SPINAL CORD: LESIONS & SYNDROMES

NEURO2 | Ruben C. Flores, MD, FPNA

19/11/2021, 10-12 NN

 lower spinal nerves take downward course to exit via

Contents
intervertebral foramina
I. Spinal Cord Anatomy
 C1-C7 spinal nerves exit above the same numbered vertebral
II. Spinal Cord Syndromes
bodies
a. Complete Spinal Cord Transection (Transverse
 subsequent nerve exits below
Myelopathy)
 spinal cord corresponding to vertebral bodies- localizing
b. Hemisection of the Spinal Cord (Brown-Sequard
lesions causing cord compression
Syndrome)
c. Central Cord Syndrome
d. Posterolateral Column Syndrome SPINAL CORD SYNDROMES
e. Posterior Column Syndrome COMPLETE SPINAL CORD TRANSECTION (TRANSVERSE
f. Anterior Horn Cell Syndromes MYELOPATHY)
g. Combined Anterior Horn Cell and Pyramidal Tract  affects all ascending tracts
Disease from below the level of the
h. Anterior 2/3 Syndrome lesion and all descending
i. Spinal Cord Compression tracts from above the level of
j. Intramedullay and Extramedullary Syndromes the lesion damage to all
k. Specific Localizing Signs motor and sensory function
III. Acute and Subacute Spinal Cord Disease  most of time, the section is
a. Neoplastic Spinal Cord Compression incomplete and irregular
b. Spinal Cord Infarction  acute onset: trauma, tumor, MS, vascular disorders
c. Hematomyelia  other causes: spinal epidural hematoma, herniated disc,
d. Spinal Epidural Abscess postvaccinal, spinal epidural abscess
e. Transverse Myelitis
f. Acute Infectious Myelopathies HEMISECTION OF THE SPINAL CORD (BROWN-SEQUARD
IV. Chronic Myelopathies SYNDROME)
a. Spondylotic Myelopathy
 loss of pain and temperature
b. Vascular Malformations
sensation contralateral to the
c. Retrovirus-Associated Myelopathies
hemisection due to
d. Syringomyelia
interruption of the crossed
e. Subacute Combined Degeneration (Vitamin B12
spinothalamic tract
Deficiency)
 ipsilateral loss of
f. Tabes Dorsalis
proprioceptive function
g. Familial Spastic Paraplegia
below the level of the lesion due to interruption of the
V. Spinal Cord Trauma
ascending fibers in the posterior columns (dorsal funiculi)
VI. Spinal Column Fractures
 ipsilateral spastic weakness with hyperreflexia and Babinski
VII. Malignant Spinal Cord Syndrome
sign caudal to the level of the lesion due to interruption of the
descending corticospinal tract
SPINAL CORD ANATOMY  segmental lower motor signs at the level of the lesion:
segmental weakness and atrophy and segmental anesthesia-
 thin, tubular extension of CNS contained within bony spinal
due to the damage of the anterior horn cells and dorsal
canal
rootlets
 originates at the medulla, continues caudally to terminate in
 ipsilateral autonomic disturbances is also observed
the filum terminale
 most often, secondary to extramedullary lesions
 fibrous extension of conus medullaris terminating at coccyx
 18 inches long, oval or round
 enlarged in cervical and lumbar regions CENTRAL CORD SYNDROME
 neurons innervate upper and lower extremities  damage starts centrally and spreads
 white matter contains ascending sensory & descending motor centrifugally
pathways  decussating fibers of spinothalamic
 nerve cell bodies clustered in inner region, shaped liked a 4- tract are initially involved-
leafed clover that surround central canal dissociation of sensory loss/ cape
 membranes covering spinal cord- pia, arachnoid, dura mater or vest-like pattern
 consists of 31 segments each consists of  loss of pain and temperature sense
 exiting ventral motor root in a cape distribution
 entering dorsal sensory root  intact light touch, joint position, and vibration sense
 in adults, spinal cord ends at L1  arm weakness out of proportion to leg weakness
 sacral sparing

