Spinal cord lesion 2 د.رشاد عبدالغني

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Degenerative disease of the spine

Pathophysiology: With increasing age the water content of the nucleus pulposus falls and splits appear in the

surrounding annulus fibrosus. If the split is located

posteriorly, elements of the nucleus pulposus can then

herniate through the split into the spinal canal.

Spinal cord lesion



A congenital weakness of the annulus may predispose

to these changes. At the same time, degenerative

changes, including the appearance of osteophytes,develop on the apophyseal joints.



The symptoms associated with degenerative disease of

the spine are therefore the consequence either of

protrusion of the annulus or the disc, or narrowing

either of an intervertebral foramen or the spinal canal

by osteophyte formation.



Posterior protrusion of the annulus fibrosus or a

herniated nucleus pulposus results in cord compression

at the cervical level, but compression of the cauda

equina in the lumbar region. Posterolateral protrusion of the annulus or a noncalcified (soft) disc, or

osteophytosis or vertebral body, can all produce

compression of the nerve root within the intervertebral

foramen, more commonly in the cervical than in the

lumbar region.



Cervical spondylosis

Degenerative disease in the cervical spine occurs most

often at the C5/6 and C6/7 levels.

Cervical radiculopathy

Typically, patients give a history of neck pain

accompanied by pain radiating to the scapula, the shoulder

or the arm itself. Sensory symptoms, whetherparaesthesiae or numbness, serve to localise the affected

nerve root. Clinical examination reveals restricted neck

movement.



Localization of the

involved root

Sensory symptoms



The distribution of muscle

weakness follows the

pattern of innervation of the affected root.

Localization of the root

involved is aided by

examination of thereflexes.



C5-6 disc protrusion

C6-7 disc protrusion





Cervical myelopathy

Cervical spondylomyelopathy is most often the result

of a disease process at the C5/6 or C6/7 disc space,though multiple level compression is common.



The clinical features are dependent on the level of

compression. Above C5 there will be a spastic

tetraparesis, below this level a combination of

radicular features (weakness, atrophy, pain andnumbness) in the upper limbs with pyramidal signs

(spasticity and exaggerated reflexes) in the lower

limbs, accompanied in some instances by long tract

sensory signs. Bladder function remains relatively

spared.

I i i



Oblique views of the cervical spine are essential to

demonstrate protrusion into the intervertebral foramen of

osteophytes.

Investigation

Plain X-rays



The evaluation of cervical myelopathy in CT myelography can demonstrate the degree of cord deformity.

Neuro-imaging



MRI is the best technique

for evaluating spondylotic

myelopathy, provides an

accurate display of the

relationship between

vertebral body, disc and

spinal cord.



Electrophysiological investigation can provide

confirmatory evidence of either root or cord

involvement.



Management

Most cervical root syndromes are managed by acombination of cervical immobilization, using an

appropriately fitting firm collar together with

analgesics. Occasionally, surgical decompression of

the affected root is necessary, and is usually successfulin producing pain relief. In the presence of a

progressive myelopathy, surgery is generally

recommended.



Thoracic disc disease

Thoracic disc disease is rare and often confused with

benign tumours. It predominates in the lower thoracic

region and is more likely to affect males than females.

The condition may simply present as a slowly progressive

spastic paraplegia but many patients complain of exercise

induced symptoms, either sensory, motor or both.



Disc calcification is found in perhaps half the cases. The

disc protrusion and calcification are best identified using CT

myelography or MRI.



Treatment is surgical, though the complication rate is

relatively high.



Lumbosacral disc disease

Degenerative disease of the lumbar spine involves the

lower two levels in over 90 per cent of cases.Posterolateral, lateral and central patterns of protrusion

are described. Pain is a prominent feature.



Posterolateral disc protrusion

Pain is a prominent feature in lumbar disc disease and

can be referred to the buttock and upper thigh in theabsence of root involvement. Areas commonly

affected by pain include the lower lumbar spine, in or

around the midline and the medial aspect of the

buttock. There may be local tenderness in these areas.



Radicular pain may be accompanied by back pain or can

appear, at least initially, in isolation. Typically,

radicular pain is exacerbated by straining. Pain

extending from the back to the anterior thigh suggests

involvement of an upper lumbar root. Medial calf pain

suggest L5 and lateral calf pain suggest S1, root

compression. Sensory symptoms are common andgenerally segmental.



Examination includes an assessment of the spine, a

search for signs indicating nerve root irritation and

finally an evaluation of any motor, sensory or reflex change relevant to the particular root. The back is

examined for areas of local tenderness and any

alteration of the normal lumbar lordosis or paravertebral

spasm.



Stretch tests

Straight-leg raising is performed by gently elevatingthe outstretched leg from the horizontal with the

patient lying supine. It indicates an irritation of a root

at or below L5 level

The femoral stretch test is performed by extending the

hip with the patient lying on one side. A positive test

suggests an irritation of the roots of L2,3 or 4.



Focal signs

Focal signs are

dependent on thedistribution of the

affected nerve root.

With L4 compression

there is weakness of

quadriceps and tibialis

anterior, with sensory

change over the medialaspect of the shin and

depression of the knee

jerk



Central disc protrusion



Central disc protrusion Following a central disc protrusion, which can occur without

an antecedent history of back pain, cauda equina compression

occurs, often in an abrupt fashion.Severe pain results, with

paravertebral localization or

with radiation into both lower limbs..



Typically, there is severe distal

lower limb weakness with foot

drop, depression of the ankle

reflexes and impaired sphincter

function. Saddle anaesthesia is

common.



