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SPINAL CORD & COMPRESSIVE DISORDERS

Dr ANOOP.K.R Asst prof.dept of medicine MMCH,calicut A

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• Basics of spinal cord• Determining the level of lesion

• Special pattern of spinal cord diseases

• Compressive disorders of spinal cord

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Concept of spinal segments• Length of spinal cord giving

origin to rootlets of one spinal nerve

• 31 spinal segments• C - 8 • T - 12• L - 5• S - 5• C - 1

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• Important for localising lesions causing spinal cord compression• For eg, sensory loss below umbilicus – T10 – involvement of cord

adjacent to 7th or 8th thoracic vertebral body

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Determining the level of lesion

1. The presence of a horizontal level below which sensory ,motor and autonomic function is impaired is a hallmark of spinal cord disease.

2. Sensory loss below a particular level is due to damage to spinothalamic tract on the opposite side one or two segments higher in case of a unilateral lesion.

SENSORY !

MOTOR !SPHINCT

ER !

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• 2nd order neurons ascend for for one or two levels as they cross anterior to the central canal to join the opposite STT

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• Sensory symptoms include numbness, tingling ,pins and needles, dermal hypersensitivity, burning sensation, altered temperature sensation and tight band like sensation.

• A complete cord syndrome- loss of all sensory modalities below the level of lesion.

• Partial syndromes produce variable findings

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• Posterior column – loss of joint sense,vibration,tactile discrimination,with positive romberg’s and ataxic gait (sensory ataxia)

• STT – Contralateral loss of pain & temperature sensation

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SENSORY LEVEL• Zone of hyperaesthesia (dorsal

column) :level of lesion is just below it

• Girdle like sensation exaggerated by cough and sneezing- dorsal column

• Involvement of specific dermatomes

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3. At the level of lesion – LMN signs – focal muscle wasting,

fasciculations, hypo- or areflexia due to involvement of AHCs

Radicular pain or dermatomal sensory loss d/t involvement of sensory roots

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4. Interruption of motor tracts (pyramidal /extrapyramidal)

UMN signs below the level of lesion if corticospinal tract – pyramidal pattern

of weakness – greater in the antigravity muscles – paraplegia in extension

if extrapyramidal tracts - progravity

muscles are affected more – paraplegia in flexion – may be associated with ‘mass reflex’

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Mass reflex• Spontaneous urination,

defaecation, sweating on scratching skin on the medial aspect of thigh

• a/w reflex ejaculation and erection on squeezing glans penis

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5.The lesions that transect the motor tracts cause paraplegia or quadriplegia with heightened DTRs ,babinski sign and eventual spasticity ( Upper motor neuron syndrome)

6. If Acute compressive lesion (traumatic/vascular/inflammatory) : stage of neuronal shock prior to the stage of spasticity

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7. Transverse damage to the cord produces

autonomic disturbances -absent sweating below the implicated cord level and bowel, bladder, sexual dysfunction

8. Most common sphincter disturbances resulting from spinal cord diseases are urgency,frequency, urge incontinence. retention

a /c transverse lesions –retention is the rule

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Localising the uppermost level of a spinal cord lesion

‘segmental signs’• Band of altered sensation

(hyperalgesia/hyperpathia) at the upper end of sensory disturbance

• Fasciculations or muscle atrophy in muscles supplied by that sement

• Absent DTR at this level

How to differenciate from focal root or peripheral nerve disorder?

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Uppercervical cord lesion:

Quadriplegia Weakness of diaphragm(above C4)Arnold chiari - downbeating nystagmus & cerebellar ataxia

Lower cervical cord lesions

Atrophy and weakness of corresponding musclesSpastic paralysis of trunk and lower limbAbsent biceps,radial jerkHorner’s syndrome

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Lumbar cord lesions

L2-L4:weakness of Flexion and adduction of thighLoss of knee jerkSpastic paralysis below,exaggerated ankle jerkExtensor plantar

Thoracic cord lesionsSensory level on the trunk, Site of midline back painBeevor’s sign positive – lesion at T9,T10Spastic paralysis of lowerlimbs

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Cauda equina and conus medullaris lesions

CONUS MEDULLARIS CAUDA EQUINAB/L saddle anaesthesia asymmetric leg weakness and

sensory loss

Prominent bowel,bladder symptoms,impotence

Relative sparing of bowel-bladder function

Bulbocavernous ( S2-s4) and anal reflexes (s4-s5) are absent

Variable areflexia in lower extremities

Muscle strength largely preserved Low back and radicular pain

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BROWN SEQUARD SYNDROME

• HEMICORD SYNDROME• I/L corticospinal,dorsal

column,spinothalamic tract

• I/L – weakness,loss of joint and vibration sense

• C/L – loss of pain,temp

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Central cord syndrome

• Selective damage to grey matter and crossing spinothalamic tracts

• Syringomyelia,intrinsic tumors of spinal cord,trauma

• Dissociated anaesthesia

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Shoulders,lower neck,upper trunk –cape distribution

