Spinal Cord lesions

Prepared by :
Saad Al-Qahtani.

Presented by :
Bandar Al-Qahtani.

Supervised by :
Dr.Esam Al-Jamal.
 Anatomy
 Spinal cord lies within protective
covering of vertebral column.

 Begins just below foramen magnum

of the skull.

 Ends opposite 2nd lumbar vertebra.

 Below L2 continue as a leash of

nerve roots known as cauda
equina.

 Prolongation of the pia matter

forms filum terminale.
Spinal cord structure
 Spinal cord structure
 The spinal cord consists of central core of grey matter
containing nerve cell bodies, and outer layer of white
matter of nerve fibers.

 Within the grey matter, the dorsal horn contains sensory

neurons, the ventral horn contains motor neurons and the
lateral horn contains preganglionic sympathetic neurons.

 Within the white matter run ascending and descending

nerve fiber tracts, which link the spinal cord to the brain.
 Spinal cord structure
 The principle ascending tracts are the spinothalamic tracts,
spinocerebellar tracts and dorsal columns. The coticospinal
tracts is an important descending tract.

 The spinal cord receives information from, and controls the

trunk and limbs.

 This is achieved through 31 pairs of spinal nerves which join

the cord at intervals along its length and contain afferent
and efferent nerve fibers connecting with the structures at
the periphery.
 Causes of spinal cord lesions

 congenital; spinal stenosis.

 Infection; TB ,abscess.
 Trauma; vertebral body fracture or facet joint
dislocation.
 Inflammatory; Rheumatoid arthritis.
 Disc and vertebral lesion.
 Vascular; epidural and subdural hemorrhage.
 Tumors.
 Spinal stenosis
 75% of cases of spinal
stenosis occur in the low
back ( lumbar spine).

 Causes :
- congenital.
- degenerative.
- trauma.
 Congenital spinal stenosis

 The patient is born with a narrow spinal canal due to

abnormally formed parts of the spine.

 This condition is most common in patients with a short

stature, such as achondroplastic dwarves.
 Other causes of spinal stenosis
 aging process (most
common cause ).

 herniated discs. (fig)

 bone and joint

enlargement.

 spondylolisthesis.

 bone spurs.
Rx Spinal Stenosis
 Initial Rx in most cases is conservative.

 Rest.
 Weight loss.
 Epidural steroid injections.
 Analgesia.
 Anti-inflammatory agents.
 Muscle relaxant -if needed-
 Physiotherapy.
Rx spinal stenosis
 Spine surgery:

used when conservative treatment failed.

-laminectomy (removing bone behind the spinal cord).

-foramenotomy (removing bone around the spinal nerve).
-discectomy (removing the spinal disc to relieve pressure).

Complications:
Dural tears.
Infections.
Instability of the spine.
 Infection

 Epidural abscess

 Usually bacterial
( staphylococcus is
common).

 Spread through:
 hematogenous route.

 Adjacent focus.

 Direct inoculation.
 Risk factor for epidural abscess
• immunodeficiency
• AIDS.
• Alcoholism.
• Chronic renal failure.
• Diabetes mellitus.
• Intravenous drug abuse.
• Malignancy.
• Spinal procedure or surgery.
• Spinal trauma.
 Infection
 Infection of spine
 Uncommon

 Either vertebral
osteomyelitis Or less
commonly intraspinal
infection.

 Causative organism :
(staph, Strep, E.coli, TB)

 Occasionally due to
unusual organisms like:
Salmonella or brucella.
Rx spinal infections
 The goals of treatment are to relieve spinal cord
compression and cure the infection.
-drain abscess.
-antibiotics or antimicrobial.
-corticosteroid.
-may need urgent surgical decompression by laminectomy.
 Tumors
 Tumors are classified
into 3 types according
to their site:

-extradural ( between the

meninges and spine bones)

-intradural extramedullary
(within meninges)

-intramedullary ( inside the

cord)
 Spinal tumors
 Most spinal tumors are extradural – about 85%

 They may be primary tumors originating in the spine, or

secondary tumors that are the result of the spread of cancer
from other locations primarily the lung, breast, prostate,
kidney, or thyroid gland.

 Any type of tumor may occur in the spine, including

lymphoma, leukemic tumors, myeloma, and others. A small
percentage of spinal tumors occur within the nerves of the
spinal cord itself, most often consisting of ependymomas and
other gliomas.
 Symptoms of spinal tumors
 Pain (in 90% of patients), numbness or sensory changes,
motor problems and loss of muscle control.

