DISEASES OF THE SPINAL CORD

Dr. Khairul P Surbakti , SpS

DISEASES OF SPINAL CORD

Related to special physiologic and anatomic Including: 1. Complete sensory motor myelopathy 2. Combined painful radicular & transverse cord syndromes 3. Hemicord (Brown-Squard syndromes) 4. Ventral cord syndromes, sparing posterior column function 5. High cervical-foramen magnum syndromes 6. Central cord or syringomyelic syndromes 7. Syndrome of conus medullaris 8. Syndromes of cauda equina

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The syndrome of acute paraplegia due to complete transverse lesion of the spinal cord (Transverse myelopathy) Trauma to the spine and Spinal cord Clinical Effects of spinal cord injury a. All involuntary movements in parts of the body below the lesion is immediately and permanently lost b. All sensation from the lower parts is abolished c. Reflex functions in all segments of the isolated spinal cord are suspended
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Spinal shock - Involves tendon as well as autonomic reflex - Duration : 1 to 6 weeks as, but sometimes longer - Riddoch : spinal cord transection - spinal shock & areflexia - heightened reflex activity - Less complete lesions little or no spinal shocks
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Stage of Spinal shock or Areflexia - Loss of motor function: Cervical cord Tetraplegia Thoracic cord Paraplegia - Immediate atonic paralysis of bladder and bowel - Gastric atony - Loss of sensation below a level corresponding to the spinal cord lesion - Muscular flaccidity - Almost complete suppression of all spinal segmental reflex activity below the lesion

- Impaired of autonomic control in the segments below the lesion - Abolished of vasomotor tone, sweating, and piloerection in the lower parts of the body temporarily - Systemic hypotension - The lower extremities lose heat - The skin becomes dry and pale - The spinchters of bladder and the rectum remain contracted to some degree due to loss of inhibitory influences of higher CNS centers, but detrussor of the bladder and smooth muscle of the rectum atonic
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- Overflow incontinence - Passive distension of the bowel - Retention of feces - Absence of peristaltic (paralytic ileus) - Genital reflexes are abolished or profoundly depressed

Stage of Heightened Reflex activity - The more familiar neurologic state that emerges within several weeks or months after spinal injury - Heightened flexion reflexes - Babinski sign (+) - The Achilles and patellar reflexes return - Retention of urine becomes less complete - Reflex defecation also begins

TRANSIENT CORD INJURY ( SPINAL CORD CONCUSSION)

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

The syndromes including: - bibrachial weakness - quadriparesis ( occasionally hemiparesis ) - paresthesia or dysesthesias in a similar distribution to the weakness or sensory symptom alone
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Central cord syndrome (Schneider syndrome) and Cruciate Paralysis - The loss of motor function is more severe in the upper limb than lower limbs and particularly severe in the hands - Bladder dysfunction with urinary retention - Sensory loss is often slight (hyperpathia over shoulder and arms may be the only sensory abnormality - Damage of the centrally ituated gray matter atrophic, areflexic paralysis, segmental loss of pain,

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Causes : - Retroflexion injury of the head and neck - Hematomyelia - Necrotizing myelitis - Fibrocartilagenous embolism - Infarction due to dissection - Compression of the vertebral artery in the medullarycervical region

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Examination and Management of the spine injured patient The level of the spinal cord and vertebral lesions can be determined from clinical findings - Diaphragmatic paralysis : lesion of the upper three cervical segments - Complete paralysis of arm and legs : fractures or dislocation C4 to C5 vertebrae

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The level of sensory loss on the trunk determined by perception of pinprick an accurate guide to the level of the lesion
If any movement or sensation is elicitable during te first 48 to 72 hours the prognosis is more favorable

If the spine can be examined safely inspection of angulation/irregularity, signs of bony injury
In all cases of suspected spinal injury the immediate concern is that the movement (especially flexion) of the cervical spine be avoided.
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The patient should be placed supine on a firm, flat surface, keep the head and neck immobile
A neurologic examination wit detailed recording of motor, sensory, and spinchter function is necessary to follow the clinical progress of SCI

Common practice to define the injury: 1. Complete : motor and sensory loss below lesion 2. Incomplete : some sensory preservation below the zone of injury 3. Incomplete : motor and sensory sparing, but the patient is nonfunctional
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4. Incomplete : motor and sensory sparing and the patient is functional (stands and walks) 5. Complete functional recovery : reflex may be abnormal
Group 2, 3, and 4 have a more favorable prognosis for recovery than does group 1

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Radiologic examination: - alignment of vertebrae and pedicles - fractures of pedicle or vertebral body - compression of spinal cord or cauda equina due to malalignment , bone debris in the spinal canal, the presence of tissue damage within cord
The MRI is ideally suited to display these process, but if it is not available myelography with CT scanning is an alternative

