Spinal cord syndromes

1. In the Name of God, Most Gracious, Most Merciful

2. SPINAL CORD
SYNDROMES
-Dr. Mohammed Sadiq Azam
II yr. Postgraduate
MD Internal Medicine
Deccan College of Medical Sciences

3. CLASSIFICATION
COMPLETE
INCOMPLETE

4. Trauma
Metastatic carcinoma
Multiple sclerosis
Spinal epidural haematoma
Autoimmune disorders
Post vaccinialsyndromes.
COMPLETE CORD SYNDROMES

5. •All ascending tracts from
below and descending tracts
from above are interrupted.
•Affects motor, sensory and
autonomic functions.
COMPLETE CORD TRANSECTION

6. SENSORY:
All sensations are affected.
Pin prick test is very valuable.
Sensory level is usually 2 segments below the level of
lesion.
Segmental paraesthesiaoccur at the level of lesion.
COMPLETE CORD TRANSECTION

7. MOTOR:
Paraplegia due to corticospinaltract involvement.
First spinal shock-followed by hypertonic hyperreflexic
paraplegia.
Loss of abdominal and cremastricreflexes.
At the level of lesion LMN signs occur.
COMPLETE CORD TRANSECTION

8. AUTONOMIC:
Urinary retention and constipation.
Anhidrosis, trophic skin changes, vasomotor instability
below the level of lesion.
Sexual dysfunction can occur.
COMPLETE CORD TRANSECTION

9. Brown Sequardsyndrome
Central cord syndrome
Anterior cord syndrome
Posterior cord syndrome
Conusmedullaris syndrome
Caudaequinasyndrome
INCOMPLETE CORD SYNDROMES

10. BROWN SEQUARD SYNDROME
= Hemi-section of the spinal cord
Caused by extramedullarylesions
Usually caused by penetrating trauma or tumour.

12. SENSORY:
Ipsilateralloss of proprioceptiondue to posterior
column involvement.
Contralateralloss of pain and temperature due to
involvement of lateral spinothalamictract.
BROWN SEQUARD SYNDROME

13. MOTOR:
Ipsilateralspastic weakness due to descending
corticospinaltract involvement
LMNsigns at the level of lesion.
BROWN SEQUARD SYNDROME

14. CENTRAL CORD SYNDROME

15. CENTRAL CORD SYNDROME

16. Commonest cause is Syringomyelia.
Other causes:
◦Hyperextension injuries of neck
◦Intramedullary tumours
◦Trauma
◦Associated with Arnold Chiari type 1 and 2, Dandy walker
malformation
CENTRAL CORD SYNDROME

17. SENSORY:
Pain and temperature are affected.
Touch and proprioception are preserved.
Dissociative anaesthesia.
Shawl like (= Cape like) distribution of sensory loss.
MOTOR:
Upper limb weakness > Lower limb
CENTRAL CORD SYNDROME

18. OTHER FEATURES :
Horner’s syndrome
Kyphoscoliosis
Sacral sparing
Neuropathic arthropathyof shoulder and elbow
joint
Prognosis is fair.
SYRINGOMYELIA

20. Commonest causes include diabetes mellitus &
neurosyphilis.
Usually occurs 10 to 20 yrs after disease onset.
POSTERIOR CORD SYNDROME

21. SENSORY :
Impaired position and vibration sense in LL
Tactile and postural hallucinations can occur.
Numbness or paresthesiaare frequent complaints..
Sensory ataxia.
Positive rhombergsign.
Positive sink sign
Positive lhermittessign.
POSTERIOR CORD SYNDROME

22. SENSORY (contd):
Abadie’ssign (of tabesdorsalis) positive
Urinary incontinence
Absent knee and ankle jerk (Areflexia, Hypotonia)
Charcot’s joint
Mioticand irregular pupil not reacting to light
ArgylRobertson Pupil
POSTERIOR CORD SYNDROME

23. CAUSES :
Vitamin B12 deficiency
AIDS
HTLV associated myelopathy
Cervical spondylosis
POSTERIO LATERAL COLUMN DISEASE

24. FEATURES :
Paresthesiain feet
Loss of proprioception and vibration in legs
Sensory ataxia
Positive Rhombergsign
Bladder atony
Corticospinaltract involvement:
◦Spasticity
◦Hyperreflexia
◦Bilateral Babinskisign -Positive
POSTERIO LATERAL COLUMN DISEASE

25. AIDS:
◦Associated dementia and spastic bladder is present
HTLV associated myelopathy:
◦Slowly progressive paraparesis
◦Increase in CSF IgGwith antibodies to HTLV 1
POSTERIO LATERAL COLUMN DISEASE

26. Due to acute disc herniationor ischemia from anterior
spinal artery occlusion.
Usually caused by hyperflexioninjuries
Area supplied by anterior spinal artery is affected
ANTERIOR CORD SYNDROME

27. Sudden onset of paralysis
(quadriparesis/paraparesis)
below the level of lesion.
Pain and temperature loss.
Dorsal column is
preserved.
Prognosis is poor.
ANTERIOR CORD SYNDROME

28. ANTERIOR SPINAL ARTERY
SYNDROME

29. ANTERIOR SPINAL ARTERY
SYNDROME

30. Commonest of the vascular syndromes of the cord.
Spinal cord infarction usually occurs in T1 to T4 segment & L1.
Occurs due to aortic dissection, atherosclerosis of aorta, SLE,
AIDS, AV malformation
Rarely due to dissection of the anterior spinal artery or systemic
arteritis. Syphilitic arteritisis now rare.
Conusmedullaris is frequently involved.
Neck pain of sudden onset is a common feature.
Also called as “Beck’s syndrome”.
ANTERIOR SPINAL ARTERY SYNDROME

