Spinal Cord Disease and Acute Bilateral Limb Weakness Flashcards Preview

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What is myelopathy?



Any neurological deficit that is caused by a lesion in the spinal cord itself




What is myelitis?



Inflammation of the spinal cord




What is cervical spondylytic myelopathy (CSM)?



Myelopathy caused by arthritic changes (spondylolysis) of the cervical spine, which results in narrowing of the spinal canal (spinal stenosis) ultimately causing compression of the spinal cord




What is a spinal cord stroke?



Occlusion of the blood vessels supplying the spinal cord or within the spinal cord itself




What are causes of a spinal cord infarction?

  • Atherosclerosis
  • Thromboembolic disease - AF, MI
  • Aortic dissection
  • Systemic hypotension
  • Thrombotic haematological disease
  • Hyperviscisity syndrome
  • Vasculitis
  • Endovascular procedures
  • Decompression sickness




What symptoms are seen in spinal cord ischaemia?

Sudden onset/several hours

  • Sudden onset Back pain with circumerencial tightness
  • Weakness
  • Numbness/paraesthesia
  • Utrinary/faecal incontinence




What spinal artery is most commonly implicated in spinal cord ischaemia (anterior or posterior)?



Anterior more commonly than posterior, as sections have poor collateral supply (especially 2nd - 4th thoracic segments)




What is the most common cause of spinal cord ischaemia?



Extravertebral feeder artery occulsion or ortic occlusion/dissection/clamping during surgery




If the anterior spinal cord artery was affected, what signs might you find in someone with spinal cord infarction?

Anterior cord syndrome

  • Complete motor paralysis below level of lesion - corticospinal tract
  • Loss of pain + temp sensation at + below the level of lesion - spinothalamic tract
  • Retained proprioception, light touch and vibratory sensation - intact dorsal columns
  • Autonomic dysfunction
    • Hypotension (either orthostatic or frank hypotension)
    • Sexual dysfunction
    • Bowel and bladder dysfunction
  • Areflexia, flaccid internal and external anal sphincter, urinary retention and intestinal obstruction - infarcted anterior horn - like a LMN injury




What are features of a central cord syndrome that can occur in trauma, syrinx or cervical spondylosis?


  • Paresis more severe in upper extremities than in lower/sacral region
  • Loss of pain and temperature sensation in a capelike distribution over the upper neck, shoulders, and upper trunk
  • Light touch, position, and vibratory sensation relatively preserved




How would you investigate suspected spinal cord infarction?







How would you manage someone with spinal cord infarction?


  • Supportive
  • Risk reduction - optimise BP, bed rest, reverese hypovolaemia, vascular risk
  • OT/PT input




If someone had occlusion of their central sulcal spinal artery, what spinal cord syndrome may present?



Brown-Sequard syndrome




What is transverse myelitis?



Acute inflammation of gray and white matter in one or more adjacent spinal cord segments, usually thoracic




What are causes of transverse myelitis?


  • Idiopathic
  • MS
  • Viral/bacterial infection
  • Autoimmune
  • Malignancy
  • Post vaccination




What are viral causes of transverse myelitis?

  • VZV
  • HSV
  • CMV
  • EBV
  • Influenza
  • Echovirus
  • HIV
  • Hep A
  • Rubella




What are autoimmune causes of transverse myelitis?


  • SLE
  • Sjogren's
  • Sarcoidosis




What is transverse myelitis most commonly due to?







What can transverse myelitis occur with in Devics syndrome?



Optic neuritis - Form of MS




What are symptoms of transverse myelitis?

Hours to days

  • Pain in the neck, back or head
  • Bandlike tighness around chest/abdomen
  • Weakness
  • Paraesthesiae
  • Numbness - feet and legs




What are signs of transverse myelitis?

Sensorimotor myelopathy (UMN lesion)

  • Paraplegia - pyramidal distribution
  • Loss of sensation below lesion
  • Urinary retention/Faecal incontinence
  • Occasional sparing of proprioception and vibration
  • Babinski +
  • Clonus
  • Hyperreflexia
  • L'Hermittes positive




What investigations might you consider doing in someone with features of transverse myelitis?


