chronic spinal cord injury (lesi medula spinalis khronis)

Chronic Spinal Cord Injury (Lesi Medula Spinalis Khronis)

Darwin AmirBgn Ilmu Penyakit Saraf

Fakultas Kedokteran Universitas Andalas

The Spinal CordCervical spinal erves

Thoracic spinal nerves

Lumbar spinal nerves

Sacral spinal nerves

Conus medullaris

Cauda equina

PROYEKSI DERMATOM DIPERMUKAAN KULIT

Ascending Spinal Cord Tract

• 1st order neuron - cutaneous receptors of skin and proprioceptors spinal cord or brain stem

• 2nd order neuron - to thalamus or cerebellum

• 3rd order neuron - to somatosensory cortex of cerebrum

Conducts sensory impulses upward through 3 successive chains of neurons

Ascending Spinal Cord Tract

The Spinal Cord

spinal cordspinal

nerve

vertebra

Cross Section of Spinal CordWhite matter:Myelinated axons

forming nerve tracts

Fissure and sulcusThree columns:

◦Ventral ◦Dorsal◦Lateral

Gray matter: Neuron cell cell

bodies, dendrites, axons

‘Horns’:◦ Posterior (dorsal)◦ Anterior (ventral)◦ Lateral

Commissures:◦ Gray: Central canal ◦ White(see later for white matter

pathways)

The Nervous SystemThe Spinal Cord-part of the CNS found within the Spinal column The spinal cord communicates with the sense organs and muscles below the level of the headBell-Magendie Law-the entering dorsal roots carry sensory information and the exiting ventral roots carry motor information to the muscles and GlandsDorsal Root Ganglia-clusters of neurons outside the spinal cord

Nerve Pathways into the Spinal Cordsensory pathway

motor pathway

Somatic Sensory Pathway

Symptoms and SignsMust be mastering in mindStart by understanding anatomy and

physiology of the Nervous SystemDon’s forget the of CNS systematically

- Anatomy of CNS - Physiology of CNS - Pathophysiology of the Disease - The steps to make the diagnosis

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

Motor disturbances

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

Causes of Chronic Lesion° Tumour ° Multiple sclerosis° Vascular disorders ° Spinal epidural hematoma/abscess° Auto immune disease ° Herniated intervertebral disc° Combine degeneration of B12 Deficiences

Complete spinal cord transection(Transverse myelopathy)

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 : ° tumour ° multiple sclerosis ° vascular disorders ° spinal epidural hematoma/ ° spinal epidural abscess ° herniated intervertebral disc ° auto immune disease

Central spinal cord lesionSpinal cord damage starts centrally

and spreads centrifugallyDecussating fibers of spinothalamic

tract involved initiallyThermo anaesthesia, analgesia in a

”vest like” or “suspended” bilateral distribution with preservation soft touch sensation and proprioception--- dissociation of sensory loss

Central spinal cord lesionForward extension of disease anterior

horn cells involved segmental neurogenic atrophy, paresis, areflexia

Lateral extension I/L Horner syndrome Kypho scoliosis Spastic paralysis Dorsal extension I/L Position sense, vibratory loss

Central spinal cord lesionExtreme venterolateral extension thermo anaesthesia, analgesia with

sacral sparingNeuropathic arthropathyPain

Posterior column disease

Posterior column diseaseTabes dorsalis-tabetic neuro syphilis,

progressive locomotor ataxiaImpaired vibration and position sense, and

decreased tactile localisationLability 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 gaitPositive sink signIn tabes dorsalis lancinating pain, urinary

incontinence, Negative patellar and ankle DTR, hypotonic limb, hyper extensible joints

abdominal, laryngeal crises, impaired light touch perception, Argyll robertson

pupil, optic atrophy, ptosis, ophthalmoplegia

Posterior column disease

○ 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 cere -bellar tract may be a primar manifestation of epidural spinal cord compression-lower extremity dysmetria and gait ataxia.

○ Pt usually have thoracic spine compression due to selective vulnerability of spinocere bellar tract in thoracic spine to compres -sive ischemia

Posterior column disease

Hemisection of the spinal cord( Brown sequard syndrome)

Hemisection of the spinal cord( Brown sequard syndrome)

Loss of pain, temp C/L to the hemisection- interruption of crossed spino thalamic tract

Loss of proprioception – interruption of ascending fibers of posterior column

Spastic weakness due to interruption of descending cortico spinal tract

Segmental LMN signs and sensory changes at the level of lesion due to damage of the roots and anterior horn cells at the level of lesion

INNERVATION OF AUTONOMIC NERVOUSSYSTEM

Thank you BrainFor all you remember

What you forgot was my fault

The End

TERIMA KASIH