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Anterior spinal artery syndrome

• Infarction d/tanterior spinal artery occlusion

• B/L tissue destruction which spares posterior column

• All spinal cord functions –motor,sensory and autonomic – are lost below the lesion

• Striking exception of retained vibration and position sense

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FORAMEN MAGNUM SYNDROME• Lesions in this area

interrupt decussating pyramidal fibres destined for the legs,which cross caudal to those of the arms resulting in weakness of the legs :CRURAL PARESIS

• Around the clock pattern of weakness

• Suboccipital pain spreading to neck and shoulders

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Compressive myelopathies

• Acute compressive Myelopathy / Chronic Myelopathy

• Extramedullary / intramedullary

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Compressive Myelopathy

Intra medullary

Intradural

Extradural

Extramedullary

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• Cord compression

Extramedullary (95 %) Intramedullary(5%)

Intradural Extradural (15%) (80%)

MENINGIOMANEUROFIBROMAPATCHY ARACHNOIDITISAV MALFORMATIONS

NEOPLASMSPOTT’S SPINEIVDPEPIDURAL ABSCESSTRAUMA

SYRINGOMYELIAGLIOMA,EPENDYMOMA OF CORD

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Extramedullary lesions

• Long duration of history• Root pain (+)• Vertebral body tenderness (+)• Motor involvement usually

asymmetrical • Sensory level, all sensations diminished

below this level• Early loss of sensation in the saddle

area ( S3,S4,S5)• Autonomic involvement late

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Intramedullary lesions

• Short duration,painless onset• early bladder involvement• Motor – usually symmetrical• Jacket sensory loss• Dissociative sensory loss • Sacral sparing

SUMMARY• A 42 yr female old operated case of right solid ovarian tumor,

presented with low back pain with root pain with numbness & tingling sensation over abdomen & both lower limbs with gradual onset progressive asymmetrical paraparesis with predominant right lowerlimb weakness without upper limb & bladder bowel involvement.

• On examination, Presence of dermal neurofibroma with asymmetrical

Paraparesis with b/l extensor plantar with absent abdominal reflex & impaired primary modalities of sensation at & below T-6 spinal segment without bladder involvement and without any spinal tenderness or deformity

Functions lost: Paraparesis. All modalities of sensation impaired from T-6 spinal

segment level downward B/L.

Structures involved B/l corticospinal tract at T-6 segment. B/l spinothalamic tract (anterior and lateral) &

posterior columns at T6 segment

PROVISIONAL DIAGNOSIS• Extramedullary Intradural Compressive

thoracic myelopathy at T-6 spinal segment---• Most probably d/t neurofibromatosis.

EXTRAMEDULLARY INTRADURAL COMPRESSIVE THORACIC MYELOPATHY

POINTS FOR gradual onset Asymmetrical paraparesis No bladder involvement. H/O root pain No spinal tenderness or

deformity.

POINTS AGAINST

DIFFERENTIAL DIAGNOSIS

• Metastases to spine• T.B. Spine

METASTASIS TO SPINE

POINTS AGAINST

No Spinal tenderness or deformity

POINTS FOR1.h/o solid ovarian tumor2.paraparesis

T.B. SPINE

POINTS FOR

paraparesis Upper level of sensory

impairement

POINTS AGAINST No spinal tenderness. No past history of

pulmonary tuberculosis.

INVESTIGATIONS1) Hb- 12.0 gm% TLC- 8,400/mm3

DLC- N77L23E0B0 M0 ESR- 10mm/1st hr2) FBS-115 mg% 2hr PPBS--1423) Blood urea- 29 mg% Sr Creat- 0.5 mg%• Sr Na- 136 mEq/L Sr K- 5.1 mEq/L5) Urine R/M- Alb trace

pus cell-12-156) HIV,HBV,HCV --Neg

X-Ray thoracic spine (AP & Lat views) centering T3 vertebra---Normal

X-Ray chest (PA view)—WNL USG ABDOMEN & PELVIS—

BULKY UTERUS B/L OVARIES NOT VISUALISED SPLEEN NOT VISUALISED .MRI Lumbosacral spine— L4—L5 Disc desication

&diffuse posterior bulge indenting thecal sac

MRI THORACIC SPINE---

FINAL DIAGNOSIS

• Extramedullary Intradural compressive thoracic myelopathy at T-6 spinal segment---

most probably d/t Neurofibromatosis type 1.

