Spinal Cord Lesions

Non-surgical
Rechdi Ahdab, MD, PhD

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Objectives

1- Review spinal cord anatomy and

clinical correlation
2- Expand DDx concerning CNS and PNS
disorders mimicking common surgical
disorders
3- Differentiate various spinal cord
syndromes

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Anatomy: ascending pathways

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Anatomy: ascending pathways

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Posterior column and
spinothalamic tracts
Posterior column Spinothalamic tract

1. Fine touch 1. Pain and Temperature

2. Pressure (lateral)
3. Proprioception 2. Touch (crude) and Pressure
4. Vibration (anterior)

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Anatomy: descending pathways

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Anatomy: descending pathways

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Spinal cord
vascular supply

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Lesions of Upper vs.
Lower Motor Neuron
Upper motor Lower motor
neuron neuron
– Motor cortex – Anterior horn cell
– Internal capsule – nerve root
– Brainstem – Plexus
– Spinal cord – peripheral nerve

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Upper and lower motor
neuron syndromes
Upper motor neuron Lower motor neuron

1. Motor weakness 1. Motor weakness

2. Spasticity 2. Muscle atrophy
3. Hyperreflexia 3. Fasciculations
4. Babinski sign 4. Cramps
5. Hoffman sign 5. Decreased or absent
6. Absent abdominal tendon reflexes
reflex 6. Decreased muscle
tone
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 Clinical Features

I. Interruption of the ascending and

descending tracts
Neurological deficit below the level of the
lesion
1. Sensory level

2. UMN signs

3. Bowel and bladder

dysfunction 11
 Clinical features

II. Segmental injury

Sensori-motor symptoms at the level of
the lesion
1. Anterior horn cells

2. Posterior horns cells

3. Interneurons
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 Clinical note
Spinal cord injury
At the level of the lesion
 Radicular pain
 Myotomal weakness

Below the level of the lesion

 Paraparesis/Quadriparesis
 Sensory loss
 Bladder\bowel and sexual dysfunction 13
Example: C7 cord injury
Long tract injury
 Weakness
– Intrinsic hand muscles
– Lower extremities
 ↑ DTR in LE
 Babinski sign
Segmental injury
 Weakness and atrophy
– Triceps
– Wrist extensors
 ↓ or absent DTR in triceps
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Spinal cord
v/s vertebral
level

Spinal cord segments do

not correspond to the
vertebral segments

Spinal cord ends at the

L1-L2 level

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History
 Onset
– Acute, subacute, chronic
 Symptoms
– Pain
– Weakness
– Sensory
– Autonomic
 Past medical conditions
 Family history
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Tempo of Spinal Cord Disease

Acute Subacute Chronic

Trauma X

Mass lesion X X

Infectious X X X

Inherited X

Vascular X X X

Autoimmune X X

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Nutritional X
Distribution of Motor weakness

 Upper cervical
– Quadriplegia
– Impaired respiration C3-5
 Lower cervical
– Proximal arm strength preserved
– Hand weakness (C8-T1) and leg
weakness
 Thoracic
– Paraplegia 18
Sensory Exam
 Establish a sensory level
– Dermatomes
 Nipples: T4-5

 Umbilicus: T10

 Posterior columns
– Vibration & Joint position
sense (proprioception)
 Spinothalamic tracts
– Pain & Temperature
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Autonomic disturbances
 Neurogenic bladder
– Urgency, incontinence, retention
 Bowel dysfunction
– Constipation more frequent than incontinence
 High cord lesion
– Loss of blood pressure control
– Loss of thoracic vasoconstriction
 Alteration in sweating
 Disturbance in temperature control

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Classical spinal cord
syndromes

1. Anterior spinal artery infarct

2. Brown-Sequard syndrome

3. Syringomyelia

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Anterior spinal artery
infarct

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Vascular Diseases of
Spinal Cord: Infarcts
 Symptoms
– Upper motor neurons type weakness
– Pain/temperature loss
– Posterior columns preserved

