DISEASES OF THE SPINALDISEASES OF THE SPINAL CORDCORD

Dr. Khairul P Surbakti , SpSDr. Khairul P Surbakti , SpS

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DISEASES OF SPINAL CORDDISEASES OF SPINAL CORDRelated to special physiologic and anatomic Related to special physiologic and anatomic Including: Including:

1 Complete sensory motor myelopathy1 Complete sensory motor myelopathy1. Complete sensory motor myelopathy1. Complete sensory motor myelopathy2. Combined painful radicular & transverse 2. Combined painful radicular & transverse

cord syndromescord syndromes3 Hemicord (Brown3 Hemicord (Brown Squard syndromes)Squard syndromes)3. Hemicord (Brown3. Hemicord (Brown--Squard syndromes)Squard syndromes)4. Ventral cord syndromes, sparing posterior4. Ventral cord syndromes, sparing posterior

column functioncolumn function5. High cervical5. High cervical--foramen magnum syndromesforamen magnum syndromes6. Central cord or syringomyelic syndromes6. Central cord or syringomyelic syndromes7. Syndrome of conus medullaris7. Syndrome of conus medullarisyy8. Syndromes of cauda equina8. Syndromes of cauda equina

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The syndrome of acute paraplegia due to The syndrome of acute paraplegia due to y p p gy p p gcomplete transverse lesion of the spinal cord complete transverse lesion of the spinal cord (Transverse myelopathy)(Transverse myelopathy)

1.1. Trauma to the spine and Spinal cordTrauma to the spine and Spinal cordClinical Effects of spinal cord injuryClinical Effects of spinal cord injurya. All involuntary movements in parts of the body a. All involuntary movements in parts of the body

below the lesion is immediately and permanentlybelow the lesion is immediately and permanentlylostlost

b. All sensation from the lower parts is abolishedb. All sensation from the lower parts is abolishedppc. Reflex functions in all segments of the isolated c. Reflex functions in all segments of the isolated

spinal cord are suspendedspinal cord are suspended

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p pp p

Spinal shockSpinal shockpp-- Involves tendon as well as autonomic reflexInvolves tendon as well as autonomic reflex-- Duration : 1 to 6 weeks as but sometimesDuration : 1 to 6 weeks as but sometimes-- Duration : 1 to 6 weeks as, but sometimesDuration : 1 to 6 weeks as, but sometimes

longerlonger-- Riddoch : spinal cord transectionRiddoch : spinal cord transection

-- spinal shock & areflexiaspinal shock & areflexia-- heightened reflex activityheightened reflex activity

-- Less complete lesionsLess complete lesions little or no spinallittle or no spinal-- Less complete lesions Less complete lesions little or no spinal little or no spinal shocksshocks

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Stage of Spinal shock or AreflexiaStage of Spinal shock or AreflexiaStage of Spinal shock or AreflexiaStage of Spinal shock or Areflexia-- Loss of motor function: Loss of motor function:

Cervical cordCervical cord TetraplegiaTetraplegiaCervical cord Cervical cord TetraplegiaTetraplegiaThoracic cord Thoracic cord ParaplegiaParaplegia

-- Immediate atonic paralysis of bladder and bowelImmediate atonic paralysis of bladder and bowel-- Gastric atonyGastric atony-- Loss of sensation below a level corresponding to the spinalLoss of sensation below a level corresponding to the spinalcord lesioncord lesion

-- Muscular flaccidityMuscular flaccidityAl t l t i f ll i l t lAl t l t i f ll i l t l-- Almost complete suppression of all spinal segmental Almost complete suppression of all spinal segmental reflex activity below the lesion reflex activity below the lesion

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-- Impaired of autonomic control in the segments belowImpaired of autonomic control in the segments belowthe lesionthe lesion

-- Abolished of vasomotor tone, sweating, andAbolished of vasomotor tone, sweating, andpiloerection in the lower parts of the body temporarilypiloerection in the lower parts of the body temporarily

-- Systemic hypotensionSystemic hypotensiony ypy yp-- The lower extremities lose heatThe lower extremities lose heat-- The skin becomes dry and paleThe skin becomes dry and paley py p-- The spinchters of bladder and the rectum remainThe spinchters of bladder and the rectum remaincontracted to some degree due to loss of inhibitorycontracted to some degree due to loss of inhibitorycontracted to some degree due to loss of inhibitorycontracted to some degree due to loss of inhibitoryinfluences of higher CNS centers, but detrussor of the influences of higher CNS centers, but detrussor of the bladder and smooth muscle of the rectumbladder and smooth muscle of the rectum atonicatonic