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SPINAL CORD: LESIONS & SYNDROMES
NEURO2 | Ruben C. Flores, MD, FPNA
19/11/2021, 10-12 NN

 causes: trauma, syringomyelia, tumors, anterior spinal artery  motor, sensory, autonomic functions
ischemia, hydromyelia, intramedullary tumors are lost below the level of the lesion
 intact vibration and position sense
POSTEROLATERAL COLUMN SYNDROME  vascular etiology- thromboembolism
of anterior spinal artery or vessel
 usually involves the cervical region
compression by a mass
 seen in subacute combined
 anterior spinal artery syndrome
degeneration of the spinal cord due
to vitamin B12 deficiency- pernicious
anemia SPINAL CORD COMPRESSION
 multifocal vacuolated and
demyelinating lesions in the 3 CLINICAL STAGES
posterior and lateral funiculi STAGE 1 Radicular pain and segmental motor and sensory
 symptoms: paresthesia in the feet and less in the hands, gait disruption
imbalance, sensory ataxia, bladder atony STAGE 2 Incomplete transection
STAGE 3 Complete cord transection
POSTERIOR COLUMN SYDNROME
 selectively damaged by tabes PAIN: IMPORTANAT EARLY SIGN OF CORD COMPRESSION
dorsalis (tabetic neurosyphilis or  radicular pain
progressive locomotor ataxia)  characterized as unilateral, lancinating, dermatomal pain
 tabes dorsalis- 10-20 years after often exacerbated by cough, sneeze, or Valsalva maneuver
luetic infection  common with extradural growths
 impaired vibration and position  vertebral pain
sense and decreased tactile  characterized by aching pain localized to the point of the
localization spine involved in the compressive process
 lower extremity> upper extremity  often accompanied by point tenderness
 gait disorder is pronounced in darkness  common in neoplastic or inflammatory extradural lesions
 lightning pins- hallmark of tabes dorsalis  funicular (central) pain
 other causes: cervical spondylosis, posterior spinal artery  common with intramedullary lesions
infarction  described as deep, ill-defined painful dysesthesias distant
from the affected spinal cord level
 poor localizing sign
ANTERIOR HORN CELL SYNDROMES
 selective damage to the anterior
INTRAMEDULLAY AND EXTRAMEDULLARY SYNDROMES
horn cells of the spinal cord
 pure motor syndrome with
preserved sensory function INTRAMEDULLARY SYNDROME
 causes: poliomyelitis, several forms  arise within the substance of the cord
of autosomal recessive spinal  poorly localizing burning pain
muscular atrophies, postradiation  spare sensation of perineal and sacral area
 corticospinal tract signs appear late
 long duration of symptoms
COMBINED ANTERIOR HORN CELL AND PYRAMIDAL TRACT
DISEASE
EXTRAMEDULLARY SYNDROME
 characterized by
 compress spinal cord or its vascular supply
degenerative changes in the
 more prominent radicular pain
anterior horn cell, motor
 early sacral sensory loss (lateral spinothalamic tract)
nuclei of the brainstem and in
 spastic weakness of legs (corticospinal tract)
the corticospinal tract
 generally malignant
 characterized by progressive
diffuse lower motor neuron
CLINICAL GUIDELINES TO DIFERENTIATE INTRAMEDULLARY VS
signs superimposed by the upper motor dysfunction
EXTRAMEDULLAY TUMORS
 all striated muscle maybe affected except the pelvic floor
SYMPTOMS/ INTRAMEDULLARY EXTRAMEDULLARY
sphincter- sparing of the Onuf’s nucleus SIGNS TUMORS TUMORS
 amyotrophic lateral sclerosis and other genetic conditions Radicular pain Unusual Common, may occur early
Vertebral pain Unusual Common
ANTERIOR 2/3 SYNDROME Funicular pain Common Less common
UMN signs Yes, late Yes, early
 extensive bilateral disease
LMN signs Prominent and diffuse Unusual, if present,
 spares posterior columns

