The Spinal - Cord

dr. Budhi Suwarma, SpS

FK UNJANI

The Spinal - Cord

Elongated cylindrical mass of nerve tissue

42-45 cm length (adult) Superior border of CI to upper border

L II Conus medullaris conical end of

spinal cord Cervical enlargement C III – Th II Lumbar enlargement Th IX – Th XII

Ending of Spinal - Cord

0-3rd month of fetal life = S V 5th month of fetal life = S I At the time of birth = L III Adult = L I

Divisions of the Spinal Cord

Anterior median fissure Posterior median sulcus Column / funiculi Fasciculus gracilis Gol Fasciculus cuneatus Burdach Central canal Anterior- , lateral- , posterior horn

Segments of the Spinal Cord

Segments Vertebras

Cervical 8 7

Thoracal 12 12

Lumbal 5 5

Sacral 5 5

Coccigeus - 4

Anatomic Relationships of spinal cord and bony spine (adult)

Cord segments

Vertebra bodies

Spinous processes

C8 C VI – VII C VI

Th 6 Th III – IV Th III

Th 12 Th IX Th VIII

L5 Th XI Th X

S Th XII – LI Th XII - LI

Ascending and Descending tracts of the Spinal Cord

Ascending Tracts

Anterior Column

Lateral Column Posterior Column

Ventral spinothalamic (light touch)Spino-olivary (reflex proprioception)

Dorsal & ventral spinocerebellar (rfl. proprioception)Lateral spinothalamic (pain and temperature)Spinotectal (reflex)

Fasciculus gracilis and fasciculus cuneatus (vibration, passive motion, joint and 2-point discrimination)

Descending Tracts

Anterior Column Lateral Column Posterior Column

•Ventral corticospinal (voluntary motion)•Vestibulospinal (balance rfl)•Tectospinal (audiovisual rfl)•Reticulospinal (muscle tone)

•Lateral corticospinal (voluntary motion)•Rubrospinal (muscle tone and synergy)•Olivospinal (reflex)

•Fasciculus interfascicularis & septomarginal fasciculus (association & integration)

Pain and Temperature pathway

• Axons of primary neuron synapse on secondary neurons at dorsal horn nuclei the level of entry

• Secondary axons cross midline near central -canal and run upward via lateral spinothalamic tract (spinal lemniscus) to the ncl VP thalamus tertiary neuron (thalamocortical) cortex

• Axon from face first descend through the brainstem to reach the secondary neuroncross midlinerun upward via trigeminal lemniscus to the ncl ventralis posterior (VP) thalamus

Propriception pathway

• Primary axons ascending in the dorsal columns (leg/fasciculus gracilis/Gol;arm/ fasciculus cuneatus/Burdach)

• Secondary neuron at the medullocervical dorsal column nucleicross the midline run upward via medial lemniscus termin ates ncl ventralis posterior (VP) thalamus cortex post central

Touch pathway

• One pathway through the dorsal column at the medullocervicalsecondary neuron cross the midline runs upward via medial lemniscus terminates in ncl VP thalamus

• Second pathway ,primary neuron synapse with secondary neuron cross the midline and then runs upward via ventral column (ventral spinothalamic) VP thalamus

Spinal Cord Circulation

Anterior Spinal Artery(ASA),formed by the union of VA narrowing at Th4

Lateral spinal arteries, branches from VA via intervertebral foramens low C and upper Th supply C7-Th2

Anterior medial spinal artery,prolonga tion of ASA

Spinal Cord Circulation (cont)

Intercostal aa from the aorta supply segmental branches to the cord. The largest/the great ventral radicular a/ radicularis magna/Adamkiewicz supply lower half cord

Posterior spinal a./posterolateral spinal

Syndrome Of The Spinal Cord Disorders

1. Transverse sensory motor myelopathy

2. Combined painful radicular and transverse cord syndrome (myeloradiculopathy)

3. Hemicord syndrome (Brown – Sequard)

4. Ventral cord syndrome (ASA)

5. Foramen magnum syndrome

6. Central cord syndrome (Syringomyelic)

7. Conus medullaris syndrome

8. Cauda equina syndrome

Syndrome Of The Spinal Cord Disorders (cont.)

e.g. Brown – Sequard syndrome Caused by hemisection of the

spinal cord ( tumor, traumatic, compression fracture )

Below the lesion Ipsilateral loss proprioceptive & ataxia Contralateral loss of exteroceptive Ipsilateral motor paralysis

Syndrome Of The Spinal Cord Disorders (cont.)

Transverse lesion of the spinal cord

motor, sensory, vegetatif, disturbances

below the lesion Intramedullary lesion of the spinal cord

e.g. > Syringomyelia (central cord ) loss of exteroceptive, but retains proprioceptive

in the affected parts( dissociated anesthesia ) Caused by gliosis around the central canal of

the spinal cord

Syndrome Of The Spinal Cord Disorders (cont.)