  • MRI - cord swelling and oedema at affected levels
  • LP - excess monocytes, increased protein, IgG elevated
  • CXR
  • Serology - mycoplasma, lyme
  • HIV test
  • ANA
  • B12, folate, copper levels
  • ESR




How would you manage someone with transverse myelitis?


  • Treat cause
  • High-dose steroids
  • Consider plasma exchange
  • Consider Antibiotics
  • Consider Immunosuppression




What is radiculopathy?



Means disease affecting nerve roots and plexopathy, the brachial or lumbosacral plexus.




What are symptoms of cervical spondylotic myelopathy (CSM)?


  • Neck pain, radiating down arms
  • Paraesthesia - both hands and feet




What are signs of cervical spondylotic myelopathy?

UMN lesion - deficits may be asymmetric, nonsegmental, and aggravated by cough or Valsalva maneuvers

  • Lhermittes phenomenon
  • Gradual spastic paresis
  • Paresthesias
  • Hyperreflexia




What are signs of cervical spondylotic myeloradiculopathy?

Combined UMN/LMN signs

  • L'hermittes phenomenon
  • UMN features below lesion level - Spastic weakness, Hyperreflexive below lesion, urinary incontinence
  • Radiculopathic (LMN) features at lesion level - radicular pain, flaccid weakness, hyporeflexia, and muscle atrophy
  • Ataxia - due to loss of proprioception







What are signs of cervical spondylotic radiculopathy?

LMN radiculopathic signs

  • Radicular pain - shooting in nature
  • Flaccid weakness
  • Hyporeflexia - dull
  • Eventual Muscle atrophy
  • Fasciculations




What is the meaning of radicular pain?



Pain "radiated" along the dermatome(sensory distribution) of a nerve due to inflammation or other irritation of the nerve root (radiculopathy) at its connection to the spinal column




How would you investigate someone with cervical spondylotic myelopathy?







How would you manage someone with cervical spondylotic myelopathy?


  • Conservative management 
  • Injection therapy
    • Interlaminar cervical epidural injections
    • Tranforminal injections
  • Consider decompressive surgery - discectomy, laminectomy, laminoplasty




What is important when trying to establish a cause of acute bilateral limb weakness?


  • Where is the lesion?
    • UMN/LMN?
    • Sensory level?
    • Bowel/bladder control loss
  • What is the lesion?
    • Sudden/rapid progressive/slow onset?
    • Signs of infection?




What are symptoms of acute spinal cord compression?


  • Bilateral leg weakness
  • Sensory level
  • Preceding back pain
  • Bladder/bowel signs - late manifestation




What are signs of spinal cord compression?


  • Normal findings above level of lesion
  • UMN signs below lesion - pyramidal spastic paresis (e.g. legs), hyperreflexia, weakness, babinski positive, clonus
  • Can have LMN signs at level of lesion - radicular pain, flaccid weakness, muscle wasting, fasciculations, hyporeflexive
  • Bowel/bladder retention - overflow incontinence




How does bladder/anal sphincter tone change in someone with spinal cord compression?


Initially starts as hesitency and frequency, and progresses to painless retention due to spastic tone of sphincters due to UMN lesion, coupled with weakness of detrusor muscle. Any incontinence that occurs is due to overflow incontinence


Faecal incontinence occurs due to loss of autonomic bowel function, leading to overflow incontinence




What are causes of spinal cord compression?


  • Secondary malignancy in spine (bone) - breast, bronchus, brostate, byroid, bidney
  • Epidural abscess
  • Cervical disc prolapse
  • Haematoma
  • Intrinsic cord tumour
  • Atlanto-axial subluxation
  • Myeloma




If someone presented with features of spinal cord compression, what might you consider as part of your differential diangosis?


  • Transverse myelitis
  • MS
  • Cord vasculitis
  • Spinal artery thrombosis/aneurysm
  • Trauma
  • Guillain-Barre syndrome




What investigations would you want to do if you suspected spinal cord compression?