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SPINAL CORD: LESIONS & SYNDROMES
NEURO2 | Ruben C. Flores, MD, FPNA
19/11/2021, 10-12 NN

segmental distribution
Paresthesia Descending progression Ascending SACRAL CORD/ CONS MEDULLARIS
progression  tapered caudal termination of spinal cord
Sphincter Early with caudal lesions Late
 comprise lower sacral and single coccygeal segments
abnormalities (conus/ cauda equina)
 S3-S5: bilateral saddle anesthesia
Trophic changes Common Unusual
 prominent bladder and bowel dysfunction, impotence
 S2-S4: absence of bulbocavernous reflex
TRACT LAMINATION
 S4-S5: absence of anal reflexes
 preserved muscle strength

SACRAL CORD/ CAUDA EQUINA SYNDROME

 severe low back pain or radicular pain
 asymmetric leg weakness of sensory loss
 variable areflexia in lower extremities
 spares bowel and bladder function
 mass lesions in lower spinal canal: mixed clinical picture of
conus medullary and cauda equina

ACUTE AND SUBACUTE SPPINAL CORD DISEASE

SPECIFIC LOCALIZING SIGNS
NEOPLASTIC SPINAL CORD COMPRESSION
CERVICAL CORD LESIONS  extramedullary (epidural or intradural): most common in adults
 C4-C5: life-threatening with quadriplegia and weakness of  intramedullary
respiratory muscles  retroperitoneal neoplasms (lymphomas, sarcomas) enter spinal
 C3-C5: diaphragmatic paralysis, uses accessory muscles of cord through intervertebral foramina
respiration  metastases to spinal canal from breast, lung, prostate, kidney,
 compressive lesions near foramen magnum: weakness of lymphoma, plasma cell dyscrasia
ipsilateral shoulder and arm, then ipsilateral leg, then  thoracic cord is commonly involved
contralateral leg, then contralateral arm; suboccipital pain  spread from Batson’s plexus (a network of vein along anterior
spreading to neck and shoulder surface of spinal cord in epidural space)
 C5-C6: spares shoulder muscles but with lost biceps and  symptoms
brachioradialis reflex  pain
 C7: weakness of finger, wrist extensor, and lost triceps reflex - aching and localized or sharp and radiating in quality
 C8: paralyze finger, wrist flexion, and finer reflex lost - worsens with movement, coughing or sneezing
 any level may have ipsilateral Horner’s syndrome (miosis, - awakens patient at night
ptosis, & facial hypohydrosis) - pain precedes signs of cord compression by weeks or
months
THORACIC CORD LESIONS  diagnostics
 lesions localized by identifying sensory level on the trunk  plain x-rays
 marker: sensory dermatomes  radionuclide bone scans
 weakness of legs and disturbance of bladder, bowel, or sexual  MRI: distinguish malignant lesions from other masses
function  therapy
 lesions at T9-T10 paralyze only lower abdominal muscles-  prompt recognition and efficient management of epidural
upward movement of umbilicus on abdominal contraction metastases
(Beevor’s sign)  glucocorticoids reduce interstitial edema (dexamethasone
 absence of superficial abdominal reflex 10-40 mg daily)
 pain: midline in location  local radiotherapy
 decompression or vertebral resection
LUMBAR CORD LESION
 progressively decrease in size SPINAL CORD INFARCTION
 focal lesions easily localized
 spinal cord supplied by:
 L2-L4: paralyze flexion and adduction of the thigh, weaken leg
 single anterior spinal artery: supply anterior 2/3
extension at the knee, abolish patellar reflex
 paired posterior spinal arteries: supply posterior columns
 L5-S1: paralyze movement of feet and ankle, knee flexion, and
 ischemia occurs at any level
thigh extension
 most common at T3-T4 & boundary zones between anterior
 S1: knee jerk lost
and posterior spinal artery territories
 L1-L2: cremasteric reflex lost