Investigation of lumbosacral disc disease

Plain X-rays

Plain X-rays are of very limited value in the investigationof a lumbar radiculopathy.



Plain CT

High-resolution CT,

without contrast, hadbeen previously

recommended as the

initial investigationfor the evaluation of

lumbar disc disease &

lumbar canal stenosis.



CT myelography

CT myelography

achieves a 60-80 per cent

accuracy in the diagnosis

of herniated lumbar disc.



MRI

MRI is now the

screening technique of choice for the accurate

definition of lumbar disc

herniation.



Spinal stenosis

Though in many

patients spinal stenosis

is congenital, in others

it is secondary to

hypertrophy of the bony

elements of the lumbar

canal, ligamental

hypertrophy or disc

degeneration.



Canal stenosis usually affects middle-aged men.

Typically, (Intermittent neurogenic claudication)

paroxysmal numbness or paraesthesiae, rather than pain,

appear in the lower limbs during walking and

sometimes in certain standing postures. The symptoms

often march from the distal parts of the extremities to

the proximal.



High-resolution CT is the

investigation of choice,

allowing definition both of the central canal and of the

lateral recess.



Spinal or foraminal stenosis is managed surgically

if the symptoms are disabling. Lumbar disc

prolapse, if central, is managed by immediatesurgery. Posterolateral disc prolapse is managed

conservatively initially but by surgery if symptoms

fail to resolve with rest.

S i l d i f i



Spinal cord infections

Spinal epidural abscess

Haematogenous spread of infection is the usual

source of an epidural abscess, but in some cases the

condition is triggered by a spinal procedure which

can include epidural injection as well as opensurgery.



Typically, the infective process, which is

usually due to Staphylococcus aureus, beginsin the vertebral body before spreading to the

epidural space. The abscesses occur most

often in the lumbosacral region.



Clinical features

Back pain with evidence of a febrile illness thenRadicular pain followed by neurological deficit

include motor, sensory and sphincter disturbance.

An elevated ESR is usual.

CSF findings: an elevated white cell count

(polymorphonuclear leucocytes or lymphocytes) and

protein concentration but with a normal glucose

level.



Investigation

Plain radiographs mayestablish the presence of a

vertebral destructive

process but can be normal.



CT Myelography,

characteristicallyreveals a total or partial

block of the

subarachnoid space,

associated with cord

compression. Rarely,

MRI has been reported

as normal in thiscondition. .



Tuberculous disease of the spine

Tuberculous disease of the spine is usually secondary to

tuberculosis elsewhere in the body and concentrates in the

thoracolumbar region. Multiple vertebral involvement is the

rule. The disease usually commences in the vertebral body.

The vertebral interspace is relatively spared but becomesinvolved when the disease is extensive.



Eventually, passage

through or round the

anterior or posterior

longitudinal ligamentsleads to paraspinal

abscess formation.

Vertebral collapse with

kyphosis is an

additional mechanism

sometimes responsible

for spinal cord damage.

Clinical features



Clinical features

Initial features of the illness include fever, malaise

and weight loss. Subsequently, pain emerges,

associated with focal tenderness. A radicular element

to the pain is often prominent.



Tracking of the

abscess in the cervical

region can lead to a

neck swelling, while

from the

thoracolumbar region,

tracking along thepsoas sheath results

eventually in a mass in

the iliac fossa, pelvis

or groin.





Investigation

Blood tests are of limited value in diagnosis.

Plain X-rays are usually but not inevitably abnormal.



Typically, there is

erosion of the vertebral

bodies with disc spacenarrowing and, in the

later stages, shadowing

secondary to

paravertebral abscessformation.

L f k b d i i h b l ll



Later more frank bone destruction with vertebral collapse or

deformity become evident.



Plain CT is highly accurate in establishing the

diagnosis. With contrast, rim enhancement is seen in

any paravertebral collection.



The MRI revealed a

multiple vertebral

involvement withrelative preservation of

the intervening discs, a

picture liable to cause

confusion withmetastatic disease.



Treatment is with standard anti-tuberculous

therapy, combined, where there is neurological

involvement, with surgery. Laminectomy isrequired if the disease is affecting the posterior

neural arch. For anterior paravertebral masses an

anterior approach is usually undertaken.



Brucellosis

Brucella spondylitis

most frequentlyinvolves the lumbar

spine at the L4 level.

CT demonstrates

rounded defects inthe vertebral end

plates though

vertebral collapse is

rare.

Incidence is more common in veterinarians and those

who are in contact with milk products.



Brucella myelitis can occur in isolation or as part of a

meningo-encephalitic syndrome. In addition, cord

involvement may follow primary vertebral disease withor without extradural granuloma formation. Most

patients have evidence of systemic brucellosis. Back

pain is common, associated with a spastic paraparesis

or quadriparesis with sphincter involvement in some

cases. The sensory deficit is less conspicuous.

Pl i X f th



Plain X-rays of the

spine are often

normal. The

vertebral andextradural

manifestations are

more successfully

demonstrated by

MRI than CT.



Schistosomiasis

Spinal cord disease in patients with schistosomiasis is

usually due to infection by S. mansoni.



Granuloma formation most frequently involves conus

medullaris. Granuloma formation both within andoutside the cord have been described.

Expanded conus



The cauda equina can also be affected. Typically, a

transverse myelitis appears, sometimes acutely. The

CSF shows a raised protein concentration, alymphocytic pleocytosis and elevated antibody

levels. Treatment combines steroids with

antischistosomal drugs with surgery in some cases.

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Spinal cord lesion 2 د.رشاد عبدالغني