• A 40 yrs hindu female presented with sudden onset weakness of both the lower limbs with band like sensation in the upper trunk and diminished sensation below umbilicus with early bladder involvement.

On examination pt had decreased tone and loss of power in both lower limbs with absent DTR in both lower limbs, B/L plantar extensor, absent abdominal reflex with loss of all modalities of sensation below T8 spinal segment.• Loss of spinal prominence and presence of tenderness

at T6 vertebral level

SUMMARY

• Functions lost: Paraplegia. Absent vibration and joint position sensation below

T8 spinal segment level. Absent pain and temperature sensation below T8 spinal

segment. Retention of urine

Structures involved: Bilateral corticospinal tract . Bilateral dorsal column at T8 spinal segment. Bilateral Spinothalamic tract at T8 spinal segment. Autonomic nervous system.

PROVISIONAL DIAGNOSIS

• Extradural compressive thoracic myelopathy at T8 spinal level probably due to prolapse intervertibral disc in neuronal shock.

COMPRESSIVE MYELOPATHY

• Points in favour:i. Sensory level.ii. Band like sensation .iii. Spinal tenderness.iv. Early bladder involvement.v. Presence of spinal deformity and tenderness.

Points against: Sudden onset. No root pain. Symmetric involvement.

EXTRADURAL LESION

• Points in favour:i. Spinal tenderness and deformity.ii. Symmetrical weakness present.

• Points against:i. No root pain.

Differential diagnosis:

• Prolapsed inter vertebral disc.• Potts paraplegia.• Acute transverse myelitis• Guillain-barre syndrome• Anterior spinal artery thrombosis.

Prolapsed inter vertebral disc

Points in favour: i. Sudden onset of weakness.ii. Sensory level.iii. Girdle like sensation .iv. Early bladder involvement.v. Presence of spinal deformity and tenderness.Points against:1. No h/o trauma.2. Uncommon site.

POTT’S PARAPLEGIA Points in favour:i. Features of extradural compressive myelopathy.ii. Most common cause of compressive myelopathy in developing

countries.iii. Involvement of thoracic spine.iv. Low socioeconomic status.

Points against:• Sudden onset• No history of fever or weight loss• No past history of tuberculosis.• No family history of tuberculosis.

• Compressive:1. Injury to the spinal cord.(# dislocation or collapse of

vertebra)2. Prolapsed intervertebral disc.3. Spinal epidural abscess.4. Spinal hematoma• Non-compressive:1. Acute transverse myelitis2. Thrombosis of anterior spinal artery.3. Hematomyelia 4. Post vaccinial5. Radiation myelopathy.

POTT’S PARAPLEGIA- GRADES

• Grade I (negligible paraplegia)- The patient is unaware of the neurological deficit but examination reveals clonus and extensor plantar response.

• Grade II (mild paraplegia)- The patient is aware of weakness but manages to walk with or without support.

Contd.

• Grade III (moderate paraplegia)- The patient is bedridden and can not walk due to severe weakness. Examination reveals paraplegia in extension and sensory deficit if present is less than 50%.

• Grade IV (severe paraplegia)- Features of grade III with flexor spasm / paralysis in flexion / flaccid paralysis and sensory deficit of more than 50%.

TREATMENT OF POTTS PARAPLEGIA:

• waiting for 4 weeks for the paraplegia to recover with rest and ATT. If there is no improvement in neurological deficit then surgical decompression should be done.

• Duration of ATT- Most authorities favour 18 -24 months. Short course chemotherapy for 9 months is equally effective.

OPERATIVE INDICATIONS FOR VERTEBRAL TUBERCULOSIS

• Decompression for neurological complications which failed to respond to conservative therapy.

• Debridement in failure of response after 3-6 months non operative treatment.

• Fusion for mechanical instability after healing.• Prevention of severe kyphosis.

SUMMARY

• A 60 yr old Hindu male, presented with H/O intermittent root pain(nape of neck and arm) and weakness of left lower limb since last 3 1/2 months and weakness of left upper limb since 3 months. Followed by weakness of both right upper and lower limb for last 2 months without bladder and bowel involvement .

On examination found to have quadriparesis ,weakness of handgrip muscle & exaggerated knee and ankle jerk and absent triceps jerk, with positive finger flexion, Wartenberg sign and hoffman sign with extensor plantar response bilaterally with absent superficial reflex and impaired pain,temperature, touch, vibration below C-7 dermatome level & absent joint position sensation in lower limb and upper limb.

