localization spinal cord

a short slideshow on low to localise lesions of spinal cord

1. Localization of lesions in spinal cord

2. Definition Plegia – severe/complete weakness Paresis – mild/moderate weakness Monoplegia – weakness of one limb Paraplegia – weakness of both lower limbs Quadriplegia – weakness of all four limbs Diplegia – quadriplegia in which lower limbs are affected more than the upper limbs

3. Spinal cord - anatomy It is a cylindrical column of about 43-45cms. length extending from the cranial border of atlas (where it continues with medulla) to the Lower border of L1 vertebra. It is covered by the three layers of meninges and lies within the vertebral column of about 70cms length.

4. Spinal cord - anatomy The caudal end is the Conus medullaris containing S3, 4, 5 and Co1 segments, from where the thread of pia matter Filum terminale extends upto the coccyx. It has 31 pairs of spinal nerves giving a segmental picture. Due to the differential growth of the spinal cord and vertebral column, the bunch of lumbo - sacral nerve roots called Cauda equina travel down long from the lower end of spinal cord to the inter vertebral foramen.

5. ORGANIZATION OF MOTOR SYSTEM

6. WEAKNESS – UMN - LESION 1.WEAKNESS – PYRAMIDAL 2.WASTING – NONE 3.FASCICULATION – NONE 4.TONE – SPASTIC 5.TENDON REFLEX – BRISK 6.PLANTAR REFLEX – EXTENSOR

7. WEAKNESS OF LMN- LESION 1.WEAKNESS – SEGMENTAL 2.WASTING – SEVERE 3.FASCICULATION – PRESENT 4.TONE – REDUCED 5.TENDON REFLEX – REDUCED /ABSENT 6.PLANTAR REFLEX – FLEXOR

8. Evaluation of the motor system 1. Nutrition of the muscles 2. Tone 3. Power 4. Reflexes a) superficial b) tendon 5. Fasciculation 6. Abnormal movement a) Flexor spasm b) spinal myoclonus

9. Muscles innervation- myotomes - upper limb

10. Muscle innervation - myotome – lower limb

11. Superficial reflexes – spinal segments Abdominal Upper - D8 -10 Lower - D10-12 Cremastric - L1 Plantar - > L5, S1 Anal - S3,4 Bulbocavernous - S3,4

12. Tendon reflexes - spinal segments

13. SENSORY SYSTEM - PATHWAY

14. SENSORY DERMATOMES

15. SENSORY DERMATOME – LOWER LIMB

16. Sensory system evaluation

17. CROSS SECTION OF SPINAL CORD

18. Anatomy of a spinal segment

19. Correlation between the spinal and vertebral segment. upper dorsal - 2 segments, Lower dorsal - 3 segments, D11 vertebra - L3-L4 segments D12 vertebra - L5 segment L1 vertebra - S1-5 and Co1 segments

20. CORD LESION ABOVE D-12 SEGMENT 1. ACUTE STATE- RETENTION 2. REFLEX BLADDER - VAGUE SENSATION - REFLEX EMPTYING - SMALL BLADDER

21. AUTONOMOUS BLADDER 1. NO BLADDER SENSATION 2. DRIBBLING 3. MORE RESIDUAL URINE CONUS LESION

22. CAUDA EQUINA LESION 1.SAME AS IN CONUS 2. BLADDER SENSATION MAY BE NORMAL

23. Results of spinal cord lesion 1. At the level a) motor: segmental LMN findings b) Sensory: segmental sensory root findings 2. Below the level a) motor: UMN findings b) sensory: tract involvement findings c) autonomic: bladder, bowel, etc. d) others:

24. Clinical approach to localization of spinal cord lesion 1. Does the patient has spinal cord lesion? 2. If so, localize the highest level of spinal segment involvement by identifying the a) motor level, b) reflex level c) sensory level, d) autonomic level 3. To identify- intramedullary / extramedullary / extramedullary-extradural , 3. Localize the corresponding vertebral level. 4. Identify the aetiology based on the history.

25. INTRAMEDULLARY LESION Dysesthesia and Paresthesias Dissociated sensory loss Sacral sparing present Spastic Paraparesis not prominent. Muscle atrophy common. Trophic skin changes common Bladder bowel disturbance occur early if the lesion is lower down.

26. EXTRAMEDULLARY LESION Root pain Segmental wasting Spastic paraparesis Bladder and bowel symptom occur late

27. CLINICAL FEATURES – EXTRA & INTRAMEDULLARY TUMORS Symptoms and signs Extra Medullary Intra Medullary 1. Sensory a. Root Pain + - b. Funicular Pain - + c. Progression of paresthesia Ascending Descending d.Sensory loss-Dissociative - + e. Sensory loss-Dermatomal + - f. Sacral sparing - + 2. Motor a. LMN signs Segmental Diffuse b. Appearance of UMN signs Early Late 3. Bladder Disturbances Late Early with caudal lesions 4.Trophic Disturbances - +

28. Clinical features of extradural lesions 1. All features of extramedullary lesions, 2. Spinal tenderness, 3. Spinal deformity, 4. Paraspinal spasm .