  • MRI Neck/Thorax - region targeted based on clinical findings
  • Biopsy - nature of mass
  • CXR
  • Bloods - FBC, ESR, B12, syphillis serology, U+E's, LFT's, PSA, Serum electrophoresis




How would you manage someone with spinal cord compression?


  • Dexamethasone - 16 mg/24 hrs
  • Surgical decompressive laminectomy +/- radiotherapy
  • Epidural abscess - decompression and antibiotics




What is cauda equina syndrome?



Syndrome that occurs due to compression of the cauda equina




What can cause cauda equina syndrome?

  • Tumour
  • LD prolapse
  • Spinal stenosis
  • Traumatic injury
  • Epidural Abscess
  • Spinal surgery
  • Spinal Manipulation
  • Spinal epidural infection




What are symptoms of cauda equina syndrome?


  • Back pain and sciatica
  • Numbness
  • Saddle anaesthaesia
  • Leg paresis - Asymmetrical, atrophic, areflexive paralysis




If there was damage of S2-S5, what motor deficit would there be?



Sphincter deficit




If there was damage at the level of S2-S5, what sensory deficit would be present?



Perianal and saddle (perineum, external genitalia)




If you suspect someone has cauda equina syndrome, how should you investigate?



Clinical Diagnosis, followed by emergency imaging - MRI





If there was damage at the S2-S5 level, what reflex would be affected?



Bulbocavernous reflex




If you have confirmed someone has cauda equina, what is the next step to take in their management?








What are signs of cauda equina syndrome?

LMN lesion - asymmetrical, atrophic, areflexive paralysis of legs

  • Areflexia
  • Flaccid/atonic paralysis
  • Sensory loss in root distribution
  • Saddle anaesthesia
  • Urinary/faecal incontinence
  • Decreased anal tone
  • Sexual dysfunction
  • Loss of bulbocavernous reflex - men




How would you differentiate spinal cord compression from cauda equina?



One had UMN signs (cord compression), other has LMN signs (cauda equina)




If you suspected cauda equina syndrome, what investigations would you want to do?


  • Immediate PR exam
  • Urgent MRI




How would conus medullaris syndrome differ from cauda equina syndrome?



Conus medullaris syndrome has mixed picture of UMN and LMN signs - early urinary retention + constipation and decreased anal tone, sacral sensory distrubance, leg weakness, ED, pain is mild




What are extradural causes of cord neoplasms?



Bony Metastases - Breast, Bronchus, Byroid, Bidney, Brostate




What are extramedullary causes of spinal cord neoplasms?


  • Meningioma
  • Neurofibroma
  • Ependymoma




What are intramedullary causes of spinal cord neoplasms?


  • Glioma
  • Ependymoa
  • Haemangioblastoma
  • Lipoma
  • AV malformation
  • Teratoma




What are causes of unilateral foot drop?


  • DM
  • Common peroneal nerve palsy
  • Stroke
  • Prolapsed disc
  • MS




What are causes of weak legs with no sensory loss?


  • MND
  • Polio
  • Parasagittal meningioma




What are causes of chronic spastic paraparesis?

  • MS
  • Cord primary/mets
  • MND
  • Syrinx
  • Subacute combined degeneration of the spinal cord
  • Hereditary spastic paraparesis
  • Taboparesis
  • Histiocytosis
  • Schistosomiasis




What are causes of chronic flaccid paraparesis of the legs?


  • Peripheral neuropathy
  • Myopathy




If someone had absent knee jerks and extensor plantars, what might your differential diangosis be?

Combined UMN and LMN signs, so:

  • Combined cervical/lumbar disc disease
  • Conus medullaris lesion
  • MND
  • Myeloradiculopathy
  • Freidrich's Ataxia
  • Subacute combined degeneration of the cord
  • Taboparesis




What is a spastic gait?



Caused by UMN lesion - Stiff, circumduction of legs +/- scuffing of the toe of the shoes 




What is an extrapyramidal gait?



"Parkinsonian shuffle"

Flexed posture, shuffling feet, slow to start, postural instability




What is an apraxic gait?


Pathognomic "gluing to the floor" on attempting walking or a wide-based unsteady gait with a tendency to fall - novice on an ice-rink




What is an ataxic gait?