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bladder and smooth muscle of the rectumbladder and smooth muscle of the rectum atonicatonic

-- Overflow incontinenceOverflow incontinence-- Passive distension of the bowelPassive distension of the bowel-- Retention of fecesRetention of feces-- Absence of peristaltic (paralytic ileus)Absence of peristaltic (paralytic ileus)-- Genital reflexes are abolished or profoundly depressedGenital reflexes are abolished or profoundly depressedp y pp y p

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Stage of Heightened Reflex activityStage of Heightened Reflex activityStage of Heightened Reflex activityStage of Heightened Reflex activity-- The more familiar neurologic state that emerges The more familiar neurologic state that emerges

within several weeks or months after spinal injurywithin several weeks or months after spinal injurywithin several weeks or months after spinal injurywithin several weeks or months after spinal injury-- Heightened flexion reflexesHeightened flexion reflexes

Babinski sign (+)Babinski sign (+)-- Babinski sign (+)Babinski sign (+)-- The Achilles and patellar reflexes returnThe Achilles and patellar reflexes return

Retention of rine becomes less completeRetention of rine becomes less complete-- Retention of urine becomes less completeRetention of urine becomes less complete-- Reflex defecation also beginsReflex defecation also begins

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TRANSIENT CORD INJURY ( SPINAL CORDTRANSIENT CORD INJURY ( SPINAL CORDCONCUSSIONCONCUSSION))

//Transient loss of motor and /or sensory functions Transient loss of motor and /or sensory functions of the spinal cord that recovers within minutes or hours of the spinal cord that recovers within minutes or hours but sometimes persist for a day or several daysbut sometimes persist for a day or several daysbut sometimes persist for a day or several daysbut sometimes persist for a day or several days

The syndromes including:The syndromes including:y gy g-- bibrachial weaknessbibrachial weakness-- quadriparesis ( occasionally hemiparesis )quadriparesis ( occasionally hemiparesis )q p ( y p )q p ( y p )-- paresthesia or dysesthesias in a similar distribution toparesthesia or dysesthesias in a similar distribution tothe weakness or sensory symptom alonethe weakness or sensory symptom alone

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Central cord syndrome (Schneider syndrome) and Central cord syndrome (Schneider syndrome) and y ( y )y ( y )Cruciate ParalysisCruciate Paralysis

-- The loss of motor function is more severe in theThe loss of motor function is more severe in theupper limb than lower limbs and particularly severe in upper limb than lower limbs and particularly severe in the handsthe hands

-- Bladder dysfunction with urinary retentionBladder dysfunction with urinary retentionS l i f li h (h hi h ldS l i f li h (h hi h ld-- Sensory loss is often slight (hyperpathia over shoulder Sensory loss is often slight (hyperpathia over shoulder and arms may be the only sensory abnormalityand arms may be the only sensory abnormalityD f h ll i dD f h ll i d-- Damage of the centrally ituated gray matter Damage of the centrally ituated gray matter atrophic, areflexic paralysis, segmental loss of pain,atrophic, areflexic paralysis, segmental loss of pain,

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CausesCauses ::CausesCauses ::-- Retroflexion injury of the head and neckRetroflexion injury of the head and neck-- HematomyeliaHematomyeliaHematomyeliaHematomyelia-- Necrotizing myelitisNecrotizing myelitis

Fibrocartilagenous embolismFibrocartilagenous embolism-- Fibrocartilagenous embolismFibrocartilagenous embolism-- Infarction due to dissectionInfarction due to dissection

Compression of the vertebral arter in the med llarCompression of the vertebral arter in the med llar-- Compression of the vertebral artery in the medullaryCompression of the vertebral artery in the medullary--cervical regioncervical region

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Examination and Management of the spine injured Examination and Management of the spine injured patientpatient