29. Clinical features of Brown- Sequard syndrome 1 . Ipsilateral a) segmental LMN signs, b) spastic weakness, c) posterior column involvement, 2. Contralateral a) spinothalamic tract involvement signs. Note: seen in extramedullary lesions, penetrating injuries

30. Localization of C-V junction bony anomalies 1. short neck, 2. low hair line, 3. restricted neck movements, 4. spastic quadriparesis ->C5, 5. others

31. C-V junction soft tissue (foramen magnum) lesion 1.V1 sensory loss, 2.Horner’s syndrome 3. down beating nystagmus , 4.cerebellar findings, 5. lower cranial involvement, 6.sensory loss over C2 dermatome, 7. spastic quadriparesis >C5

32. Localization C- 5 segment lesion 1.At C5: a) motor-LMN weakness of C5 myotome -deltoid and biceps, b) reflex: absent biceps DTR, c) sensory: radicular symptoms at-C5; 2) Below C5 a) UMN findings b) posterior column and spinothalamic tract involvement.

33. Localization at D10 segment 1.At D10 level a) weakness of lower abdominal muscles, b) absent lower abdominal reflex c) sensory dematomal signs at D10. 2. Below D10 a) UMN findings b) posterior column and spinothalamic tract involvement.

34. CONUS LESION (S3-Co1) CLINICAL FEATURES 1.BLADDER INCONTINENCE 2.BOWEL INCONTINENCE 3.LOSS OF PENILE TUMESCENCE 4. LOSS OF ANAL REFLEX 5. LOSS OF BULBOCAVERNOUS REFLEX 6. PERIANAL SENSORY LOSS 7. NO MOTOR WEAKNESS Localization at Conus

35. CAUDA EQUINA (L2-CO1 ROOTS) LESION CLINICAL FEATURES 1.asymmetric LMN signs in both lower limbs 2.asymmetric segmental sensory loss in both lower limbs 3.bladder disturbance Localization at Cauda equina

36. Noncompressive spinal cord syndromes

37. Spinal cord syndrome-transverse section 1.At the level a) Motor- Segmental LMN signs. b) sensory-segmental root symptoms 2. Below the level a) UMN signs-paraplegia/quadriplegia, b) posterior column signs, c) spinothalamic tract, d) autonomic disturbances. Note: trauma, transverse myelitis

38. Spinal cord syndrome-SCD 1. signs of posterior column involvement, 2. signs of lateral column (pyramidal tract) involvement. Note: additional sensory motor peripheral neuropathy may be present.

39. Spinal cord syndrome-ALS 1. Signs of lateral tract (pyramidal tract) in all four limbs, 2. Signs of anterior horn cell (LMN) involvement, 3. absence of sensory signs. Note: presence of LMN and UMN signs in the same limb symmetrically with absent sensory signs is the characteristic feature.

40. Spinal cord syndrome-anterior spinal artery thrombosis 1.Signs of Lateral tract (pyramidal tract) signs(paraplegia/quadriplegia), 2. Signs of spinothalamic tract involvement, 3. Bladder and bowel impairment, 4. Intact posterior column. Note: the common vascular watershed regions are D1-4 and L1 segment.

41. Case History A 32 year old lady presented with progressive weakness of both upper and lower limbs of two months duration without sensory, cerebellar and bladder disturbances. Examination revealed moderate weakness of all four limbs, proximal more than distal muscles; no muscle wasting; normal tone and DTR; no sensory disturbances.

42. A 18 year old person presented with abrupt onset of weakness of all four limbs of three days duration. Examination revealed weakness of all four limbs with power of grade 2, diminished tone and tendon reflexes, plantar flexor; vibration sense diminished over the tip of the toes.

43. A 15 year old girl presented with shooting pain on the right mid abdomen and weakness of right lower limb of six months duration without bladder bowel disturbances. Examination revealed spastic weakness of both lower limbs right more than left, absent lower abdominal reflex and diminished sensation below umbilical region. No spinal tenderness

44. A 48 year old person presented with progressive weakness of all four limbs of thee months duration without any autonomic disturbances. Examination revealed moderate weakness and wasting of muscles both arm, forearm and hands; mild spastic weakness of both lower limbs. DTR were diminished in upper limbs and exaggerated lower limbs with extensor plantar reflex. Pain and temperature were disproportionately more diminished in both upper limbs. No spinal tenderness.

45. A 26 year old person presented with low back pain and fever of one month and weakness of both lower limbs as well as difficulty in initiating micturition of 12 days duration. Examination revealed flail weakness of both lower limbs (right more than left), DTR in both lower limbs were diminished with diminished sensation over the posterior part of right thigh and sacral region of both sides.

46. A52 year old person presented with numbness of both fate and imbalance of walking and tends to fall down while washing face of two months duration. On examination there is mild weakness of both lower limbs upper and lower abdominal reflex absent, planter bilateral extensor. DTR upper limb normal and lower limb knee brisk, anti diminished. Sensation all modalities diminished below ankle, vibration was diminished upto the dorsal spine.

47. Clinical localization and MRI imaging

48. Thank you…