Postero lateral column
disease
• SACD- B12 def
• Vacuolar myelopathy-
AIDS-HTLV 1, tropical
spastic paraparesis
• Cervical spondylosis
-paraesthesia, diffficulty
with gait , balance, loss of
vibration and
proprioception, sensory
ataxia, rombergs +,
bladder atony, reflexes
lost or hypo active –
super imposed peripheral
neuropathy

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Conus medullaris lesion
• Pelvic floor weakness, early sphincter dysfunction
• Autonomous neurogenic bladder
• Constipation, impaired ejeculation and errection
• Symmetric saddle anaesthesia
• Pain
• Tethered spinal cord:
– numbness feet
– asymmetric muscle atrophy of calf and thigh, UMN
signs, bowel bladder dysfunction,foot deformities,
cutaneous manifestations of spinal dysraphism

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Cauda equina lesion

• Compression lumbar sacral roots below L3


vertebra
• U/L early radicular pain, worse at night
• Flaccid hypotonic areflexic paralysis
producing peripheral paraplegia
• Asymmetrical sensory loss in saddle area
• KJ variable, ankle ↓↓
• Sphincter dysfunction similar to conus
lesion but late
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Conus lesion Cauda lesion
Spont pain -ve, B/L +ve, severe,
Radicular, U/L
sensory Saddle, B/L saddle., U/L
deficit dissociation All forms affected
Motor loss Symmetric, Asymmetric , atro
fasciculations Phy, no fasciculn
DTR Ankle -ve KJ, ankle -ve
Bowel,bld early late
trophic +ve -ve
Sex fn impaired Less impaired
onset Sudden. b/l Gradual, u/l
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Etiology of
Spinal Cord
Disease

L/O/G/O
Traumatic Spinal Cord
Disease
• 10,000 new spinal cord injuries per year
• MVA, sports injuries the most common
• Victims under 30 yrs old, male>>females
• Fx/dislocation of vertabrae most likely to
occur at:
– C5,6
– T12, L1
– C1,2

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Tumors
• Metastatic or primary
• Extramedullary
– Extradural - most common
• Bony - breast, prostate
– Intradural - very rare
• Meninges - meningioma
• Nerve root - schwannoma
– Intramedullary - very rare
• Metastatic
• Primary - astrocytoma or ependymoma
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SIGNS INTRAMEDULLARY EXTRAMEDULLARY
Radicular unusual common
pain
Vertebral unusual common
pain
Funicular common Less common
pain
UMN Sign +, late +, early
LMN sign +++, diffuse Unusual, segmental
Paraesthesi descending ascending
a progr
Sphincter early late
Trophic common unusual
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B12 Deficiency

• Subacute combined degeneration of the


cord
• B12 deficiency
– malabsorption of B12 secondary to pernicious
anemia or surgery
– insufficient dietary intake - vegan
• Posterior columns and CST involvement
with a superimposed peripheral
neuropathy
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Transverse myelitis

• Inflammation of the spinal cord


– Post-infectious
– Post-vaccinial
– Multiple sclerosis
• Pain at level of lesion may preceed onset
of weakness/sensory change/b&b
disturbance
• Spinal tap may help with diagnosis

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Infections Involving the Spinal Cord

• Polio
– only the anterior horn cells are infected
• Tabes dorsalis
– dorsal root ganglia and dorsal columns are
involved
– tertiary syphillis
– sensory ataxia, “lightening pains”
• HIV myelopathy
– mimics B12 deficiency
• HTLV-1 myelopathy -
– tropical spastic paraparesis

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Multiple Sclerosis
• Demyelination is the underlying pathology
• Cord disease can be presenting feature of
MS or occur at any time during the course
of the disease
• Lesion can be at any level of the cord
– Patchy
– Transverse
• Devic’s syndrome or myelitis optica
– Transverse myelitis with optic neuritis
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Vascular Diseases of the
Spinal Cord
• Infarcts
– Anterior spinal artery infarct
• from atherosclerosis, during surgery in which
the aorta is clamped, dissecting aortic
aneurysm
– less often, chronic meningitis or following trauma
• posterior columns preserved (JPS, vib)
• weakness (CST) and pain/temperature loss
(spinothalamic tracts)
– Artery of Adamkiewicz at T10-11
– Watershed area
• upper thoracic
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Vascular Diseases of the
Spinal Cord, cont
• Arteriovenous malformation (AVM) and
venous angiomas
– Both occur in primarily the thoracic cord
– May present either acutely, subacutely or
chronically (act as a compressive lesion)
– Can cause recurrent symptoms
– If they bleed
• Associated with pain and bloody CSF
– Notoriously difficult to diagnose
• Hematoma - trauma, occasionally tumor
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Other Disease of the Spinal Cord
• Hereditary spastic paraparesis
– Usually autosomal dominant
• Infectious process of the vertebrae
– TB, bacterial
• Herniated disc with cord compression
– Most herniated discs are lateral and only
compress a nerve root
• Degenerative disease of the vertebrae
– Cervical spondylosis with a myelopathy
– Spinal stenosis
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Motor Exam
• Strength - helps to localize the lesion
– Upper cervical
• Quadriplegia with impaired respiration
– Lower cervical
• Proximal arm strength preserved
• Hand weakness and leg weakness
– Thoracic
• Paraplegia
– Can also see paraplegia with a midline lesion in the
brain

