In the Name of God, Most Gracious, Most Merciful

SPINAL CORD SYNDROMES

- Dr. Mohammed Sadiq Azam
II yr. Postgraduate

MD Internal Medicine
Deccan College of Medical Sciences

CLASSIFICATION

COMPLETE

INCOMPLETE

COMPLETE CORD SYNDROMES

Trauma Metastatic carcinoma Multiple sclerosis Spinal epidural haematoma Autoimmune disorders

Post vaccinial syndromes.

COMPLETE CORD TRANSECTION

All ascending tracts from

below and descending tracts from above are interrupted. Affects motor, sensory and

autonomic functions.

COMPLETE CORD TRANSECTION

SENSORY:

All sensations are affected. Pin prick test is very valuable. Sensory level is usually 2 segments below the level of lesion.

Segmental paraesthesia occur at the level of lesion.

COMPLETE CORD TRANSECTION

MOTOR:

Paraplegia due to corticospinal tract involvement. First spinal shock-followed by hypertonic hyperreflexic paraplegia.

Loss of abdominal and cremastric reflexes.

At the level of lesion LMN signs occur.

COMPLETE CORD TRANSECTION

AUTONOMIC:

Urinary retention and constipation. Anhidrosis, trophic skin changes, vasomotor instability below the level of lesion.

Sexual dysfunction can occur.

INCOMPLETE CORD SYNDROMES

Brown Sequard syndrome Central cord syndrome Anterior cord syndrome Posterior cord syndrome Conus medullaris syndrome Cauda equina syndrome

BROWN SEQUARD SYNDROME

= Hemi-section of the spinal cord

Caused by extramedullary lesions

Usually caused by penetrating trauma or tumour.

BROWN SEQUARD SYNDROME

SENSORY:

Ipsilateral loss of proprioception due to posterior column involvement.

Contralateral loss of pain and temperature due to involvement of lateral spinothalamic tract.

BROWN SEQUARD SYNDROME

MOTOR:

Ipsilateral spastic weakness due to descending

corticospinal tract involvement

LMN signs at the level of lesion.

CENTRAL CORD SYNDROME

CENTRAL CORD SYNDROME

CENTRAL CORD SYNDROME

Commonest cause is Syringomyelia.

Other causes:
Hyperextension injuries of neck

Intramedullary tumours
Trauma Associated with Arnold Chiari type 1 and 2, Dandy walker malformation

CENTRAL CORD SYNDROME

SENSORY:

Pain and temperature are affected.

Touch and proprioception are preserved. Dissociative anaesthesia. Shawl like (= Cape like) distribution of sensory loss.

MOTOR:

Upper limb weakness > Lower limb

SYRINGOMYELIA
OTHER FEATURES :

Horners syndrome Kyphoscoliosis

Sacral sparing
Neuropathic arthropathy of shoulder and elbow joint Prognosis is fair.

POSTERIOR CORD SYNDROME

Commonest causes include diabetes mellitus &

neurosyphilis.

Usually occurs 10 to 20 yrs after disease onset.

POSTERIOR CORD SYNDROME

SENSORY :

Impaired position and vibration sense in LL

Tactile and postural hallucinations can occur. Numbness or paresthesia are frequent complaints.. Sensory ataxia. Positive rhomberg sign.

Positive sink sign

Positive lhermittes sign.

POSTERIOR CORD SYNDROME

SENSORY (contd):

Abadies sign (of tabes dorsalis) positive

Urinary incontinence

Absent knee and ankle jerk (Areflexia, Hypotonia)

Charcots joint Miotic and irregular pupil not reacting to light Argyl Robertson Pupil

POSTERIO LATERAL COLUMN DISEASE

CAUSES :

Vitamin B12 deficiency

AIDS

HTLV associated myelopathy

Cervical spondylosis

POSTERIO LATERAL COLUMN DISEASE

FEATURES :

Paresthesia in feet Loss of proprioception and vibration in legs Sensory ataxia Positive Rhomberg sign Bladder atony Corticospinal tract involvement:
Spasticity Hyperreflexia Bilateral Babinski sign - Positive

POSTERIO LATERAL COLUMN DISEASE

AIDS:
Associated dementia and spastic bladder is present

HTLV associated myelopathy:

Slowly progressive paraparesis Increase in CSF IgG with antibodies to HTLV 1

ANTERIOR CORD SYNDROME

Due to acute disc herniation or ischemia from anterior spinal artery occlusion.

Usually caused by hyperflexion injuries Area supplied by anterior spinal artery is affected

ANTERIOR CORD SYNDROME

Sudden onset of paralysis

(quadriparesis/paraparesis)
below the level of lesion.

Pain and temperature loss. Dorsal column is preserved.

Prognosis is poor.

ANTERIOR SPINAL ARTERY SYNDROME

ANTERIOR SPINAL ARTERY SYNDROME

ANTERIOR SPINAL ARTERY SYNDROME

Commonest of the vascular syndromes of the cord. Spinal cord infarction usually occurs in T1 to T4 segment & L1. Occurs due to aortic dissection, atherosclerosis of aorta, SLE, AIDS, AV malformation

Rarely due to dissection of the anterior spinal artery or systemic arteritis. Syphilitic arteritis is now rare.

Conus medullaris is frequently involved.

Neck pain of sudden onset is a common feature.