-- The level of the spinal cord and vertebral lesions canThe level of the spinal cord and vertebral lesions canbe determined from clinical findingsbe determined from clinical findings-- Diaphragmatic paralysis : lesion of the upper three Diaphragmatic paralysis : lesion of the upper three

cervical segmentscervical segments-- Complete paralysis of arm and legs : fractures orComplete paralysis of arm and legs : fractures or

dislocation C4 to C5 vertebraedislocation C4 to C5 vertebrae

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The level of sensory loss on the trunk The level of sensory loss on the trunk determined by determined by yy yyperception of pinprick perception of pinprick an accurate guide to the level of the an accurate guide to the level of the lesionlesion

If any movement or sensation is elicitable during te first 48 to 72 If any movement or sensation is elicitable during te first 48 to 72 hours hours the prognosis is more favorablethe prognosis is more favorablep gp g

If the spine can be examined safely If the spine can be examined safely inspection of inspection of angulation/irregularity, signs of bony injuryangulation/irregularity, signs of bony injury

I ll f t d i l i jI ll f t d i l i j th i di tth i di tIn all cases of suspected spinal injury In all cases of suspected spinal injury the immediate the immediate concern is that the movement (especially flexion) of the cervical concern is that the movement (especially flexion) of the cervical spine be avoided.spine be avoided.

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pp

The patient should be placed supine on a firm, flat surface, keep The patient should be placed supine on a firm, flat surface, keep p p p , , pp p p , , pthe head and neck immobile the head and neck immobile

A neurologic examination wit detailed recording of motor, A neurologic examination wit detailed recording of motor, sensory, and spinchter function is necessary to follow the clinical sensory, and spinchter function is necessary to follow the clinical progress of SCIprogress of SCIp gp g

Common practice to define the injury:Common practice to define the injury:1. Complete : motor and sensory loss below lesion1. Complete : motor and sensory loss below lesion2. Incomplete : some sensory preservation below the 2. Incomplete : some sensory preservation below the

zone of injuryzone of injury3. Incomplete : motor and sensory sparing, but the patient3. Incomplete : motor and sensory sparing, but the patient

is nonfunctionalis nonfunctional

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is nonfunctionalis nonfunctional

4. Incomplete : motor and sensory sparing and the4. Incomplete : motor and sensory sparing and the4. Incomplete : motor and sensory sparing and the4. Incomplete : motor and sensory sparing and thepatient is functional (stands and walks)patient is functional (stands and walks)

5 Complete functional recovery : reflex may be5 Complete functional recovery : reflex may be5. Complete functional recovery : reflex may be 5. Complete functional recovery : reflex may be abnormalabnormal

Group 2, 3, and 4 have a more favorable prognosisGroup 2, 3, and 4 have a more favorable prognosisfor recover than does gro p 1for recover than does gro p 1for recovery than does group 1for recovery than does group 1

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Radiologic examination:Radiologic examination:Radiologic examination: Radiologic examination: -- alignment of vertebrae and pediclesalignment of vertebrae and pedicles-- fractures of pedicle or vertebral bodyfractures of pedicle or vertebral bodyfractures of pedicle or vertebral bodyfractures of pedicle or vertebral body-- compression of spinal cord or cauda equina due to compression of spinal cord or cauda equina due to malalignment , bone debris in the spinal canal, themalalignment , bone debris in the spinal canal, themalalignment , bone debris in the spinal canal, the malalignment , bone debris in the spinal canal, the presence of tissue damage within cordpresence of tissue damage within cord

The MRI is ideally suited to display these process, but if The MRI is ideally suited to display these process, but if it is not available myelography with CT scanning is an it is not available myelography with CT scanning is an y g p y gy g p y galternativealternative

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Once the degree of injury to spine and cord have been Once the degree of injury to spine and cord have been g j y pg j y passessed assessed Administer of metylprednisolone in high Administer of metylprednisolone in high

dosage ( bolus of 30 mg/kg followed by 5.4 dosage ( bolus of 30 mg/kg followed by 5.4 mg/kg every hour), beginning within 8 h of mg/kg every hour), beginning within 8 h of the injury and continued for 23 h.the injury and continued for 23 h.j yj y

The greatest risk to the patient with spinal cord injury isThe greatest risk to the patient with spinal cord injury isg p p j yg p p j ythe first 10 days : gastric dilatation, ileus, shock, the first 10 days : gastric dilatation, ileus, shock, infectioninfection