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Once the degree of injury to spine and cord have been assessed Administer of metylprednisolone in high dosage ( bolus of 30 mg/kg followed by 5.4 mg/kg every hour), beginning within 8 h of the injury and continued for 23 h. The greatest risk to the patient with spinal cord injury is the first 10 days : gastric dilatation, ileus, shock, infection
The mortality rate falls rapidly after 3 months
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Aftercare of patient with paraplegia : - psychologic support - management of bladder and bowel dirturbances - care of skin - prevention of pulmonary embolism - maintenance of nutrition - decubitus ulcers can be prevented by frequent turning to avoid pressure necrosis - use of special mattresses - morning suppositories - physical therapy
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MYELITIS = infective and non infective inflammatory process of the spinal cord. If it is confined to gray matter poliomyelitis white matter leukomyelitis If approximately the whole cross-sectional area of the cord is involved transverse myelitis

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The evolution of myelitic symptoms : - Acute more or les within days - Sub acute 2 to 6 weeks - Chronic more than 6 weeks
CLASIFICATION OF INFLAMMATORY DISEASE OF THE SPINAL CORD I. Viral myelitis A. Enteroviruses ( groups A and B Coxsackie virus, poliomyelitis, others)
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B. Herpes zoster C. Myelitis of AIDS D. Epstein-Barr virus (EBV), cytomegalovirus (CMV), herpes simplex. E. Rabies F. Arboviruses-flaviviruses (Japanese, West Nile, etc.) G. HTLV-1 (tropical spastic parapareis) II. Myelitis secondary to bacterial, fungal, parasitic, and primary granulomatous diseases of the meninges and spinal cord
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A. Mycoplasma pneumoniae B. Lyme disease C. Pyogenic myelitis 1. Acute epidural abscess and granuloma 2. Abscess of spinal cord D. Tuberculous myelitis 1. Pott disease with spinal cord compression 2. Tuberculous meningomyelitis 3. Tuberculoma of spinal cord

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E. Parasitic and fungal infections producing epidural granuloma, localized meningitis, or meningomyelitis and abscess, especially certain form of shistosomiasis F. Syphilitic myelitis 1. Chronic meningoradiculitis (tabes dorsalis) 2. Chronic meningomyelitis 3. Meningovascular syphilis 4. Gummatous meningitis including chronic spinal pachymeningitis G. Sarcoid meningitis
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III. Myelitis (myelopathy) of noninfectious inflammatory type A. Postinfectious and postvaccinal myelitis B. Acute and chronic relapsing or progressive multiple sclerosis (MS) C. Subacute necrotizing myelitis and Devic disease D. Myelopathy with lupus or other forms of connective tissue disease and antipospholipid antibody E. Paraneoplastic myelopathy and poliomyelitis

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TUBERCULOUS SPINAL OSTEOMYELITIS ( POTT DISEASE ) - Tuberculous osteitis of the spine with kyphosis (Pott disease) is well known in regions of endemic tuberculosis - Children and young adults are most often affected - The osteomyelitis is the result of reactivation of tuberculosis at a site previously established by hematogenous spread

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An infectious endarteritis bone necrosis and collapse of a thoracic or upper lumbar ( less often cervical ) vertebral body angulated kyphotic deformity Symptoms : fever, night sweats, elevated sedimentation rate In some cases : spinal deformity compresive myelopathy Treatment :- external stabilization of the spine - long term antituberculous medication

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TUBERCULOUS MYELITIS
- Pus or caseous granulation tissue may extrude from infected vertebra and gives rise to an epidural compression of the cord Pott paraplegia

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DEMYELINATIVE DISEASE ( ACUTE MULTIPLE SCLEROSIS ) - The most typical mode of clinical expression of demyelinative myelitis is with numbness that spread over one or both sides of the body: from the sacral segments to the feet ant. Thighs up over the trunk coincident with asymmetric weakness then paralysis
- As this process becomes complete, bladder is affected
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Acute spinal MS is relatively painless and without fever the patient usually improves with variable residual signs Treatment : - Corticosteroid may lead to regression of symptoms sometimes with relapse when the medication is discontinued. - Plasma exchange - IVIG

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The combination of spinal cord necrosis and optic neuritis Neuromyelitis optica (Devics disease)

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VASCULAR DIEASE OF THE PINAL CORD

- In comparison with the brain , the spinal cord is an uncommon site of vascular disease - The spinal arteries tend not to be susceptible to atherosclerosis and emboli rarely lodge there.
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Vascular disorders of spinal cord : - infarction - dural fistula - bleeding - arteriovenous malformation

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INFARCTION OF THE SPINAL CORD ( MYELOMALACIA)

HEMORRHAGE OF THE SPINAL CORD AND SPINAL CANAL (HEMATOMYELIA) VASCULAR MALFORMATIONS OF THE SPINAL CORD AND OVERLYING DURA

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SYRINGOMYELIA SYRINX = PIPE OR TUBE A CHRONIC PROGRESSIVE DEGENERATIVE OR DEVELOPMENTAL DISORDER OF THE SPINAL CORD CLINICALLY : PAINLESS WEAKNESS AND WASTING OF THE HAND AND ARMS PATHOLOGICALLY: CAVITATION OF THE CENTRAL PARTS OF SPINAL CORD
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USUALLY IN THE CERVICAL REGION BUT EXTENDING UPWARD IN SOME CASES INTO MEDULLA OBLONGATA AND PONS ( SYRINGOBULBIA ) OR DOWNWARD INTO THE THORACIC OR EVEN THE LUMBAR SEGMENTS

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