Conus syndrome (tumor,fract LI,etc) Saddle anesthesia Motoric intact Vegetative disturbance

Cauda syndrome(HNP,tumor,stenosis) Asymmetrical motor and sensory disturb. Vegetative disturbance ±

Syndrome Of The Spinal Cord Disorders (cont.)

Foramen magnum syndrome : Quadriparesis : around the clock pattern Headback pain,stiff neck Weakness & atrophy hands,dorsal neck Variable sensory changes Cerebellar and lower CN involvement

Neoplasm

Less frequent than brain (l5%),mostly benign,compression effect

Intramedullary (5%):lesion within cord

Extramedullary : lesion outside cord Intradural (40%) / Extra Dural (55%)

Neoplasm (Cont.)

Primary extramedullary are neurofibro- ma and meningioma (55%) ; others : sarcoma,vascular tumor,chordoma

Primary intramedullary are ependymo ma (60%),astrocytoma(25%),oligoden- droglyoma

Secondary are extradural metastasis lymphoma,Ca vertebra,Ca paraspinal

Neoplasm (Cont.)

Extramedullar Intramedullar

Pain Radicular Not characteristic

Sensibility Brown Sequard

Dissosiation of sensibility

Localization Unilateral bilateral

Examination

X-ray Vertebrae Myelografi / CTMM MRI

Trauma to The Spine and Spinal Cord

Fracture – dislocations (3)Pure fractures (1)Pure dislocations (1)

Vertebral injury C I-II, C IV-VI, Th XI-LIISatisfactorily demonstrated by CT, MRI, lateral spine X-ray

Tearing of ligaments can only inferred from the spinal displacement

Whiplash / recoil injuryExtremes of extension / flexion of the neck

Other Spinal Cord Injury

Bullet / missile Sharpnel Stab wound Spinal cord concussion

Pathology In Most Traumatic Lesions

Central part of the spinal cord with its

vascular gray matter suffers greater than

the peripheral parts

( Central cervical cord syndrome ) /

Schneider syndrome

Clinical Stage Of Spinal Cord Injury

1. Stage of spinal shock / areflexia

2. Stage of heightened reflex activity

The separation of these two stages is not

as sharp as this statement

Less complete lesion / slowly develops lesion

may result in little or no spinal shock

American Spinal Injury Association (Asia ~ Frankel Scale)

1. Complete : Motor and sensory below the lesion

2. Incomplete : Some sensory preservation below the lesion

3. Incomplete : Motor and sensory sparing, but the patient is non – functional

4. Incomplete : idem and the patient is functional (stands & walks)

5. Complete functional recovery,even reflexes may be abnormal

Inflammatory Disease Of The Spinal Cord

1. Viral myelitis (enterovirus,herpes zos ter,EBV,CMV,HSV1-2,Rabies,HTLV-1 ,AIDS,Varicella zoster)

2. Bacterial, fungal, parasitic,granuloma (TBC,abscess,lues)

3. Non infectious inflammatory type (post infectious,post vaccination,MS, lupus,paraneoplastic)

AIDS vacuolar myelopathy

1. Incidence ¼ AIDS cases

2. Symptoms and signs are obscured by neuropathy/cerebral disorders

3. Mono/hemi/asymetrical parese sen sory and sphincter disordersdeath

4. Posterior and lateral white matter resemble Subacute Combined Deg.

HTLV-1 Tropical spastic paraparesis

Slowly progressive UMN paraparesis CSF cell 10-50/mm3 lymphocyte T,

glucose and protein normal Serum : antibody HTLV-1 + MRI : thinning of the Spinal cord Neuropathology : posterior collum and

corticospinal tract are the main sites

Myelitis e.c. bacterial, fungal, parasitic and granulomatous dis.

Leptomeningitis,pachymeningitis,abscess/granuloma epidural

Pial a./v.thrombosedmyelomalacia

Progressive constrictive pial fibrosis Arachnoiditis

Spinal Epidural Abscess

Fever,pain at the back radicular pain. Spine percussion tenderness

Headache and Nuchal rigidity ± After several dtransverse cord lesion CSF cell < 100/mm3 (except needle pe

netrates the abscess pus),protein 100-400 mg%,glucose normal

Tuberculous (TBC) Myelitis

TBC Spine Osteitis with kyphosis (Pott’s dis)pus/caseous granulation tissueepidural compression of the cordparaplegi