 Pain can feel as if it is coming from various parts of the body.

 Numbness or sensory changes can include decreased skin

sensitivity to temperature and progressive numbness or a
loss of sensation, particularly in the legs.

 Motor problems and loss of muscle control can include

muscle weakness, spasticity (in which the muscles stay stiffly
contracted), and impaired bladder and/or bowel control.
 Spinal tumors
 17% have Multiple level involvement.

 Metastatic lesion mostly found in Thoracic spine.

 Myelopathy develops over days to weeks.

 Acute SCC does occur if tumor enlarges very rapidly due to

hemorrhage or if a vertebral body suddenly collapses.
 Extradural tumors
 The most common spinal
tumor – 85%
 mostly metastatic.
 Arise from osseous element
of spinal column.
 Grow rapidly.
 Primary ; Lung, Breast,
prostate and kidney.
 Compress the spinal cord by
Growing in epidural space
Causing collapse of
vertebrae, distortion and
narrowing.
e.g. lymphoma, hemangioma
and neuroblastoma.
Intradural extramedullary tumors
 Inside the dura but outside
the spinal cord.
 e.g. Meningioma,
Neurinoma.
 Arise from the dural sheath
around the cord or showann
cell sheath around the spinal
root.
 Multiple tumors in Pt. with
neurofibromatosis.
 Can grow extradurally into
retropleural or
retroperitoneal through
intervertebral foramen.
Intradural intramedullary tumors
 Inside the spinal cord
 Examples: Glioma, ependymoma,
astrocytoma
 Arise from glial elements of
spinal cord or trapped
ectodermal elements.
 More common in children.
 Astrocytoma of spinal cord is
the most common intramedullary
tumor of childhood.
 Ependymoma of spinal cord is
the most common intramedullary
tumor of adulthood.
 Arise from ependyma of central
canal.
 Well demarcated.
 Investigations
 Plain X-rays.

 Myelography “contrast material is injected into the

thecal sac fluid surrounding the spinal cord and
nerve root within the spinal canal”

 CT.

 MRI ( study of choice ).

Rx spinal tumors
The goal of treatment is to reduce or prevent nerve
damage from compression of the spinal cord, relieve
pain and maintain the function.
- Surgical excision is the treatment for extramedullary
tumors.
- Radiation therapy for intramedullary tumors.
The traditional treatment of intramedullary gliomas has been
biopsy followed by radiation therapy.
Radiotherapy is clearly of value in metastatic lesions.
- Chemotherapy can be considered in patients with
progression of disease after radiation therapy.
 Spinal cord compression (SCC)
 The act of exerting an abnormal amount of pressure on the
spinal cord.
 Causes and risk factors :
- Traumatic injury.
- Spinal cord tumors.
- Spinal stenosis.
- Ruptured disks.
- Abscesses.
- Arteriovenous malformations.
- Degenerative diseases, such as arthritis.
 Spinal cord compression

Spinal Cord Compression in Three Main Areas

Thoracic Lumbosacral Cervical

70% 20% 10%
 Clinical presentation
Symptoms vary depending on the cause of the
compression, its location, severity, extent and rate
of development but can include:

- Back pain at the spinal site of compression.

- Pain or burning in other parts of the body.
- Difficulty breathing.
- Weakness in the arms, legs, or both.
- Numbness or tingling in the neck, shoulder, arms, hands, or
legs.
- Loss of coordination or difficulty walking.
- Loss of fine motor skills.
- Loss of sexual function.
- Loss of bladder or bowel control.
- Paralysis.
 Clinical presentation
- Cervical spine disease produce Quadriplegia.
- Thoracic spine disease produce paraplegia.

- TENDON REFLEXES
 Increase; below level of compression

 Absent; at the level of compression

 Normal; above the level of compression

- Sphincter disturbances are late feature of cervical and thoracic

cord compression.
 Clinical presentation
 Cauda equina syndrome;
is a serious condition caused by compression of the nerves in
the lower portion of the spinal canal .
is considered a surgical emergency because if left untreated it
can lead to permanent loss of bowel and bladder control and
paralysis of the legs.
 Investigation
 X ray.
 CT scan.
 MRI.
 Myelogram.
 Biopsy.
 Bone scan.
 Blood and spinal fluid
studies.
Rx spinal cord compression
 Acute cord compression is a 'surgical' emergency.