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SPINAL CORD: LESIONS & SYNDROMES
NEURO2 | Ruben C. Flores, MD, FPNA
19/11/2021, 10-12 NN

 signs determined by level of lesion and individual vascular  Staphylococcus, Streptococcus, anaerobes, fungi, TB
anatomy, areas of watershed flow, and potential anastomosis  diagnostics
 symptoms  MRI
 sudden & dramatic or progressive over minutes or hours  high cervical LP- pleocytosis, increase PMNs, increase
 paraplegia or quadriplegia protein, decreased glucose level
 dissociated sensory loss affecting pain and temperature  blood cultures
 spares vibration, position sense, and loss of sphincter  management
control  emergency decompressive laminectomy with debridement
 sharp midline or radiating back pain with long-term antibiotic treatment
 areflexia  hyperreflexia  spasticity  surgical evacuation
 associated with aortic atherosclerosis, dissecting aortic  long-term systemic and oral antibiotics
aneurysm, hypotension
 predisposing condition: cardiogenic emboli, vasculitis, surgical TRANSVERSE MYELITIS
clipping of aortic aneurysm, pregnancy, acute back trauma,  acute or subacute monophasic, inflammatory disorder of the
exercise spinal cord
 diagnostics  autoimmune response triggered by infection
 MRI  associated with antecedent infection or vaccination
 lumbar puncture  measles, varicella, EBV, CMV, rubeola, mycoplasma
 ESR  onset upon recovering from infection
 VDLR  symptoms
 evaluate for aortic or cardiac disease  focal neck or back pain, paresthesia, sensory loss, motor
 management weakness, and sphincter disturbance within hours to days
 treatment of predisposing conditions  posterior columns, anterior spinothalamic tracts, or one
 anticoagulation if presumed thromboembolism hemicord
 dysesthesias ascend symmetrically involving the trunk
HEMATOMYLEIA  areflexia initially, then hyperreflexia
 haemorrhage into the spinal cord  persistent areflexia indicates necrosis over multiple
 rare segments of spinal cord
 results from trauma, intraparenchymal vascular malformation,  differentials
vasculitis, bleeding disorders, spinal infection, neoplasm  GBS
 acute painful transverse myelopathy, subarachnoid  multiple sclerosis
hemorrhage  SLE
 diagnostics  Sjogren’s syndrome
 MRI  Bechet’s disease
 selective spinal angiography  diagnostics
 management  MRI with contrast
 supportive  CSF examination- pleocytosis, increased mononuclear cells,
 surgical intervention to evacuate clot presence of PMNs, oligoclonal bands
 emergency surgical decompression  treatment
 IV methylprednisolone then oral prednisone
SPINAL EPIDURAL ABSCESS
 triad of pain, fever, and rapidly progressive weakness ACUTE INFECTIOUS MYELOPATHIES
 anywhere along the spinal canal  inflammatory disorder from direct invasion of the spinal cord
 increased WBC and ESR by infectious agents
 as the abscess expands  venous congestion and thrombosis,  poliomyelitis
thrombophlebitis of the epidural space, spinal artery disease or  Herpes Zoster
cord compression  CMV,
 risk factors: impaired immune status, IV drug abuse, skin  EBV
infections  HSV-2: recurrent sacral myelitis
 hematogenous infection- 2/3  schistosomiasis
 furunculosis  toxoplasmosis: common in AIDS patients
 pharyngeal or dental abscess
 bacterial endocarditis
 direct extension of local infection to subdural space- 1/3
 vertebral osteomyelitis
 decubitus ulcer CHRONIC MYELOPATHIES
 complications of lumbar punctures, epidural anesthesia

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SPINAL CORD: LESIONS & SYNDROMES
NEURO2 | Ruben C. Flores, MD, FPNA
19/11/2021, 10-12 NN