The mortality rate falls rapidly after 3 monthsThe mortality rate falls rapidly after 3 months

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y p yy p y

Aftercare of patient with paraplegia :Aftercare of patient with paraplegia :-- psychologic supportpsychologic support-- management of bladder and bowel dirturbancesmanagement of bladder and bowel dirturbances-- care of skincare of skin-- prevention of pulmonary embolismprevention of pulmonary embolism-- maintenance of nutritionmaintenance of nutrition-- decubitus ulcers can be prevented by frequent turning decubitus ulcers can be prevented by frequent turning to avoid pressure necrosisto avoid pressure necrosis

-- use of special mattressesuse of special mattressesi i ii i i-- morning suppositoriesmorning suppositories

-- physical therapyphysical therapy

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MYELITISMYELITISMYELITISMYELITIS= infective and non infective inflammatory process of = infective and non infective inflammatory process of

the spinal cordthe spinal cordthe spinal cord.the spinal cord.

If i i fi dIf i i fi d li li ili li iIf it is confined to gray matter If it is confined to gray matter poliomyelitispoliomyelitiswhite matter white matter leukomyelitisleukomyelitis

If i l h h lIf i l h h l i l f hi l f hIf approximately the whole crossIf approximately the whole cross--sectional area of thesectional area of thecord is involved cord is involved transverse myelitistransverse myelitis

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The evolution of myelitic symptoms :The evolution of myelitic symptoms :The evolution of myelitic symptoms :The evolution of myelitic symptoms :-- Acute Acute more or les within daysmore or les within days-- Sub acuteSub acute 2 to 6 weeks2 to 6 weeksSub acute Sub acute 2 to 6 weeks2 to 6 weeks-- Chronic Chronic more than 6 weeksmore than 6 weeks

CLASIFICATION OF INFLAMMATORY DISEASECLASIFICATION OF INFLAMMATORY DISEASEOF THE SPINAL CORDOF THE SPINAL CORDOF THE SPINAL CORDOF THE SPINAL CORDI. Viral myelitisI. Viral myelitis

A E i ( A d B C ki iA E i ( A d B C ki iA. Enteroviruses ( groups A and B Coxsackie virus,A. Enteroviruses ( groups A and B Coxsackie virus,poliomyelitis, others)poliomyelitis, others)

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B. Herpes zosterB. Herpes zosterppC. Myelitis of AIDSC. Myelitis of AIDSD. EpsteinD. Epstein--Barr virus (EBV), cytomegalovirus Barr virus (EBV), cytomegalovirus pp ( ) y g( ) y g

(CMV), herpes simplex.(CMV), herpes simplex.E. RabiesE. RabiesF. ArbovirusesF. Arboviruses--flaviviruses (Japanese, West Nile, flaviviruses (Japanese, West Nile,

etc.)etc.)G. HTLVG. HTLV--1 (tropical spastic parapareis)1 (tropical spastic parapareis)

II. Myelitis secondary to bacterial, fungal, parasitic, andII. Myelitis secondary to bacterial, fungal, parasitic, andprimary granulomatous diseases of the meninges primary granulomatous diseases of the meninges and spinal cordand spinal cord

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A. Mycoplasma pneumoniaeA. Mycoplasma pneumoniaey p py p pB. Lyme diseaseB. Lyme diseaseC. Pyogenic myelitisC. Pyogenic myelitisy g yy g y

1. Acute epidural abscess and granuloma1. Acute epidural abscess and granuloma2. Abscess of spinal cord2. Abscess of spinal cord2. Abscess of spinal cord2. Abscess of spinal cord

D. Tuberculous myelitisD. Tuberculous myelitis1 Pott disease with spinal cord compression1 Pott disease with spinal cord compression1. Pott disease with spinal cord compression1. Pott disease with spinal cord compression2. Tuberculous meningomyelitis2. Tuberculous meningomyelitis3 Tuberculoma of spinal cord3 Tuberculoma of spinal cord3. Tuberculoma of spinal cord3. Tuberculoma of spinal cord

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E. Parasitic and fungal infections producing E. Parasitic and fungal infections producing epidural granuloma, localized meningitis, orepidural granuloma, localized meningitis, ormeningomyelitis and abscess, especially certainmeningomyelitis and abscess, especially certainform of shistosomiasisform of shistosomiasis