31. SENSORY :
Loss of pain and temperature.
Preservation of position and vibration.
MOTOR :
Sudden onset flaccid and areflexic paraplegia.
AUTONOMIC :
Urinary incontinence +
ANTERIOR SPINAL ARTERY SYNDROME

32. UNCOMMON
Loss of proprioception and vibratory sense.
Pain and temperature is preserved.
Absence of motor deficit.
POSTERIOR SPINAL ARTERY
SYNDROME

33. CAUSED BY SPINAL MUSCULAR ATROPHY
◦Spinal muscular atrophy (SMA) is an autosomal recessive
disorder that causes decreased survival of the anterior horn
cells –motor neurons –that innervate voluntary muscles,
resulting in progressive muscle atrophy and weakness.
◦Types I to IV
◦Eponyms: Werdnig-Hoffman disease, Kugelberg-Welander
disease, SMA, Anterior horn cell disease
ANTERIOR HORN CELL SYNDROMES

34. MOTOR :
Weakness, atrophy and fasciculations.
Hypotonia, depressed reflexes.
Muscles of trunk and extremities are affected.
Sensory system is not affected.
ANTERIOR HORN CELL SYNDROMES

35. Occurs in amytrophiclateral sclerosis (ALS).
◦Also called Lou Gehrig's disease.
◦A form ofMotor Neuron Disease caused by the degeneration of
upper and lowerneurons, located in theventral hornof
thespinal cordand thecortical neuronsthat provide
theirefferentinput.
Affects the anterior horn cells and corticospinaltract.
Both LMN and UMN signs occur.
ANTERIOR HORN CELL & PYRAMIDAL
TRACT SYNDROME

36. MOTOR :
Ant horn cell related:
◦Paresis, Atrophy and Fasciculations.
Corticospinaltract related:
◦Paresis, Spasticity and Extensor plantar response.
ANTERIOR HORN CELL & PYRAMIDAL
TRACT SYNDROME

37. It is usually unilateral with muscle weakness +
Reflexesare often exaggerated.
Bulbar and pseudo bulbar involvement occurs.
Sensory system is not affected.
Superficial reflex -Abdominal reflex is preserved.
ANTERIOR HORN CELL & PYRAMIDAL
TRACT SYNDROME

38. CONUS MEDULLARIS & CAUDA EQUINA
SYNDROMES

39. CM: Lies opposite to vertebral bodies of T12 and L1.
Contributes to 25% of spinal cord injuries.
Caused by flexion distraction injuries and burst
fractures.
Both UMN and LMN deficits occur.
Development of neurogenicbladder.
CONUS MEDULLARIS SYNDROME

40. CE: Begins at L2 disk space
distal to conusmedullaris.
CE syndrome occurs due to:
◦Acute disk herniation
◦Epidural haematoma
◦Tumour
CAUDA EQUINA SYNDROME

41. MOTOR :
Flaccid lower extremities.
Knee and ankle jerk absent.
SENSORY :
Asymmetrical sensory loss
Saddle anaesthesia
Loss of sensation around perineum, anus, genitals.
CAUDA EQUINA SYNDROME

42. AUTONOMIC:
Loss of bladder and bowel function.
Urinary retention.
CAUDA EQUINA SYNDROME

43. DDx: CONUS vsCAUDA
FEATURE CONUS MEDULARIS CAUDA EQUINA
PRESENTATION Sudden & Bilateral Gradual & Unilateral
REFLEXES Knee present, Ankle –
(If the epiconusis
involved, patellar reflex
maybe absent but
bulbocavernosusis
spared)
Knee & Ankle –
Bulbocavernosusreflex
is absent in low CE
(sacral) lesions
RADICULAR PAIN Less severe More severe
LOW BACK ACHE More Less
Ref: http://www.emedicine.com/neuro/topic667.htm

44. FEATURE CONUS MEDULARIS CAUDA EQUINA
SENSORY
SYMPTOMS
Numbness tends to be
more localized to
perianalarea;
symmetrical and
bilateral; sensory
dissociation occurs.
Sensory loss of pin
prick& temperature
sensations (Tactile
sensation is spared.)
Numbness tends to be more
localized to saddle area;
asymmetrical, maybe
unilateral; no sensory
dissociation; loss of sensation
in specific dermatomes in lower
extremities with numbness and
paresthesia; possible numbness
in pubic area, including glans
penis or clitoris.
Ref: http://www.emedicine.com/neuro/topic667.htm

45. FEATURE CONUS MEDULARIS CAUDA EQUINA
MOTOR
SYMPTOMS
Typically symmetric,
distal paresisof lower
limbs that is less
marked; fasciculations
may be present.
Asymmetric areflexic paraplegia
that is more marked;
fasciculations rare;
atrophy more common .
IMPOTENCE Frequent Less frequent; ED is common
erectile dysfunction that includes
inability to have erection, inability
to maintain erection, lack of
sensation in pubic area (including
glanspenis or clitoris), and inability
to ejaculate.
Ref: http://www.emedicine.com/neuro/topic667.htm

46. FEATURE CONUS MEDULARIS CAUDA EQUINA
SPHINCTER
DYSFUNCTION
Urinary retention and
atonicanal sphincter
cause overflow urinary
incontinence and fecal
incontinence
Tend to present early
in courseof disease.
Urinary retention
Tends to present late in
courseof disease
EMG Mostly normal lower
extremity with external
anal sphincterinvlmnt
Multiple root level
involvement; sphincters may
also be involved.
OUTCOME Less favourable More Favourable
Ref: http://www.emedicine.com/neuro/topic667.htm