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

Trauma

Metastatic carcinoma

Multiple sclerosis

Spinal epidural haematoma

Autoimmune disorders

Post vaccinial syndromes.

COMPLETE CORD SYNDROMES

• 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.

COMPLETE CORD TRANSECTION

Brown Sequard syndrome

Central cord syndrome

Anterior cord syndrome

Posterior cord syndrome

Conus medullaris syndrome

Cauda equina syndrome

INCOMPLETE CORD SYNDROMES

BROWN SEQUARD SYNDROME

= Hemi-section of the spinal cord

Caused by extramedullary lesions

Usually caused by penetrating trauma or tumour.

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.

BROWN SEQUARD 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

CENTRAL CORD SYNDROME

OTHER FEATURES :

Horner’s syndrome

Kyphoscoliosis

Sacral sparing

Neuropathic arthropathy of shoulder and

elbow joint

Prognosis is fair.

SYRINGOMYELIA

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):

Abadie’s sign (of tabes dorsalis) positive

Urinary incontinence

Absent knee and ankle jerk (Areflexia, Hypotonia)

Charcot’s joint

Miotic and irregular pupil not reacting to light

Argyl Robertson Pupil

POSTERIOR CORD SYNDROME

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

POSTERIO LATERAL COLUMN DISEASE

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 CORD 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 “Beck’s 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 +

ANTERIOR SPINAL ARTERY SYNDROME

UNCOMMON

Loss of proprioception and vibratory sense.

Pain and temperature is preserved.

Absence of motor deficit.

POSTERIOR SPINAL ARTERY SYNDROME

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 SYNDROMES

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.

ANTERIOR HORN CELL & PYRAMIDAL TRACT SYNDROME

CONUS MEDULLARIS & CAUDA EQUINA SYNDROMES

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.

CONUS MEDULLARIS 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.

CAUDA EQUINA SYNDROME

DDx: CONUS vs CAUDA

FEATURE CONUS MEDULARIS CAUDA EQUINA

PRESENTATION Sudden & Bilateral Gradual & Unilateral

REFLEXES Knee present, Ankle

–

(If the epiconus is

involved, patellar

reflex maybe absent

but bulbocavernosus

is spared)

Knee & Ankle –

Bulbocavernosus

reflex is absent in low

CE (sacral) lesions

RADICULAR PAIN Less severe More severe

LOW BACK ACHE More 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

MOTOR SYMPTOMS

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

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

IMPOTENCE Frequent Less frequent; ED is commonerectile 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 CONUS

MEDULARIS

CAUDA EQUINA

SPHINCTER

DYSFUNCTION

Urinary retention and

atonic anal sphincter

cause overflow

urinary

incontinence and

fecal incontinence

Tend to present

early in course of

disease.

Urinary retention

Tends to present late in

course of disease

EMG Mostly normal

lower extremity

with external anal

sphincter invlmnt

Multiple root level

involvement; sphincters

may also be involved.

OUTCOME Less favourable More Favourable

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