F. Syphilitic myelitisF. Syphilitic myelitisyp yyp y1. Chronic meningoradiculitis (tabes dorsalis)1. Chronic meningoradiculitis (tabes dorsalis)2. Chronic meningomyelitis2. Chronic meningomyelitisg yg y3. Meningovascular syphilis3. Meningovascular syphilis4. Gummatous meningitis including chronic4. Gummatous meningitis including chronic4. Gummatous meningitis including chronic4. Gummatous meningitis including chronic

spinal pachymeningitisspinal pachymeningitisG Sarcoid meningitisG Sarcoid meningitis

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G. Sarcoid meningitisG. Sarcoid meningitis

III. Myelitis (myelopathy) of noninfectiousIII. Myelitis (myelopathy) of noninfectiousinflammatory typeinflammatory typeA. Postinfectious and postvaccinal myelitisA. Postinfectious and postvaccinal myelitisB. Acute and chronic relapsing or progressiveB. Acute and chronic relapsing or progressive

multiple sclerosis (MS)multiple sclerosis (MS)p ( )p ( )C. Subacute necrotizing myelitis and Devic diseaseC. Subacute necrotizing myelitis and Devic diseaseD. Myelopathy with lupus or other forms of D. Myelopathy with lupus or other forms of y p y py p y p

connective tissue disease and antipospholipidconnective tissue disease and antipospholipidantibodyantibodyantibodyantibody

E. Paraneoplastic myelopathy and poliomyelitisE. Paraneoplastic myelopathy and poliomyelitis

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TUBERCULOUS SPINAL OSTEOMYELITIS TUBERCULOUS SPINAL OSTEOMYELITIS ( POTT’ DISEASE )( POTT’ DISEASE )

-- Tuberculous osteitis of the spine with kyphosisTuberculous osteitis of the spine with kyphosis(Pott disease) is well known in regions of endemic(Pott disease) is well known in regions of endemic(Pott disease) is well known in regions of endemic (Pott disease) is well known in regions of endemic tuberculosistuberculosis

-- Children and young adults are most often affectedChildren and young adults are most often affected-- Children and young adults are most often affectedChildren and young adults are most often affected-- The osteomyelitis is the result of reactivation of The osteomyelitis is the result of reactivation of

tuberculosis at a site previously established bytuberculosis at a site previously established bytuberculosis at a site previously established by tuberculosis at a site previously established by hematogenous spreadhematogenous spread

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An infectious endarteritisAn infectious endarteritis bone necrosis and collapsebone necrosis and collapseAn infectious endarteritis An infectious endarteritis bone necrosis and collapsebone necrosis and collapseof a thoracic or upper lumbar ( of a thoracic or upper lumbar ( less often cervical ) vertebral bodyless often cervical ) vertebral bodyless often cervical ) vertebral bodyless often cervical ) vertebral body

angulated kyphotic deformityangulated kyphotic deformityS t f i ht t l t d di t tiS t f i ht t l t d di t tiSymptoms : fever, night sweats, elevated sedimentationSymptoms : fever, night sweats, elevated sedimentation

raterateI i l d f iI i l d f i i li lIn some cases : spinal deformity In some cases : spinal deformity compresive myelocompresive myelo--

pathypathyTreatment :Treatment :-- external stabilization of the spineexternal stabilization of the spine

-- long term antituberculous medicationlong term antituberculous medication

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TUBERCULOUS MYELITISTUBERCULOUS MYELITISTUBERCULOUS MYELITISTUBERCULOUS MYELITIS

-- Pus or caseous granulation tissue may extrude fromPus or caseous granulation tissue may extrude fromPus or caseous granulation tissue may extrude fromPus or caseous granulation tissue may extrude frominfected vertebra and gives rise to an epidural infected vertebra and gives rise to an epidural compression of the cordcompression of the cord Pott paraplegiaPott paraplegiacompression of the cord compression of the cord Pott paraplegiaPott paraplegia

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DEMYELINATIVE DISEASEDEMYELINATIVE DISEASE( ACUTE MULTIPLE SCLEROSIS )( ACUTE MULTIPLE SCLEROSIS )

