neurology conference

8/14/2019 Neurology Conference

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Neurology Conference

Introduction to Spinal Cord Diseases

Danish Ejaz Bhatti


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SPINAL CORD TRACTS


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Gross Anatomy


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White Matter Tracts


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Sensory Pathway


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Gray Matter


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Spino-thalamaic Tract


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Dorsal Coulmn


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Sensory Tracts


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CorticoSpinal Tract


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LOCALIZING THE LESION


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Localizing the Lesion

Types of Symptoms:

Motor

Sensory

Autonomic


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Localizing the Lesion

UMN

No wasting

Tone Increased

Fasciculations

absent

Reflexes increased

Abdominal reflexesabsent

Plantar reflex -

extensor

LMN

Muscle wasting

Decreased tone

Fasciculations

Diminished reflexes

or absent

Abdominal reflexusually present

Plantar reflex -

flexor


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Babinski Sign

Joseph Babinski polish born French Neurologist described babinski sign

in 1896


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Grading of Reflex

0 - no movement at all

1 - visible muscle contraction but no joint

movement

2 - movement at the adjacent joint

3 - movement at distant joint

4 - clonus


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Grading of Motor Stregnth

0/5

1/5

2/5 3/5

4/5

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Categories of symptoms/signs

Radicular Symptoms

Segmental Symptoms

Motor

Sensory

Reflexes

Autonomic


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Diseases of the spinal Cord


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Non-traumatic diseases of Spinal Cord

Inflammatory Diseases

Infectious Diseases

Vascular Diseases

Toxic/Metabolic Diseases

Neoplasms

Inherited De-generative Diseases Others


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Inflammatory Diseases

Transverse Myelitis

Sarcoidosis

Para-neoplastic Syndromes


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Transverse Myelitis

Inflammation of spinal cord

Acute to sub-acute onset

Presentation

Motor

Sensory

Autonomic


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Disease Association of Transverse Myelitis

Para-infectious/Post infectious

Post-vaccination (rabies, cowpox) ADEM

Systemic autoimmune disease

Systemic lupus erythematosis

Sjogren's syndrome

Sarcoidosis

Multiple Sclerosis (Devic's Disease)

Para-neoplastic syndrome

Vascular

Thrombosis of spinal arteries

Vasculitis secondary to heroin abuse

Spinal arterio-venous malformation


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Transverse Myelitis


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Transverse Myelitis

CSF Exam

Elevated protein and mod lymphocytosis

Oligo-clonal bands

Recovery

1-3 months, absent to complete

IV Steroids http://www.myelitis.org/local/md/index.htm


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Para-neoplastic Syndromes

Motor Neuron Syndrome

Acute Necrotizing Myelopathy

Sub-acute Sensory Neuronopathy

Encephalomyelitis


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Sarcoidosis

Extra-medullary and Intra-medullary MRI and CSF

Calcium and ACE and CXR

Steroids

http://www.connotea.org/add?uri=http://www.nature.com/sc/journal/v44/n1/full/3101782a.html


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Infections

Epidural abscess

Acute Viral Myelitis

AIDS Myelopathy

HTLV-1 Myelopathy

Syphilis

Tuberculosis Schistosomiasis

Others


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Spinal Epidural Abcess


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Spread Contagious vs blood stream

Clinical Triad

Fever

Spinal Pain

Neurological Deficit

Staphylococcal Aureus

MRI

Surgery with Abx

http://www.aafp.org/afp/20020401/1341.html


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Acute Viral Myelitis

Two distinct syndrome Gray matter lesion of spinal cord

Enteroviruses: Polio, Coxsackie, Enterovirus 71

Flavivirus: West Nile, Japanese Encephilitis

Differentiating from Guillain Barre

Asymmetric involvement

MRI

CSF

Transverse Myelitis like syndrome

CMV, VZV, HSV, HCV, EBV

Antiviral agents & Steroids


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AIDS Myelopathy

Presentation:

Motor: Slowly progressive spastic

paraperesis Sensory: Loss of vibration and position

Autonomic: Urinary frequency and

incontinence Late stages of AIDS with death in 6

months

MRI : normal


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AIDS Myelopathy

Vacoular myelopathy of dorsal columnand dorsal half of lateral column - Similarto SACD (lipid loaded macrophages)