 In those with malignant disease radiotherapy may be

treatment of choice.

 In general, tumor, infection and disc disease produces

anterior compression.

 Surgical decompression should be achieved through an

anterior approach.
 Spinal trauma
 Spinal cord trauma is damage to the spinal cord. It may result
from direct injury to the cord itself or indirectly from damage to
surrounding bones, tissues, or blood vessels.
 Symptoms:
Symptoms vary depending on the location of the injury.

Spinal cord injury causes weakness and sensory loss at and

below the point of the injury.

we can divide spinal trauma into 3 levels according to its

location in the spinal cord ( cervical - thoracic – Lumbosacral ).
 Cervical injuries
- When spinal cord injuries occur near the neck,
symptoms can affect both the arms and the legs:

 Breathing difficulties (from paralysis of the breathing muscles).

 Loss of normal bowel and bladder control (may include
constipation, incontinence, bladder spasms).
 Numbness.
 Sensory changes.
 Spasticity (increased muscle tone).
 Pain.
 Weakness, paralysis.
 Thoracic injuries
- When spinal injuries occur at chest level, symptoms
can affect the legs:

 Breathing difficulties (from paralysis of the breathing muscles)

 Loss of normal bowel and bladder control (may include
constipation, incontinence, bladder spasms).
 Numbness.
 Sensory changes.
 Spasticity (increased muscle tone).
 Pain.
 Weakness, paralysis.
 Injuries to the cervical or high-thoracic spinal cord may also
result in blood pressure problems, abnormal sweating, and
trouble maintaining normal body temperature.
 Lumbosacral injuries
- When spinal injuries occur at the lower-back
level, varying degrees of symptoms can affect
the legs:

 Loss of normal bowel and bladder control (may include

constipation, incontinence, bladder spasms).
 Numbness.
 Pain.
 Sensory changes.
 Spasticity (increased muscle tone).
 Weakness and paralysis.
 Investigations
 A CT scan or MRI of the spine may show the location and
extent of the damage and reveal problems such as blood clots
(hematomas).

 Myelogram (an x-ray of the spine after injection of dye) may be

necessary in rare cases.

 Somatosensory evoked potential (SSEP) testing or magnetic

stimulation may show if nerve signals can pass through the
spinal cord.

 Spine x-rays may show fracture or damage to the bones of the

spine.
Rx Spinal trauma
 ABC
 Spine Immobilization to prevent further injury to the spinal
cord.
 In cervical injuries higher than C5, intubation and
respiratory support are usually needed.
 Corticosteroids, rest, analgesics and muscle relaxant.
 Surgery (decompression laminectomy ).
 Extensive physical therapy and other rehabilitation
interventions are often required after the acute injury has
healed.
 Disc prolapse
Rupture of the disc or
prolapse as it is usually
called, can press on the
spinal cord and its nerve
roots leading to pain,
numbness and weakness
and may also affect the
control of bowel and
urinary bladder.
Dx: X-ray, CT scan or MRI.
Rx Disc Prolapse
 Initial Rx in most cases is conservative.

 Rest.
 Analgesia.
 Anti-inflammatory agents.
 Muscle relaxant -if needed-.
 Physiotherapy.
Rx Disc Prolapse
 laminectomy, involves excision of a portion of the
lamina and removal of the protruding disk.
 spinal fusion, may be necessary to overcome segmental
instability.
 Laminectomy and spinal fusion are sometimes
performed concurrently to stabilize the spine.
 Microdiskectomy, can also be used to remove
fragments of nucleus pulposus.
 Chemonucleolysis: Injection of the enzyme
chymopapain into the herniated disk produces a loss of
water and proteoglycans from the disk, thereby reducing
both the disk’s size and the pressure in the nerve root.
 Spondylolisthesis
 Spondylolisthesis
is a condition in which the
there is a defect in a
portion of the spine,
causing vertebra to slip to
one side of the body.
Rx Spondylolisthesis
 Non-surgical treatment may include one or a combination
of:
- NSAID’s (e.g. ibuprofen, COX-2 inhibitors)
- Oral steroids
- Physical therapy
- Manual manipulation (e.g. chiropractic manipulation).

 Spinal fusion surgery.

Thank
you