-- The most typical mode of clinical expression of The most typical mode of clinical expression of demyelinative myelitis is with numbness that spreaddemyelinative myelitis is with numbness that spreadover one or both sides of the body:over one or both sides of the body:

from the sacral segments to the feet from the sacral segments to the feet ant. Thighsant. Thighsup over the trunk up over the trunk coincident with asymmetriccoincident with asymmetric

weakness weakness then paralysisthen paralysis

-- As this process becomes complete, bladder is affectedAs this process becomes complete, bladder is affected

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Acute spinal MS is relatively painless and without feverAcute spinal MS is relatively painless and without feverp y pp y pthe patient usually improves with variable residual signsthe patient usually improves with variable residual signsTreatment :Treatment :-- Corticosteroid Corticosteroid may lead to regression of symptomsmay lead to regression of symptoms

sometimes with relapse when thesometimes with relapse when thesometimes with relapse when the sometimes with relapse when the medication is discontinued.medication is discontinued.

-- Plasma exchangePlasma exchange-- Plasma exchange Plasma exchange -- IVIG IVIG

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The combination of spinal cord necrosis and The combination of spinal cord necrosis and ppoptic neuritis optic neuritis Neuromyelitis optica (Devic’s Neuromyelitis optica (Devic’s disease)disease)))

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VASCULAR DIEASE OF THE PINALVASCULAR DIEASE OF THE PINALVASCULAR DIEASE OF THE PINAL VASCULAR DIEASE OF THE PINAL CORDCORD

-- In comparison with the brain , the spinal cord In comparison with the brain , the spinal cord i i f l dii i f l diis an uncommon site of vascular diseaseis an uncommon site of vascular disease

-- The spinal arteries tend not to be susceptible The spinal arteries tend not to be susceptible to atherosclerosis and emboli rarely lodgeto atherosclerosis and emboli rarely lodgeto atherosclerosis and emboli rarely lodge to atherosclerosis and emboli rarely lodge there.there.

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Vascular disorders of spinal cord :Vascular disorders of spinal cord :Vascular disorders of spinal cord :Vascular disorders of spinal cord :-- infarctioninfarction

d l fi ld l fi l-- dural fistuladural fistula-- bleedingbleeding-- arteriovenous malformationarteriovenous malformation

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INFARCTION OF THE SPINAL CORDINFARCTION OF THE SPINAL CORD( MYELOMALACIA)( MYELOMALACIA)

HEMORRHAGE OF THE SPINAL CORD HEMORRHAGE OF THE SPINAL CORD AND SPINAL CANAL (HEMATOMYELIA)AND SPINAL CANAL (HEMATOMYELIA)AND SPINAL CANAL (HEMATOMYELIA)AND SPINAL CANAL (HEMATOMYELIA)

VASCULAR MALFORMATIONS OF THE VASCULAR MALFORMATIONS OF THE SPINAL CORD AND OVERLYING DURASPINAL CORD AND OVERLYING DURA

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SYRINGOMYELIASYRINGOMYELIASYRINGOMYELIA SYRINGOMYELIA SYRINX = “PIPE” OR “TUBE” SYRINX = “PIPE” OR “TUBE” A CHRONIC A CHRONIC PROGRESSIVE DEGENERATIVE OR PROGRESSIVE DEGENERATIVE OR DEVELOPMENTAL DISORDER OF THE DEVELOPMENTAL DISORDER OF THE SPINAL CORDSPINAL CORD

CLINICALLY : PAINLESS WEAKNESS AND CLINICALLY : PAINLESS WEAKNESS AND WASTING OF THE HAND AND ARMS WASTING OF THE HAND AND ARMS

PATHOLOGICALLY: CAVITATION OF THE PATHOLOGICALLY: CAVITATION OF THE CENTRAL PARTS OF SPINAL CORDCENTRAL PARTS OF SPINAL CORD

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USUALLY IN THE CERVICAL REGION USUALLY IN THE CERVICAL REGION BUT EXTENDING UPWARD IN SOME BUT EXTENDING UPWARD IN SOME CASES INTO MEDULLA OBLONGATA CASES INTO MEDULLA OBLONGATA AND PONS ( SYRINGOBULBIA ) OR AND PONS ( SYRINGOBULBIA ) OR DOWNWARD INTO THE THORACIC OR DOWNWARD INTO THE THORACIC OR EVEN THE LUMBAR SEGMENTSEVEN THE LUMBAR SEGMENTS

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