Medical Diseases of the Spinal Cord

Question 1

What is myelopathy?

Answer 1

Pathology of the spinal cord

Question 2

What is myelitis?

Answer 2

Inflammation of the spinal cord

Question 3

What is radiculopathy?

Answer 3

Pathology of nerves (radiculo = nerve)

Question 4

What is radiculitis?

Answer 4

Inflammation of the nerves (not common)

Question 5

What is myeloradiculopathy?

Answer 5

Pathology of the spinal cord and nerve

Question 6

How can the causes of myelopathy or radiculopathy be divided?

Answer 6

Intrinsic or extrinsic

Medical or Surgical

Question 7

What are the medical causes of myelopathy or radiculopathy?

Answer 7

Inflammation
Infarction
Infiltration
Infection
Degenerative (neurons)

Question 8

What are the surgical causes of myelopathy or radiculopathy?

Answer 8

• Tumour: extradural, intradural/ extramedullary, intramedullary
• Vascular abnormalities: haemorrage, AVM, dural fistula
• Degenerative (spine)
• Trauma

Question 9

What are the signs of a Upper Motor Neuron problem?

Answer 9

Increased tone

• Spasticity
• Clasp knife

Increased reflexes

Pyramidal pattern of weakness

Babinski sign

Pronator drift (associated with spasticity)

Question 10

What is a pyramidal pattern of weakness?

Answer 10

A pattern of weakness in the extensors of upper limbs and flexors in lower limbs

Question 11

What are the signs in lower motor neuron lesions?

Answer 11

Nerve damage causes muscle wasting

Decreased tone
Decreased reflexes
Weakness

Question 12

What is the difference in paralysis of uper motor neuron lesion and lower motor neuron lesion?

Answer 12

Lower motor neuron lesion = flaccid paralysis
-Paralysis accompanied by loss of muscle tone.

This is in contrast to an upper motor neuron lesion, = spastic paralysis -Paralysis accompanied by severe hypertonia.

Question 13

What are the sensory signs in radiculopathy?

Answer 13

Dermatomal pattern of sensory loss

C5,6
L5,S1

Question 14

What is Brown-Sequard Syndrome?

Answer 14

Ipsilateral Side

• UMN signs (Corticospinal tract damage)
• Loss of sensory information (vibration, proprioception - Dorsal column)

Contralateral side
-Loss of pain and temperature
(STT)

Question 15

What are the medical causes of myelopathy?

Answer 15

Demyelination (MS)
Ischaemic
Transverse myelitis
Neurodegenerative
Metabolic, B12 deficiency
Malignant/ infiltrative
Infective
Inflammatory

Question 16

What are the ischaemic causes of myelopathy?

Answer 16

Atheromatous disease
Thromboembolic disease
Arterial dissection
Systemic hypertension
Hyperviscosity syndromes
Vasculitis
Venous occlusion
Endovascular procedures
Decompression sickness
Meningovascular syphilis

Question 17

What is transverse myelitis?

Answer 17

Transverse myelitis = spinal cord is inflamed across entire width.

Inflammation damages nerve fibers, causes them to lose their myelin coating -> decreased electrical conductivity in the CNS.

Partial transverse myelitis and partial myelitis = inflammation of the spinal cord that affects part of the width of the spinal cord.

Question 18

What neurodegenerative disorders can cause myelopathy?

Answer 18

Friedrich’s ataxia

Spinocerebellar ataxias

Question 19

What infections can cause myelopathy?

Answer 19

Lyme disease

AIDS

Question 20

Explain the posterior and anterior spinal cord in relation to stroke

Answer 20

Anterior 2 thirds of the spinal cord are supplied by a single spinal artery

Posterior 1 third supplied by 2 arteries

Anterior (where all the motor function is) is much more at risk to spinal stroke

Question 21

What is the clinical presentation of spinal cord stroke?

Answer 21

May have vascular risk factors

Onset may be sudden or over several hours (unlike brain stroke)

Pain

• Back pain/ radicular
• Visceral referred pain

Weakness

Numbness and paraesthesia

Urinary symptoms

Question 22

Describe weakness in spinal stroke

Answer 22

Usually paraparesis rather than quadraparesis given vulnerability of thoracic cord flow related ischaemia

Question 23

What urinary symproms may you see in spinal stroke?