TBC meningitispial arteritisspinal cord infection

Post Infectious and Post Vaccinal myelitides

Temporal relationship to viral infection/ vaccination

Asymmetric weakness and numbness Sphinteric disturbance and backache CSF mononuclear 10-100/mm3, gluco

sa normal, protein slightly raised MRI : swollen cord

Paraneoplastic Myelitis

Bronchogenic Ca,Visceral lymphoma Rapid progression long tracts signs CSF : few mononuclear,protein slight

increase No evidence of an infective-inflammato

ry/ischemic lesion No tumor cells in CSF,meningen,cord

Vascular disease Of The Spinal Cord

Infarction (myelomalacia)ASA syndr. Hemorrhage into the cord/spinal canal Vascular malformation Uncommon (1,2% compare to brain) Spinal a.not susceptible to atheroscle

rosis and emboli rarely lodge there Watershed-borderzone infarction

ASA syndrome

Sudden onset of paraparese Bilateral loss of sensory Dorsal collum intact

Hematomyeli (cord) and Hematorrhachis (spinal canal)

Hematomyeli is rare compared to ICH e.c.trauma,AVM,bleeding disease,AC)

Epidural/subdural hemorrhagecom pressive myelopathy immediate radi ologic studysurgical evacuation

Advances in the techniques of selectiv spinal angiography and microsurgery

Vascular Malformation

Venous angioma, dorsal surface lower half cord,middle age/elderly,nevus, series episodes cramplike,lancinating sciatica,worse in recumbency weak ness one/both legs

Arteriovenous angioma,dorsal surface Th and upper L or anterior C,young, slow cord compression

Nutritional Deficiency

Subacute combined degeneration Degeneration of the posterior & lateral

column Loss of proprioceptive Tetraparalysis In the advanced cases of pernicious

anemia ( vit. B12 deficiency )

Demyelinisasi : Multiple Sclerosis

Episodes of focal disorder of 2nd CN, spinal cord and brain which remit and recur over a period of many years

Long perod of latencydelay the D/ Prevalence 1/100.000 equatorial areas Diagnosa :CSF cell < 50,protein ↑,oligo

clonal IgG,evoked potential,MRI

Other Myelopathy (Primary/Secondary)

Amyotropic Lateral Sclerosis (ALS) Progressive Muscular Atrophy (PMA) Syringomyelia Cervical Spondylosis HNP

Amyotrophic Lateral Sclerosis

Incidence 0,4-1,76/100.000 population, men>women,>50 yrs old

Triad : atrophic weakness hands&fore- arms,slight spasticity arms&legs,gene- ralized hyperreflexia,absence of senso ry change

Progressive Muscular Atrophy

men>women,mostly symmetrical wasting intrinsic hand musclesmore proximal arms

Progress slower than ALS Tendon reflex ↓ or -,signs of UMN -

Progressive Bulbar Palsy

Weakness jaw,face,tongue,phraynx and larynx,difficult to pronounce r,n,l,b,m,p,f,d,t,k,g.

Bulber palsy,lower face weaken-sag, fasciculation and atrophy of tongue, bulldog reflex,pathologic laughter and crying respiratory muscles weakness

Syringomyelia

Chronic progressive degenerative cavi tation of central cord usually at C, in severe cases extending up/downward

90% associated with type I Chiari malf. Segmental weakness&atrophy hand-

arm,tendon reflex-,dissociation pain- touch sensation

Syringobulbi : face,tongue,palatum

Cervical Spondylosis

40% beyond 50 yrs,75% showed radio logic abn of C canal, painful stiff neck

Pain at the back of neck + brachialgia/ radiculopathy C, Lhermitte’s sign

Compressive myelopathy Paraparesis UMN Unsteady gait (sensory ataxia) Altered sphincter control

Hernia Nucleus Pulposus

Fraying of the annulus fibrosusextru sion of disc material (# bulging)

CVI-VII(7th C-70%),CV-VI(6th C-20%), CIV-V(5th C-5%),CVII-ThI(8th C-5%)

LV-SI(1st S)LIV-VLIII-IV NCV,H reflex,X-ray photo,MRI

HNP Lumbar

3rd-4th decade,flexion injury, trauma ? Degeneration NP,ligamentum,annulus Radiating pain,unnatural spine posture

paresthesia,weakness,tendon reflex ↓, pain over facet joint and Valleix points, limited Laseque,Bragard,Neri,Naffziger and Contra Laseque.

Failed-Back Syndrome

Have had a disc removed but still have back and leg pain (10% re-operate)

Overlooked : lateral protrusion,intradu ral herniation,extrusion original site/ another level,foraminal stenosis,facet hypertrophy,spinal stenosis,arachnoid it is,epidural scarring

HNP Cervical

Neck ROM ↓,pain ↑ with hyperextens ion,coughing,sneezing,flexion

7th C root:pain shoulder blade,pectoral, medial axilla,posterolateral upper arm, elbow,dors fore arm,index-midle finger

6th C root:pain trapezius ridge,tip shoul der,anterior upper arm,radial fore arm, thumb

SELESAI