SPONDYLOTIC MYELOPATHY  cavitary expansion of the spinal cord that may produce a
progressive myelopathy
 related degenerative disease of the spine
 syrinxes occur in the lower cervical or high thoracic region
 neck and shoulder pain with stiffness
which may extend to the medulla or pons
 radicular pain in C5-C6 distribution
 developmental disorder of the posterior fossa and foramen
 compression of cervical cord  progressive spastic paraparesis
magnum
with paresthesia in feet and hands
 acquired cases: intramedullary tumors, trauma, chronic
 cough and straining cause leg weakness
arachnoiditis, inflammatory condition
 dermatomal sensory loss in arms, vibratory sense, atrophy of
 Chiari Type 1
intrinsic hand muscles, increase DTR in legs and extensor
 protrusion of the cerebellar tonsils through foramen
plantar reflexes
magnum and into cervical spinal cord
 urinary urgency or incontinence
 meningocele: protrusion of meninges
 gait difficulty
 meningomyelocele: protrusion of meninges + cord
 diagnostics
 Chiari Type 2
 MRI
 Arnold Chiari
 decompression by posterior laminectomy
 platybasia: basilar skull impression
 Dandy-Walker syndrome: atresia of the foramen of
VASCULAR MALFORMATIONS
Magendie, or cysts of the posterior fossa
 located posteriorly, within dura, along surface of the cord,
 interference with normal outflow of CSF from 4th ventricle to
below midthoracic level
SAH due to obstruction of foramina of Luschka and Magendie
 middle-aged man with progressive myelopathy
 blockage leads to downward pressure on the cervical spinal
 worsen rapidly or may have periods of remission
cord and progressive syrinx formation
 acute deterioration due to hemorrhage into spinal cord or
 symptoms begin in adolescence or early adulthood, progress
subarachnoid space
irregularly, spontaneous arrest after several years
 male=female
 central cord syndrome:
 have intramedullary component to the malformation and may
 dissociated sensory loss
bleed
 areflexic weakness in the upper limbs
 symptoms
 loss of pain and temperature sensation suspended over
 sensory: pain either dysesthesia or radicular pain
nape, shoulders, upper arms in cape distribution
 motor with a mixture of UMN and LMN signs
 begins asymmetrically with unilateral sensory loss
 bladder disturbance
 muscle wasting and loss of reflexes reflecting extension to
 intermittent claudication
anterior horns
 skin overlying back have vascular lesion, lipoma or altered
 spasticity, weakness of legs, bladder and bowel
pigmentation
dysfunction, Horner’s syndrome
 bruits are rare
 thoracic kyphoscoliosis
 AVM syndrome: progressive myelopathy with paraparesis
 numbness and sensory loss on face from damaged
developing over weeks or months associated with thick
descending tract of CN5
hyalinized vessels
 cough, headache, neck, arm, and facial pain in Chiari
 diagnostics
malformation
 MRI with contrast
 syringobulbia: palatal or vocal cord paralysis, dysarthria,
 CT myelography
horizontal or vertical nystagmus, episodic dizziness,
 selective spinal angiography
tongue weakness
 management
 diagnostics
 embolization with occlusion of major feeding vessels
 MRI scans: delineates full extent of syrinx, assess posterior
fossa structures, and determine hydrocephalus
RETROVIRUS-ASSOCIATED MYELOPATHIES  contrast-enhanced MRI: for Chiari malformation
 associated with HTLV-1  management
 thoracic involvement  posterior fossa decompression for tonsillar herniation
 slowly progressive spastic paresis with variable sensory and - suboccipital craniotomy
bladder disturbance - upper cervical laminectomy
 back or leg pain - placement of a dural graft
 asymmetric, sensory deficit without levelling, hyperreflexia in  direct decompression of the fluid cavity
the arms  shunting of hydrocephalus in Chiari malformation
 diagnostics  resection of intramedullary spinal tumor
 specific antibody in serum by ELISA, Western blot analysis,
or radioimmunoprecipitation of viral gag or env genes
SYRINGOMYELIA SUBACUTE COMBINED DEGENERATION (VIT. B12 DEFICINECY)

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SPINAL CORD: LESIONS & SYNDROMES
NEURO2 | Ruben C. Flores, MD, FPNA
19/11/2021, 10-12 NN