• Tone
– Increased distal to the lesion www.themegallery.com
Scale of Motor Strength in SCI

• The American Spinal Injury Association:


– 0 - No contraction or movement
– 1 - Minimal movement
– 2 - Active movement, but not against gravity
– 3 - Active movement against gravity
– 4 - Active movement against resistance
– 5 - Active movement against full resistance
• Assessment of sensory function helps to identify
the different pathways for light touch,
proprioception, vibration, and pain. Use a
pinprick to evaluate pain sensation.
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Sensory Exam

• Establish a sensory level


– Dermatomes
• Nipples: T4-5
• Umbilicus: T8-9
• Posterior columns
– Vibration
– Joint position sense (proprioception)
• Spinothalamic tracts
– Pain
– Temperature www.themegallery.com
Autonomic disturbances

• Neurogenic bladder
– Urgency, incontinence, retention
• Bowel dysfunction
– Constipation more frequent than incontinence
• With a high cord lesion, loss of blood
pressure control
• Alteration in sweating

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Investigation of Spinal Cord Disease

• Radiographic exams
– Plain films
– Myelography
– CT scan with myelography
– MRI
• Spinal tap
– If you suspect: inflammation, MS, rupture of a
vascular malformation

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Ringkasan

• 1.Brown Sequard Syndrome


• 2. Anterior Syndrome
• 3.Central Cord Syndrome
• 4. Posterior Cord Syndrome
• 5. Syringo Myelia
• 6. Cauda Equina Syndrome
• 7. Conus Medullaris Syndrome
• 8.
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Treatment Focus

• The treatment team must specialize in treating


SCI
• The focus should be on family and patient
participation where the clients personal abilities
are maximized towards independence
• Client should be a principal contributor to
treatment decisions and goal making
• Treatment should be on a regular scheduled
basis for at least three hours per day

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Treatment Fields
• Occupational Therapy
• Physiotherapy
• Physicians
• Social Workers
• Therapeutic Recreation
• Rehabilitation
• Psychologists
• Vocational Counsellors
• Nutrition Assistance
• Telemedicine-employing
a SCI caregiver

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Pre-hospital Care

• Most pre-hospital care providers recognize the


need to stabilize and immobilize the spine on the
basis of mechanism of injury, pain in the
vertebral column or neurological symptoms.
• Patients are usually transported to the hospital
with a cervical hard collar on a hard backboard.
– Commercial devices are available to secure the
patient to the board.
– The patient should be secured so that in the event of
vomiting, the backboard may be rapidly rotated 90
degrees while the patient remains fully immobilized in
neutral position. Spinal immobilization protocols
should be standard in all pre-hospital care systems.

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Basic Life Changes

• The Kinesiologist will need to determine through


conversation with the client, as well as subjective and
objective assessment:
• Eating
• Dressing
• Bowel/Bladder function
• Weight Management- nutrition and fitness
• Respiratory Issues
• Pain
• Psychosocial Issues
• Sex and Pregnancy
• Independence
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Equipment / Accessibility
• Kinesiologist should plan
with client ways to
improve personal
mobility:
– Homes
– Vehicles
– Public Access
– Types of wheelchairs,
mobility devices, splinting
and seating available

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Prognosis
• Patients with a complete cord injury have a less than 5%
chance of recovery. If complete paralysis persists at 72 hours
after injury, recovery is essentially zero.
• The prognosis is much better for the incomplete cord
syndromes.
• If some sensory function is preserved, the chance that the
patient will eventually be able walk is greater than 50%.
• Ultimately, 90% of patients with SCI return to their homes and
regain independence.
• In the early 1900s, the mortality rate 1 year after injury in
patients with complete lesions approached 100%. Much of the
improvement since then can be attributed to the introduction
of antibiotics to treat pneumonia and urinary tract infection.
• Currently, the 5-year survival rate for patients with a traumatic
quadriplegia exceeds 90%. The hospital mortality rate for
isolated acute SCI is low.
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Thank you!

L/O/G/O