Also called as Becks syndrome.

ANTERIOR SPINAL ARTERY SYNDROME

SENSORY :

Loss of pain and temperature. Preservation of position and vibration.

MOTOR :

Sudden onset flaccid and areflexic paraplegia.

AUTONOMIC :

Urinary incontinence +

POSTERIOR SPINAL ARTERY SYNDROME

UNCOMMON
Loss of proprioception and vibratory sense. Pain and temperature is preserved. Absence of motor deficit.

ANTERIOR HORN CELL SYNDROMES

CAUSED BY SPINAL MUSCULAR ATROPHY

Spinal muscular atrophy (SMA) is an autosomal recessive disorder that causes decreased survival of the anterior horn

cells motor neurons that innervate voluntary muscles,

resulting in progressive muscle atrophy and weakness. Types I to IV

Eponyms: Werdnig-Hoffman disease, Kugelberg-Welander

disease, SMA, Anterior horn cell disease

ANTERIOR HORN CELL SYNDROMES

MOTOR :

Weakness, atrophy and fasciculations. Hypotonia, depressed reflexes. Muscles of trunk and extremities are affected. Sensory system is not affected.

ANTERIOR HORN CELL & PYRAMIDAL TRACT SYNDROME

Occurs in amytrophic lateral sclerosis (ALS).

Also called Lou Gehrig's disease. A form of Motor Neuron Disease caused by the degeneration of

upper and lower neurons, located in the ventral horn of

the spinal cord and the cortical neurons that provide their efferent input.

Affects the anterior horn cells and corticospinal tract.

Both LMN and UMN signs occur.

ANTERIOR HORN CELL & PYRAMIDAL TRACT SYNDROME

MOTOR :

Ant horn cell related:

Paresis, Atrophy and Fasciculations.

Corticospinal tract related:

Paresis, Spasticity and Extensor plantar response.

ANTERIOR HORN CELL & PYRAMIDAL TRACT SYNDROME

It is usually unilateral with muscle weakness +

Reflexes are often exaggerated. Bulbar and pseudo bulbar involvement occurs. Sensory system is not affected. Superficial reflex - Abdominal reflex is preserved.

CONUS MEDULLARIS & CAUDA EQUINA SYNDROMES

CONUS MEDULLARIS SYNDROME

CM: Lies opposite to vertebral bodies of T12 and L1. Contributes to 25% of spinal cord injuries. Caused by flexion distraction injuries and burst

fractures.

Both UMN and LMN deficits occur. Development of neurogenic bladder.

CAUDA EQUINA SYNDROME

CE: Begins at L2 disk space distal to conus medullaris.

CE syndrome occurs due to:

Acute disk herniation
Epidural haematoma Tumour

CAUDA EQUINA SYNDROME

MOTOR :

Flaccid lower extremities.

Knee and ankle jerk absent.

SENSORY :

Asymmetrical sensory loss Saddle anaesthesia Loss of sensation around perineum, anus, genitals.

CAUDA EQUINA SYNDROME

AUTONOMIC:

Loss of bladder and bowel function.

Urinary retention.

DDx: CONUS vs CAUDA

FEATURE CONUS MEDULARIS CAUDA EQUINA

PRESENTATION
REFLEXES

Sudden & Bilateral

Knee present, Ankle (If the epiconus is involved, patellar reflex

Gradual & Unilateral

Knee & Ankle Bulbocavernosus reflex

maybe absent but

bulbocavernosus is spared) RADICULAR PAIN LOW BACK ACHE Less severe More

is absent in low CE
(sacral) lesions

More severe Less

Ref: http://www.emedicine.com/neuro/topic667.htm

FEATURE

CONUS MEDULARIS

CAUDA EQUINA

SENSORY SYMPTOMS

Numbness tends to be more localized to perianal area; symmetrical and bilateral; sensory dissociation occurs. Sensory loss of pin prick & temperature sensations (Tactile sensation is spared.)

Numbness tends to be more localized to saddle area; asymmetrical, maybe unilateral; no sensory dissociation; loss of sensation in specific dermatomes in lower extremities with numbness and paresthesia; possible numbness in pubic area, including glans penis or clitoris.

Ref: http://www.emedicine.com/neuro/topic667.htm

FEATURE

CONUS MEDULARIS

CAUDA EQUINA
Asymmetric areflexic paraplegia that is more marked; fasciculations rare; atrophy more common .

MOTOR SYMPTOMS

Typically symmetric, distal paresis of lower limbs that is less marked; fasciculations may be present.

IMPOTENCE Frequent

Less frequent; ED is common erectile dysfunction that includes inability to have erection, inability to maintain erection, lack of sensation in pubic area (including glans penis or clitoris), and inability to ejaculate.

Ref: http://www.emedicine.com/neuro/topic667.htm

FEATURE
SPHINCTER DYSFUNCTION

CONUS MEDULARIS CAUDA EQUINA

Urinary retention and atonic anal sphincter cause overflow urinary incontinence and fecal incontinence Tend to present early Tends to present late in course of disease Urinary retention

in course of disease.

EMG

Mostly normal lower

Multiple root level

extremity with external involvement; sphincters may anal sphincter invlmnt OUTCOME Less favourable also be involved. More Favourable

Ref: http://www.emedicine.com/neuro/topic667.htm