 paresthesia of the hands and feet  crystalloid or colloids for mild hypotension and
 early loss of vibration and position sense bradycardia
 progressive spastic and ataxic weakness  high doses of glucocorticoids within 8h of injury to inhibit
 loss of reflexes due to superimposed peripheral neuropathy lipid peroxidation
 optic atrophy, irritability, and mental changes  CT scan with contrast to spinal SAH to demonstrate a
 diffuse myelopathy: symmetric and reflect predominant block to the flow of CSF
involvement of the posterior and lateral tracts  MRI
 no focal spinal cord level  reduction if there is evidence of vertebral aberration on x-
 low serum level of B12, (+) Schilling test ray
 early decompressive laminectomy
TABES DORSALIS  surgical fusions to ensure instability of fractured vertebral
bodies
 rare; usually arise in individuals with HIV
 complications
 fleeting and repetitive, lancinating pains occurring in the legs,
 atlantoaxial dislocations:
less common in the back, thorax, abdomen, arms, and face
- quadriplegia and death from respiratory failure
 ataxia of legs and gait due to loss of position sense
 high cervical cord injury <C5 level
 paresthesia, bladder disturbance, acute abdominal pain, and
- comatose: absent reflexes, small pupils, paradoxical
vomiting
breathing
 loss of reflexes in the legs, impaired position and vibratory
 C5-C6: weak biceps
sense
 C4-C5: weak deltoid, infraspinatus, and supraspinatus
 Romberg’s sign and Argyll Robertson pupils
 C7: triceps, wrist extensors, forearm pronators
 T1 below: paraplegia
FAMILIAL SPASTIC PARAPLEGIA
 central cord syndrome
 spasticity and weakness of legs
- brief compression of cervical cord
 sphincter disturbance
- disruption of central gray matter
 mild degree of sensory loss but no spinal cord levelling
- weakness of arms, pinprick loss over the arms and
 nystagmus, ataxia, optic atrophy
shoulder
 onset at early life or at mid adulthood
- spares leg power and sensation on trunk and legs
 treamtment
- carriable bladder abnormality
 steroid and bone marrow transplantation if with
- very good prognosis
adrenoluekodystrophy
 cauda equina
- incomplete spinal cord injury, involves peripheral
SPINAL CORD TRAUMA nerves
 causes - surgically remediable
 fracture, dislocation, vertical compression with flexion or
hyperextension SPINAL COLUMN FRACTURES
 pre-existing spondylosis, congenitally narrowed spinal
 detect vertebral dislocations causing cord compression
canal, hypertrophied ligamentum flavum
 instability caused by fractures may lead to misalignment and
 instability of apophyseal joints of adjacent vertebrae:
cord compression
rheumatoid arthritis
 proper treatment of fractures through the pedicles, facets, or
 pathophysiology
vertebral bodies
 trauma to the spinal cord
 pericapillary hemorrhages that coalesce and enlarge in the
Jefferson’s fractures
gray matter
 burst fracture of the ring of atlas
 reduced regional blood flow from direct capillary damage
 force descending on the vertex of the
and prolonged 2° ischemia
skull in diving accidents
 complete axonal disruption
 infarction of the gray and white matter within 4h of blunt Hangman’s fractures
injury  hyperextension and longitudinal
 global infarction 8h after injury, causing irreversible distraction of the upper cervical spine
necrosis  in penal hanging or striking of the chin
 gliosis results in necrotic areas over months and may on a steering wheel in a head on
cavitate collision
 progressive syringomyelic syndrome
 management
 immobilize neck to avoid extension or rotation of neck
during transportation, PE, and radiologic exam
 blind nasotracheal intubation

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SPINAL CORD: LESIONS & SYNDROMES
NEURO2 | Ruben C. Flores, MD, FPNA
19/11/2021, 10-12 NN

Teardrop fractures
 crushing of a vertebral body, with
fragment left anteriorly
 associated with ligamentous disruption
and spinal instability

Thoracolumbar fractures
 impact in the high or middle back while
patient is bent over
 combination of cauda equina and conus
medullaris dysfunction

Hyperreflexion
dislocation of cervical
vertebra
 traumatic
quadriplegia
 neck pain

MALIGNANT SPINAL CORD SYNDROME

 expansion of a vertebral metastasis into the epidural space
 symptoms
 pain- 90%; dull, aching, localized tenderness
 radicular pain
 sensory loss
 weakness
 autonomic dysfunctions: urinary and fecal incontinence,
impotence
 primary tumors: breast, lung, and prostate cancer
 neurologic signs determined by level of the lesion, most often
on thoracic cord
 signs progress rapidly
 early recognition and treatment of malignancy will prevent
devastating complication of irreversible neurologic deficits

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