 Anterior spinal artery infarct

– Aortic disease and surgery
– Artery of Adamkiewicz (T10-11)
– Watershed area (T3-T4)
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Brown-Sequard Syndrome

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Brown-Sequard Syndrome

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Brown-Sequard Syndrome

Dissociated sensory loss

Ipsilateral to lesion Contralateral to lesion

 Large sensory fiber  Loss of pain and

dysfunction temperature sensation
 Upper motor neuron  1-2 levels below the
dysfunction lesion

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Syringomyelia

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Syringomyelia

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Syringomyelia

 Fluid filled cavity in the cord

 Cervical cord most common site
– Loss of pain and temperature (crossing fibers)
– Weakness /atrophy/hyporeflexia (AHC)
– Corticospinal trat involved later with brisk reflexes,
spasticity & weakness in legs
 May occur as a late sequelae to trauma
 Seen in association with Arnold-Chiari II malformation

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 Syringomyelia
I. Segmental injury II. Injury to descending tracts

 Loss of pain and  Brisk reflexes, spasticity

temperature (crossing and weakness in legs
fibers)  Later complication
 Weakness ,atrophy,
hyporeflexia (AHC)

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Etiology of Spinal Cord
Disease – non-surgical

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B12 Deficiency

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B12 Deficiency (Subacute
combined degeneration)
 Malabsorption of Vit B12 (pernicious
anemia or surgery)
 Insufficient dietary intake
 Clinical findings
– Dorsal and lateral column dysfunction
– Peripheral neuropathy
– Patellar reflex brisk, Achilles less
– Babinski sign
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Treatment Subacute
Combined Degeneration
 IM/SQ B12 – 1mg weekly for 1 month
then 1mg monthly
 Assess B12 and MMA after completion
of 1 month course – establish
adequate replacement

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Non-surgical Spinal Cord
Disease

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Transverse myelitis

 Inflammation of the spinal cord

– Post-infectious or vaccine
– Auto-immune
 Pain at level of lesion may precede
onset of weakness/sensory
change/sphincter disturbance
 May be asymmetric/incomplete
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Multiple Sclerosis
 Demyelination is the underlying pathology
 Presenting feature or occur at anytime
 Lesion can be at any level of the cord
– Patchy
– Transverse
 Devic’s syndrome or neuomyelitis optica
– Transverse myelitis with optic neuritis
– Specific antibodies: anti-NMO (directed
against aquaporine 4)
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Transverse Myelitis
assessment
 Lumbar puncture
– Cell count, Glu, Igg Index/SR, OCB
 Serum Assays
– Consider ANA, ACE, VDRL/FTA, Lyme,
West Nile & other arbovirus, HTLV I
 Additional CSF
– ACE, VDRL
 MRI/Evoked potential
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Treatment Transverse
Myelitis
 IV methylprednisolone 1000mg daily
for 3-5 days
 Consider IVIG or pheresis if ineffective
(anecdotal information)

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Non-surgical Disorders of
the Spinal Cord

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Infections Involving the
Spinal Cord
 Polio
– Only the anterior horn cells are infected
 Tabes dorsalis
– Dorsal root ganglia and dorsal columns
– Tertiary syphillis
– Sensory ataxia, “lightening pains”
 HIV myelopathy (vacuolar myelopathy)
– Mimics B12 deficiency
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Non-surgical Disorders of
the Spinal Cord

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 Vascular Diseases of the
Spinal Cord
 Arteriovenous malformation (AVM)
– Primarily in thoracic cord
– May present either acutely, subacutely
or chronically
– Can cause recurrent symptoms
– If they bleed
 Associated with pain & bloody CSF

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Hereditary Disease of the
Spinal Cord
 Hereditary spastic paraparesis
– Usually autosomal dominant
 Spinocerebellar Atrophy
 Spinomuscular atrophies
– Anterior horn cell injury

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Other spinal cord
disorders
 Paraneoplastic

 Toxic
– Chemotherapy (intrathecal)
– Radiation

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Other spinal cord
disorders

 Motor Neuron Disease

– ALS
– SMA
– Primary lateral sclerosis

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