Wide based, cannot walk heel to toe - falls often 




What is a myopathic gait?



Waddling gait, cannot climb steps or stand from sitting due to hip girdle weakness




What are causes of an ataxic gait?


  • Cerebellar lesions - MS, Posterior fossa lesion, alcohol, phenytoin toxicity
  • Proprioception loss - Sensory neuropathy, decreased B12




What is the pathophysiology of cervical spodylotic myelopathy?


Osteophyte formation on adjacent vertebrae leads to narrowing of the spinal cord and intervertebral foramen. as neck flexes and extends, the cord is dragged over these protruding bony spurs anteriorly and indented by a thickened ligamentum flavum posteriorly




If someone with known cervical radiculopathy developed UMN signs below the level of the lesion, what might this suggest?



Spinal cord compression




What motor, sensory, reflex and pain features might you expect to see in someone with radiculopathy of C5 nerve root?


  • Motor - weak deltoid/supraspinatus
  • Sensory - numb from outer aspect shoulder down to elbow
  • Reflex - Decreased biceps jerk and supinator
  • Pain - neck/shoulder radiating down front of arm to elbow




What motor, sensory, reflex and pain features might you expect to see in someone with radiculopathy of C6 nerve root?


  • Motor - weak biceps/brachioradialis
  • Sensory - numb from outer aspect elbow down to thumb and index finger
  • Reflex - Decreased supinator jerk
  • Pain - shoulder radiating down arm below elbow




What motor, sensory, reflex and pain features might yo expect to see in someone with radiculopathy of C7 nerve root?


  • Motor - weak triceps/finger extension
  • Sensory - numb middle finger
  • Reflex - Decreased triceps jerk
  • Pain - Pain in upper arm and dorsal forearm




What motor, sensory, and pain features might yo expect to see in someone with radiculopathy of C8 nerve root?


  • Motor - weak finger flexors and small muscles of hand
  • Sensory - numb 5th and ring finger
  • Pain - Pain in upper arm and medial forearm




What are features of an epidural abscess?

Deficits progress over hours to days.

  • Begin with local or radicular back pain
  • Percussion tendernesspain may be worsened by recumbency
  • Fever 
  • Features of Spinal cord compression may develop




What is the most common causative organism of an epidural abscess?



Staph aureus, followed by E. Coli




How would you manage an epidural abscess?


  • Antibiotics
  • Immediate drainage




What are features of spinal stenosis?


  • Lower back pain
  • Unsteady wide-based gait, reduced lower extremity reflexes
  • Neuropathic claudication: a group of typical symptoms (see table below) of spinal stenosis; affected by postural changes




What distinguishes neuropathic claudication from vascular?


  • Bilateral radiation of pain to buttocks and/or legs
  • Associated cramping, numbness, weakness, ortingling in the legs
  • Exacerbation - Spinal extension : standing, walking downhill, or even at rest
  • Relief - Spinal flexion : sitting, cycling, walking uphill, bending forward





What sensory pathway is typically spared in anterior cord syndrome?



Dorsal colums - light touch, vibration and proprioception




What are features of posterior cord syndrome?



Ipsilateral loss of vibration and proprioceptive sensation below the lesion




What are features of brown sequard syndrome?


  • Contralateral temp and pain loss
  • Ipsilateral vibration, prop and light touch
  • Complete ipsilateral flaccid paresis at level of lesion
  • Spastic paresis ipsilateral below lesion




What are initial features of spinal shock?


  • Flaccid areflexic paralysis
    • Paraplegia or tetraplegia, if cervical cord is involved
    • Sensory disturbances: analgesia and anesthesia
    • Areflexia: absence of the proprioceptive and polysynaptic reflexes
    • Loss of bladder control
    • Loss of bowel control
  • Hypotension and bradycardia
  • Absent bulbocavernosus reflex → incontinence




What features occur after 48 hours of spinal shock?



Progresses back to normality, or (far more often) the underlying injury remains and causes UMN signs after 48–72 hours: spasticity, hyperreflexia, and clonus