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?
Thromboembolic disease - AF, MI
- Aortic dissection
- Systemic hypotension
- Thrombotic haematological disease
- Hyperviscisity syndrome
- Endovascular procedures
- Decompression sickness
What symptoms are seen in spinal cord ischaemia?
Sudden onset/several hours
- Sudden onset Back pain with circumerencial tightness
- 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
- 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?
- 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?
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?
- Viral/bacterial infection
- Post vaccination
What are viral causes of transverse myelitis?
- Hep A
What are autoimmune causes of transverse myelitis?
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
- 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 +
- 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
- Serology - mycoplasma, lyme
- HIV test
- B12, folate, copper levels
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
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
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
- 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?
- 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
- Intrinsic cord tumour
- Atlanto-axial subluxation
If someone presented with features of spinal cord compression, what might you consider as part of your differential diangosis?
- Transverse myelitis
- Cord vasculitis
- Spinal artery thrombosis/aneurysm
- 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
- 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?
- 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
- Saddle anaesthaesia
- Leg paresis - Asymmetrical, atrophic, areflexive paralysis
If there was damage of S2-S5, what motor deficit would there be?
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?
If you have confirmed someone has cauda equina, what is the next step to take in their management?
IMMEDIATE SURGICAL DECOMPRESSION - Within 48h
What are signs of cauda equina syndrome?
LMN lesion - asymmetrical, atrophic, areflexive paralysis of legs
- 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?
What are intramedullary causes of spinal cord neoplasms?
- AV malformation
What are causes of unilateral foot drop?
- Common peroneal nerve palsy
- Prolapsed disc
What are causes of weak legs with no sensory loss?
- Parasagittal meningioma
What are causes of chronic spastic paraparesis?
- Cord primary/mets
- Subacute combined degeneration of the spinal cord
- Hereditary spastic paraparesis
What are causes of chronic flaccid paraparesis of the legs?
- Peripheral neuropathy
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
- Freidrich's Ataxia
- Subacute combined degeneration of the cord
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?
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 tenderness - pain may be worsened by recumbency
- 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?
- 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