Answer 23

Retention followed by bladder and bowel incontinence as spinal shock settles

Question 24

Give some general points about spinal cord stroke

Answer 24

Very rarely posterior spinal artery -> dorsal column spared

Usually anterior spinal artery

Occlusion of a central sulcal artery can present as a partial Brown-Sequared syndrome

Usually mid thoracic

May be spinal shock

Question 25

What is spinal shock?

Answer 25

Spinal shock is a loss of sensation accompanied by motor paralysis with initial loss but gradual recovery of reflexes, following a spinal cord injury (SCI) – most often a complete transection. Reflexes in the spinal cord below the level of injury are depressed (hyporeflexia) or absent (areflexia), while those above the level of the injury remain unaffected.

Question 26

What is the investigation for spinal cord stroke?

Answer 26

MRI

Question 27

What is the treatment for spinal cord stroke?

Answer 27

Supportive Reduced risk of recurrence - Maintain adequate BP - Bed rest - Reverse hypovolaemia/ arrhythmia Occupational therapy and physiotherapy Manage vascular risk factors

Question 28

What is the prognosis for spinal cord stroke?

Answer 28

Return of function depends of degree of parenchymal damage Unless significant motor recovery in first 24 hours chance of major recovery is low Pain may be persistent and significantly contribute to disability 20% mortality, only 35-40% have more than minimal recovery

Question 29

What is demyeliniting myelitis?

Answer 29

Usually part of MS Common cause of medical spinal cord disease Can affect the young

Question 30

What is demyelinating myelitis of MS?

Answer 30

Characterised by pathological lesions of inflammation and demyelination leading to temporary neuronal dysfunction Affects the white matter of the CNS One or more lesions anywhere

Question 31

Describe the presentation of demyelination myelitis of MS

Answer 31

Partial or incomplete transverse myelitis May be the initial presentation of MS -60-70% have MRI brains typical of MS Subacute onset (over days to a week) May be history of previous neurological or ophthalmic episodes

Question 32

How do you diagnose Myelitis in MS?

Answer 32

Typical history -> MRI -> diagnosis If the history and scan are atypical you can go a lumbar puncture

Question 33

What is the treatment of MS Myelitis?

Answer 33

Supportive -lots of options for symptoms Methylprednisolone - Very high dose steroids - Helps with current episode - Will not prevent future relapse Disease modifying treatments

Question 34

What are the causes for transverse myelitis?

Answer 34

``` Idiopathic Viral Other infections Autoimmune Malignancies Post vaccination ```

Question 35

What virus' may cause transverse myelitis?

Answer 35

VZV, HSV, CMV, EBV, influenza, echo virus, HIV, hepA, rubella

Question 36

What other infections may cause transverse myelitis?

Answer 36

Syphilis Measles LYMES DISEASE

Question 37

What autoimmune disorders may cause transverse myelitis?

Answer 37

SLE sjogren's syndrome sarcoidosis

Question 38

Describe vitamin B12 deficiency

Answer 38

Abundant in meat, fish and most animal by-products Legumes Absorption from gut requires intrinsic factor Complicates total gastrectomy, Crohn's, tape worms

Question 39

What is Pernicious anaemia?

Answer 39

Autoimmune condition in which antibodies to intrinsic factor prevent B12 absorption

Question 40

Where does B12 deficiency effect in the nervous system

Answer 40

Most of it: - Myelopathy (L'hermitte's) - Peripheral neuropathy - Brain - Eye/optic nerves - Brainstem - Cerebellum

Question 41

What are the signs of B12 deficiency?

Answer 41

Parasthesia hands and feet, areflexia First UMN sign is upturned plantars Degeneration of: - CST -> paraplegia - Dorsal column -> sensory ataxia Painless retention of urine

Question 42

In a patient with absent ankle jerk and upgoing plantars what should you suspect?

Answer 42

B12 dieficiency should be investigated