Functions lost: Quadriparesis impairement of pain,temparature, vibration sensation below

C7 downward. Loss of joint position in all four limbs.Structures involved: Bilateral corticospinal tract below C7. Bilateral posterior columns & bilateral lateral spinothalamic

tract below C7.

PROVISIONAL DIAGNOSIS

Extramedulary Extradural Compressive cervical

myelopathy at C7spinal segment level probably due to

cervical spondylosis

COMPRESSIVE MYELOPATHY

Points in favour:

Gradual onset. Root pain Asymmetrical progression Upper level of sensory loss

Points against:

No bony deformity.No bony tenderness.No Girdle like sensation.No bowel and bladder

involvement. .

EXTRAMEDULLARY LESION

Points in favor:

Root pain. No bowel and bladder

involvement No dissociated sensory loss. UMN involvement

Points against

No bony deformityNo vertebral tenderness

EXTRADURAL LESION

Points in favor

More common.Root pain

Points against

No bony deformity.No bony tenderness.Asymmetrical onset

DIFFERENTIAL DIAGNOSIS

• Cervical spondylosis.• Metastasis to cervical spine• POTT’S spine.• Spinal Tumor(Extramedullary intradural

Metastatic spinal cord compression

POINTS FOR1. Age of the patient2. No evidence of primary lesion3. Features of extramedullary extradural

compression

POINTS AGAINST• No bony deformity.• No weight loss.• No Lymphadenopathy.• Involvement of cervical vertebra.

Cervical spondylosis

POINTS IN FAVOUR •Age•Root pain•Insidious onsetAsymmetrical. No bladder and bowel involvement

POINTS AGAINSTNo zone of hypereasthesia.No bony deformityNo restricted neck movement.

POTT’S cervical spine

POINTS IN FAVOUR Features of

extramedullary extradural compression.

Endemic area. Low socioeconomic

stasus.

POINTS AGAINST No History

suggestive of previous TB

No gibbus. No h/o fever and

weight loss. Involvement of

cervical vertebra.

Spinal Tumor(Extramedullary intradural)

Features of extramedullary extradural compression.

Gradual onset.asymmetric

•Involvement of cervical vertebrae•Root pain•No bladder bowel and bladder involvement

POINTS IN FAVOUR POINTS AGAINST

INVESTIGATIONS Hb- 9 gm% DC- N87L13E0 TLC- 11,400/mm3

ESR- 50 mm/1st hr RBS- 161 mg% Blood urea- 32 mg% Sr Creat- 1.3 mg% Sr Na- 135 mEq/L Sr K- 4.7 mEq/L Urine R/M - Normal X-Ray chest (PA view)- WNL HIV, HBV, HCV -negative. X ray cervical spine

degenerative changes and osteophytes

MRI of CERVICAL SPINE Atlanto odontoid subluxation with increased

antlanto odontoid interval. Multilevel degenerative disc disease and

spondylosis change seen from C2-C3 TO C6- C7 level with degenerative kyphosis

C5-C6 posterior disc osteophytes and ligamentum flavum buckling causing spinal stenosis with compression of cervical spinal cord and producing ill defined focal increased T2 signal suggestive of myelomelacia

C3-C4 and C4-C5 level decreased disc height anterior osteophytes and posterior central disc osteophytes indenting thecal sac.

Acute transverse myelitis:

• Points in favour:i. Sudden onset of symmetrical weakness.ii. Sensory level.iii. Early bladder involvement.iv. Involvement of mid thoracic region.v. Absence of root pain.• Points in against:

i. No h/o of preceding infection.ii. Presence of spinal deformity and tenderness.

Guillain-barre syndrome:• Points in favour:

1. Paraplegia 2. Areflexia Points against:3. Early bladder involvement.4. Sensory involvement.5. Presence of bony deformity and spinal

tenderness.

Anterior spinal artery thrombosis:

• Points favour: Sudden onset Paraplegia Involvement of thoracic region.• Points against: Presence of bony deformity and spinal

tenderness. Absence of dissociative sensory loss.

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EXTRADURAL EXTRAMEDULLARY CAUSES

• 1. DICS PROLAPSE : Cervical disc prolapse :most common if centrally located, can cause acute or

subacute cord compression Thoracic disc protrusions : sub a/c or

chronic cord compression.Can cause paraparesis / brown sequard syndrome due to asymmetrical compression

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• Clear cut sensory level is usual• Neurological symptoms may

fluctuate over time• MRI demonstrate the cord

compression due to disc prolapse.

