Chronic Spinal Cord Injury (Lesi Medula Spinalis Khronis)Darwin AmirBgn Ilmu Penyakit SarafFakultas Kedokteran Universitas AndalasThe Spinal CordCervical spinal ervesThoracic spinal nervesLumbar spinal nervesSacral spinal nervesConus medullarisCauda equinaPR!"KSI #"RM$TM #IP"RM%K$$& K%LIT$scendin' Spinal Cord Trac()s( order neuron - cutaneous receptors of skin and proprioceptors spinal cord or rain stem*nd order neuron - to t!alamus or cereellum+rd order neuron - to somatosensory corte" of cererum#onducts sensory impulses upward t!roug! $ successive c!ains of neurons$scendin' Spinal Cord Trac(The Spinal Cord The Spinal Cordspinal cordspinal nerveverteraCross Sec(ion o, Spinal Cord%!ite matter&'yelinated a"ons forming nerve tractsFissure and sulcus(!ree columns&) *entral ) Dorsal) +ateral,ray matter&-euron cell cell odies. dendrites. a"ons/0orns1&) Posterior 2dorsal3) Anterior 2ventral3) +ateral#ommissures&) ,ray& #entral canal ) %!ite2see later for w!ite matter pat!ways3The &ervous Sys(em(!e Spinal #ord-part of t!e #-S found wit!in t!e Spinal column (!e spinal cord communicates wit! t!e sense organs and muscles elow t!e level of t!e !eadBell-'agendie +aw-t!e entering dorsal roots carry sensory information and t!e e"iting ventral roots carry motor information to t!e muscles and ,landsDorsal 4oot ,anglia-clusters of neurons outside t!e spinal cordNerve Pathways into the Spinal Cord Nerve Pathways into the Spinal Cordsensory pat!waymotor pat!waySoma(ic Sensory Pa(h-ayCRTICSPI&$L TR$CTSSymp(oms and Si'ns'ust e mastering in mindStart y understanding anatomy and p!ysiology of t!e -ervous SystemDon1s forget t!e of #-S systematically- Anatomy of #-S- P!ysiology of #-S- Pat!op!ysiology of t!e Disease- (!e steps to make t!e diagnosisSensory dis(urbances5 Soft touc!. pain. temperature. position. viration impaired elow t!e level of lesion5 Band like radicular pain6segmental paraest!esia at t!e level of lesion5 localised verteral spine pain- destructive lesionsMo(or dis(urbances5 Paraplegia67uadriplegia5 Acute-flaccid 6 Arefle"ic-spinal s!ock latter-!ypertonic 6 !yper refle"ic. loss of superficial refle"es. Bainski 8. fle"or6e"tensor spasm5 9"tension of !ip. knee occurs in !ig! spinal : Incomplete lesion; Fle"ion of !ip . knee occur in low spinal : complete lesion; At t!e level of lesion < paresis. atrop!y. fasciculations.and arefle"ia2+'- signs3 in a segmental distriution ecause of damage to t!e anterior !orn cells and ventral rootsMo(or dis(urbances$u(ononomic dis(urbancesinitially atonic. latter spastic ladder. rectal sp!incter disturancesort!ostatic !ypotensiontrop!ic skin c!angesan!ydrosisimpaired temperature controlvasomotor instailityse"ual disturancesI6+ !orner syndromeCauses o, Chronic Lesion= (umour = 'ultiple sclerosis= *ascular disorders= Spinal epidural !ematoma6ascess= Auto immune disease = 0erniated interverteral disc= #omine degeneration of B>? Deficiences Comple(e spinal cord (ransec(ion(Transverse myelopa(hy)Comple(e spinal cord (ransec(ion(Transverse myelopa(hy)All acsending tracts from elow t!e level of t!e lesion and all descending tract from aove t!e level of lesion interrupted@ 'otor. sensory. autonomic functions elow t!e level of lesion distured#auses & = tumour= multiple sclerosis = vascular disorders= spinal epidural !ematoma6 = spinal epidural ascess = !erniated interverteral disc = auto immune diseaseCen(ral spinal cord lesionSpinal cord damage starts centrally and spreads centrifugallyDecussating fiersof spinot!alamic tract involved initially(!ermo anaest!esia. analgesia in a Avest likeA or BsuspendedA ilateral distriution wit! preservation soft touc! sensation and proprioception--- dissociation of sensory lossCen(ral spinal cord lesionForward e"tension of disease anterior !orn cells involved segmental neurogenic atrop!y. paresis. arefle"ia+ateral e"tension I6+ 0orner syndrome Kyp!o scoliosis Spastic paralysisDorsal e"tension I6+ Position sense. viratory lossCen(ral spinal cord lesion9"treme venterolateral e"tensiont!ermo anaest!esia. analgesia wit! sacral sparing-europat!ic art!ropat!yPain Pos(erior column diseasePos(erior column disease(aes dorsalis-taetic neuro syp!ilis. progressive locomotor ata"iaImpaired viration and position sense. and decreased tactile localisation+aility of mec!anical sensation t!res!old. tactile : postural !allucinations. persistence of mec!ano receptor sensation. disturances in t!e knowledge of e"tremity movement and positions 2temporal : spatial disturances3Sensory ata"ia in dark. 4omerg 283Ata"ic 6 stomping6 doule tapping gaitPositive sink signIn taes dorsalis lancinating pain. urinary incontinence. -egative patellar and ankle D(4. !ypotonic lim. !yper e"tensile Coints adominal. laryngeal crises. impaired lig!t touc! perception. Argyll roertson pupil. optic atrop!y. ptosis. op!t!almoplegiaPos(erior column disease +!ermitte sign or arer c!air syndrome due to increased mec!ano sensitivity (runcal and gait ata"ia & also seen in mets causing cord compression Impaired conduction in dorsal spino cere -ellar tract may e a primar manifestation of epidural spinal cord compression-lower e"tremity dysmetria and gait ata"ia@ Pt usually !ave t!oracic spine compression due to selective vulneraility of spinocere ellar tract in t!oracic spine to compres -sive isc!emiaPos(erior column disease.emisec(ion o, (he spinal cord( /ro-n sequard syndrome).emisec(ion o, (he spinal cord( /ro-n sequard syndrome)+oss of pain. temp #6+ to t!e !emisection- interruption of crossed spino t!alamic tract+oss of proprioception < interruption of ascending fiers of posterior columnSpastic weakness due to interruption of descending cortico spinal tractSegmental +'- signs and sensory c!anges at t!e level of lesion due to damage of t!e roots and anterior!orn cells at t!e level of lesionI&&"R0$TI& 1 $%T&MIC &"R0%SS!ST"MThan2 you /rain1or all you remember%!at you forgot was my fault