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HTLV-1 Myelopathy

Carribean, southern Japan, South america Tropical Spastic Paresis (TSP)

Primarily thoracic cord

Relative sparing of the dorsal column

MRI: atrophy

Anti HTLV-1 antibodies


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HTLV-1 Myelopathy


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Syphilis

Tabes Dorsalis Dorsal column and dorsal nerve root

Ataxia with lancinating pain

Westphals sign absent knee jerk in tabes dorsalis


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Tuberculosis

Tubercular spondylitis(Potts Disease)

Cord Compression


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Tuberculosis

Tuberculomas

hi i i


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Schistosomiasis

S mansoni and S hematobium

Rapidly progressing Transverse Myelitis

Most commonly lower thoracic cord

Glucocorticoids & Praziquental

http://www.uiowa.edu/~c064s01/nr390.htm

O h


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Others

Lyme disease Rarely involve spinal cord similar toTransverse Myelitis

Bacterial meningitis Epidural abcess

Vasculitic infarction

myeltitis

T i /M b li Di


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Toxic/Metabolic Diseases

Sub-acute Combined Degeneration

Radiation Myelopathy

Electrical Injury

Hepatic Myelopathy

Decompression Sickness Myelopathy

Lathyrism and Konzo

S b C bi d D i f C d


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Sub acute Combined Degeneration of Cord

Vitamin B12 deficiency - Lichtheim's disease

Dorsal and lateral white matter of spinal cord

S b C bi d D i f C d


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Sub acute Combined Degeneration of Cord

May not have anemia & macrocytosis Nitrous Oxide abuse

Copper deficiency

Parenteral feeding, excessive zinc ingestion


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R di ti M th


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Radiation Myeopathy

Transient Myelopathy 2-6 months

Late progressive myelopathy

6-12 months

Electrical Inj r


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Electrical Injury

Keraunoparalysis transient flaccid paralysis 24 hours

Lightening strike

Other late myelopathies

Other metabolic myelopathies


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Other metabolic myelopathies

Hepatic Myelopathy Demyelination of lateralcorticospinal tract

Liver transplant

Decompression sicknessmyelopathy

Thoracic cord Multi focal white matter

degeneration in posterior andlateral columns

Lathyrism Grass or chickling pea

Demyelination in corticospinaland spinocerebellar tracts

Konzo Acute spastic paresis

Bitter cassava cyanogeniccompounds

Vascular Diseases


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Vascular Diseases

Spinal Cord Infarction Vascular Malformations

Spinal Cord Infarction


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Pathologies: Aortic dissection, surgery on abdominal

artery

Severe systemic hypotension Mid thoracic cord

Anterior spinal artery territory

MRI: normal or T2 changes of ischemia

Infarction of adjacent vertebrae

Vascular malformation


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Dural AV Fistula- Found on dural surface and drain intradurally



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Intramedullary spinalAV malformations

Present in mid 20 or

earlier

Mass effect of lesion,

ischemia or hemorrhage

MRI and MRA

Inherited De-generative Diseases


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Inherited De-generative Diseases

Amyotrophic Lateral Sclerosis Hereditary Spastic Paraplegias

Adrenoleukodystrophy

Friedreich Ataxia

Amyotrophic Lateral sclerosis


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Amyotrophic Lateral sclerosis

Motor: mixed upper and lower

Sensory: none to some numbness

MRI: normal

Electromyography

Familial form: autosomal

recessive D90A mutation

Primary lateral sclerosis

Riluzole

Hereditary Spastic Paraplegia


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Hereditary Spastic Paraplegia

Degeneration of corticospinal tract >28 genetic loci

Usually autosomal dominant

Slowly progressive spastic paraparesis

Gait disturbance and urine incontinence

Friedreich Ataxia


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Friedreich Ataxia

Autosomal recessive Dorsal column, spinocerebellar tracts & sensory cells of

dorsal root ganglia

Sparing of spino-thalamic

Cardiomyopathy & Diabetes

Syringomyelia


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Syringomyelia

Fluid filled and gliosis linedcavity

C2-T9

Dilation of spinal canal or

separate pocket

Associations:

Arnold Chiari malformation I

Post infectious

Post inflammatory

Neoplasms

Post traumatic


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