Chronic Spinal Cord Injury (Lesi Medula Spinalis Khronis) Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

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Chronic Spinal Cord Injury (Lesi Medula Spinalis Khronis) Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas Slide 2 The Spinal Cord Cervical spinal erves Thoracic spinal nerves Lumbar spinal nerves Sacral spinal nerves Conus medullaris Cauda equina Slide 3 PROYEKSI DERMATOM DIPERMUKAAN KULIT Slide 4 Ascending Spinal Cord Tract 1 st order neuron - cutaneous receptors of skin and proprioceptors spinal cord or brain stem 2 nd order neuron - to thalamus or cerebellum 3 rd order neuron - to somatosensory cortex of cerebrum Conducts sensory impulses upward through 3 successive chains of neurons Slide 5 Ascending Spinal Cord Tract Slide 6 The Spinal Cord spinal cord spinal nerve vertebra Slide 7 Slide 8 Cross Section of Spinal Cord White matter: Myelinated axons forming nerve tracts Fissure and sulcus Three columns: Ventral Dorsal Lateral Gray matter: Neuron cell cell bodies, dendrites, axons Horns: Posterior (dorsal) Anterior (ventral) Lateral Commissures: Gray: Central canal White (see later for white matter pathways) Slide 9 The Nervous System The Spinal Cord-part of the CNS found within the Spinal column The spinal cord communicates with the sense organs and muscles below the level of the head Bell-Magendie Law-the entering dorsal roots carry sensory information and the exiting ventral roots carry motor information to the muscles and Glands Dorsal Root Ganglia-clusters of neurons outside the spinal cord Slide 10 Nerve Pathways into the Spinal Cord sensory pathway motor pathway Slide 11 Somatic Sensory Pathway Slide 12 Slide 13 CORTICOSPINAL TRACTS Slide 14 Symptoms and Signs Must be mastering in mind Start by understanding anatomy and physiology of the Nervous System Dons forget the of CNS systematically - Anatomy of CNS - Physiology of CNS - Pathophysiology of the Disease - The steps to make the diagnosis Slide 15 Sensory disturbances S oft touch, pain, temperature, position, vibration impaired below the level of lesion Band like radicular pain/segmental paraesthesia at the level of lesion localised vertebral spine pain- destructive lesions Slide 16 Motor disturbances Paraplegia/quadriplegia Acute-flaccid / Areflexic-spinal shock latter-hypertonic / hyper reflexic, loss of superficial reflexes, Babinski +, flexor/extensor spasm Extension of hip, knee occurs in high spinal & Incomplete lesion Slide 17 Flexion of hip, knee occur in low spinal & complete lesion At the level of lesion paresis, atrophy, fasciculations,and areflexia(LMN signs) in a segmental distribution because of damage to the anterior horn cells and ventral roots Motor disturbances Slide 18 Autononomic disturbances initially atonic, latter spastic bladder, rectal sphincter disturbances orthostatic hypotension trophic skin changes anhydrosis impaired temperature control vasomotor instability sexual disturbances I/L horner syndrome Slide 19 Causes of Chronic Lesion Tumour Multiple sclerosis Vascular disorders Spinal epidural hematoma/abscess Auto immune disease Herniated intervertebral disc Combine degeneration of B 12 Deficiences Slide 20 Slide 21 Slide 22 Complete spinal cord transection (Transverse myelopathy) Slide 23 All acsending tracts from below the level of the lesion and all descending tract from above the level of lesion interrupted. Motor, sensory, autonomic functions below the level of lesion disturbed Causes : tumour multiple sclerosis vascular disorders spinal epidural hematoma/ spinal epidural abscess herniated intervertebral disc auto immune disease Slide 24 Slide 25 Central spinal cord lesion Spinal cord damage starts centrally and spreads centrifugally Decussating fibers of spinothalamic tract involved initially Thermo anaesthesia, analgesia in a vest like or suspended bilateral distribution with preservation soft touch sensation and proprioception-- - dissociation of sensory loss Slide 26 Central spinal cord lesion Forward extension of disease anterior horn cells involved segmental neurogenic atrophy, paresis, areflexia Lateral extension I/L Horner syndrome Kypho scoliosis Spastic paralysis Dorsal extension I/L Position sense, vibratory loss Slide 27 Central spinal cord lesion Extreme venterolateral extension thermo anaesthesia, analgesia with sacral sparing Neuropathic arthropathy Pain Slide 28 Slide 29 Slide 30 Posterior column disease Slide 31 Tabes dorsalis-tabetic neuro syphilis, progressive locomotor ataxia Impaired vibration and position sense, and decreased tactile localisation Lability of mechanical sensation threshold, tactile & postural hallucinations, persistence of mechano receptor sensation, disturbances in the knowledge of extremity movement and positions (temporal & spatial disturbances) Sensory ataxia in dark, Romberg (+) Slide 32 Ataxic / stomping/ double tapping gait Positive sink sign In tabes dorsalis lancinating pain, urinary incontinence, Negative patellar and ankle DTR, hypotonic limb, hyper extensible joints abdominal, laryngeal crises, impaired light touch perception, Argyll robertson pupil, optic atrophy, ptosis, ophthalmoplegia Posterior column disease Slide 33 Lhermitte sign or barber chair syndrome due to increased mechano sensitivity Truncal and gait ataxia : also seen in mets causing cord compression I mpaired conduction in dorsal spino cere - bellar tract may be a primar manifestation of epidural spinal cord compression-lower extremity dysmetria and gait ataxia. P t usually have thoracic spine compression due to selective vulnerability of spinocere bellar tract in thoracic spine to compres - sive ischemia Posterior column disease Slide 34 Slide 35 Hemisection of the spinal cord ( Brown sequard syndrome) Slide 36 Loss of pain, temp C/L to the hemisection- interruption of crossed spino thalamic tract Loss of proprioception interruption of ascending fibers of posterior column Spastic weakness due to interruption of descending cortico spinal tract Segmental LMN signs and sensory changes at the level of lesion due to damage of the roots and anterior horn cells at the level of lesion Slide 37 INNERVATION OF AUTONOMIC NERVOUS SYSTEM Slide 38 Slide 39 Slide 40 Slide 41 Slide 42 Slide 43 Slide 44 Slide 45 Slide 46 Slide 47 Slide 48 Slide 49 Thank you Brain For all you remember What you forgot was my fault