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• Treatment : • immobilising in a cervical collar• If highly symptomatic – surgical

decompression• Complication of cervical disc surgery

– irreversible paraplegia due to cord infarction

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2. Spinal epidural abscess clinical triad : Midline dorsal pain

(Over spine / Radicular) Fever

(WBC,ESR,CRP elevation) Progressive limb

weakness

Prompt recognition to prevent permanent sequelae

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• Abscess expand – venous congestion and thrombosis – further cord damage

• Rapid progression once the features of myelopathy develops

• a/w impaired immune status, IV drug abuse,skin and tissue infections

(furunculosis,pharyngeal/dental abscess/bacterial endocarditis,pott’s spine,)

local causes :epidural anaesthesia, LP ,decubitus ulcer ,vertebral osteotomies

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• S.aureus, Streptococcus, anaerobes, gram neg bacilli, fungi

• MRI ,sometimes LP• Treatment : Surgical evacuation, decompressive

laminectomy , long term antibiotics

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TUMORS AND COMPRESSIVE MYELOPATHY

Metastasis - epiduralThracic is common; Lumbar & Sacral – Prostate and ovarianBreast > Lung > Prostate > Kidney > Lymphoma old age pt :Vertebral pain with a/c onset of neurological deficit

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MRI – hypointense lesion in T1; does not cross the adjacent disc spaceBone scan may be useful to detect the all other metastasis

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Management:-Glucocorticoid – upto 40mg/d Dexamethasone-RT – 3000cGy in 15 daily fractions

Newer : IMRT (INTENSITY MODUALTED RT)-Surgery- laminectomy or vertebral resection (IF neuro signs worsen even with RT)

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Prognosis:• Ambulatory pt – good response

with RT• Fixed motor deficit once

established <12hr good response

>12hr chance to improve

>48hr no improvement

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NEUROFIBROMA: • arises near posterior root• May or may not be a/w generalised NF• Can occur at any level of spinal cord• Equally in both sexesMENINGIOMA: • Benign -thoracic cord level more common in females

Diagnosis• Thorough physical examination

– Palpation– Gentle percussion over bony areas– Neurologic exam

• Laboratory data – Increased alkaline phosphatase may indicate bony involvement

Diagnosis

• Radiographs- may reveal erosion of the pedicle,– Lytic lesions of the vertebral body– Collapse of the vertebral body

• Bone scan- 20% of scans reveal lesions missed on plain films

• CT– Used to determine extent of tumor

Diagnosis

• MRI ( Tool of choice)– Able to determine prevertebral, vertebral,

extradural, intradural, extramedullary and intramedullary lesions

– Provides better anatomic visualization with sagittal and axial images of the spinal cord

• Fine needle aspiration– May provide tissue confirmation

Treatment• Criteria:

–Primary tumor type–Level of myelopathy–Degree of spinal block–Potential for neurologic reversibility

Treatment

• Surgery– Radical resection if an a candidate– Complete block– Single lesion where complete removal is possible– Diagnosis is uncertain– Mild deficits– New data supports surgery over treatment with RT

if patient is a good surgical candidate

Treatment

• Radiation therapy– If not a surgical candidate– Incomplete block– Severe deficits– Relapse in area of prior radiation if short survival is

expected

TreatmentRadiation- often initiated as an emergency if not

a surgical candidate– Therapy

• Treatment field extends 1-2 vertebral bodies above and below level of compression

• 3000-4000 cGy over 2-4 weeks• 2/3 of patients remain stable or improve• 65-75% achieve pain relief

Treatment• Steroids

– Dexamethasone• Bolus IV 10 mg• Oral 4-6 mg q 6 hours for 2 days then a slow taper• 25% of patients with cord compression require

maintenance to maintain neurologic function• Steroid related side effects may occur

– Hyperglycemia– GI bleeding– Psychosis

Treatment

• Chemotherapy– May be given in highly sensitive tumors– Always given with other modalities

Outcome• Pretreatment ambulatory ability is the

main determinant of post treatment ambulatory ability

• 90% of patients ambulatory before therapy are after

• Only 10% of paraplegics become ambulatory after therapy

Prognosis

• Median survival is 6 months if patient presents as a paraplegic

• 50% of patients who walk in with a cord compression are alive at 1 year

• If patient was ambulatory prior to RT survival is 8-10 months

Recurrent Disease

• Options– If RT given may be a surgical candidate if

survival of > 12 months predicted– Repeat RT

• Risks of repeat RT –Radiation myelopathy–Collateral damage

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