Spinal Cord lesions

1
Spinal Cord lesions

• Prepared by
• Saad Al-Qahtani.
• Presented by
• Bandar Al-Qahtani.
• Supervised by
• Dr.Esam Al-Jamal.

2
Anatomy

• Spinal cord lies within protective covering of
  vertebral column.
• Begins just below foramen magnum of the skull.
• Ends opposite 2nd lumbar vertebra.
• Below L2 continue as a leash of nerve roots known
  as cauda equina.
• Prolongation of the pia matter forms filum
  terminale.

3
Spinal cord structure
4
Spinal cord structure

• The spinal cord consists of central core of grey
  matter containing nerve cell bodies, and outer
  layer of white matter of nerve fibers.
• Within the grey matter, the dorsal horn contains
  sensory neurons, the ventral horn contains motor
  neurons and the lateral horn contains
  preganglionic sympathetic neurons.
• Within the white matter run ascending and
  descending nerve fiber tracts, which link the
  spinal cord to the brain.

5
Spinal cord structure

• The principle ascending tracts are the
  spinothalamic tracts, spinocerebellar tracts and
  dorsal columns. The coticospinal tracts is an
  important descending tract.
• The spinal cord receives information from, and
  controls the trunk and limbs.
• This is achieved through 31 pairs of spinal
  nerves which join the cord at intervals along its
  length and contain afferent and efferent nerve
  fibers connecting with the structures at the
  periphery.

6
Causes of spinal cord lesions

• congenital spinal stenosis.
• Infection TB ,abscess.
• Trauma vertebral body fracture or facet joint
  dislocation.
• Inflammatory Rheumatoid arthritis.
• Disc and vertebral lesion.
• Vascular epidural and subdural hemorrhage.
• Tumors.

7
Spinal stenosis

• 75 of cases of spinal stenosis occur in the low
  back ( lumbar spine).
• Causes
• - congenital.
• - degenerative.
• - trauma.

8
Congenital spinal stenosis

• The patient is born with a narrow spinal canal
  due to abnormally formed parts of the spine.
• This condition is most common in patients with a
  short stature, such as achondroplastic dwarves.

9
Other causes of spinal stenosis

• aging process (most common cause ).
• herniated discs. (fig)
• bone and joint enlargement.
• spondylolisthesis.
• bone spurs.

10
Rx Spinal Stenosis

• Initial Rx in most cases is conservative.
• Rest.
• Weight loss.
• Epidural steroid injections.
• Analgesia.
• Anti-inflammatory agents.
• Muscle relaxant -if needed-
• Physiotherapy.

11
Rx spinal stenosis

• Spine surgery
• used when conservative treatment failed.
• -laminectomy (removing bone behind the spinal
  cord).
• -foramenotomy (removing bone around the spinal
  nerve).
• -discectomy (removing the spinal disc to relieve
  pressure).
• Complications
• Dural tears.
• Infections.
• Instability of the spine.

12
Infection

• Epidural abscess
• Usually bacterial
• ( staphylococcus is common).
• Spread through
• hematogenous route.
• Adjacent focus.
• Direct inoculation.

13
Risk factor for epidural abscess

• immunodeficiency
• AIDS.
• Alcoholism.
• Chronic renal failure.
• Diabetes mellitus.
• Intravenous drug abuse.
• Malignancy.
• Spinal procedure or surgery.
• Spinal trauma.

14
Infection

• Infection of spine
• Uncommon
• Either vertebral osteomyelitis Or less commonly
  intraspinal infection.
• Causative organism
• (staph, Strep, E.coli, TB)
• Occasionally due to unusual organisms like
• Salmonella or brucella.

15
Rx spinal infections

• The goals of treatment are to relieve spinal cord
  compression and cure the infection.
• -drain abscess.
• -antibiotics or antimicrobial.
• -corticosteroid.
• -may need urgent surgical decompression by
  laminectomy.

16
Tumors

• Tumors are classified into 3 types according to
  their site
• -extradural ( between the meninges and spine
  bones)
• -intradural extramedullary (within meninges)
• -intramedullary ( inside the cord)

17
Spinal tumors

• Most spinal tumors are extradural about 85
• They may be primary tumors originating in the
  spine, or secondary tumors that are the result of
  the spread of cancer from other locations
  primarily the lung, breast, prostate, kidney, or
  thyroid gland.
• Any type of tumor may occur in the spine,
  including lymphoma, leukemic tumors, myeloma, and
  others. A small percentage of spinal tumors occur
  within the nerves of the spinal cord itself, most
  often consisting of ependymomas and other
  gliomas.

18
Symptoms of spinal tumors

• Pain (in 90 of patients), numbness or sensory
  changes, motor problems and loss of muscle
  control.
• Pain can feel as if it is coming from various
  parts of the body.
• Numbness or sensory changes can include decreased
  skin sensitivity to temperature and progressive
  numbness or a loss of sensation, particularly in
  the legs.
• Motor problems and loss of muscle control can
  include muscle weakness, spasticity (in which the
  muscles stay stiffly contracted), and impaired
  bladder and/or bowel control.

19
Spinal tumors

• 17 have Multiple level involvement.
• Metastatic lesion mostly found in Thoracic spine.
• Myelopathy develops over days to weeks.
• Acute SCC does occur if tumor enlarges very
  rapidly due to hemorrhage or if a vertebral body
  suddenly collapses.

20
Extradural tumors

• The most common spinal tumor 85
• mostly metastatic.
• Arise from osseous element of spinal column.
• Grow rapidly.
• Primary Lung, Breast, prostate and kidney.
• Compress the spinal cord by
• Growing in epidural space
• Causing collapse of vertebrae, distortion and
  narrowing.
• e.g. lymphoma, hemangioma and neuroblastoma.

21
Intradural extramedullary tumors

• Inside the dura but outside the spinal cord.
• e.g. Meningioma, Neurinoma.
• Arise from the dural sheath around the cord or
  showann cell sheath around the spinal root.
• Multiple tumors in Pt. with neurofibromatosis.
• Can grow extradurally into retropleural or
  retroperitoneal through intervertebral foramen.

22
Intradural intramedullary tumors

• Inside the spinal cord
• Examples Glioma, ependymoma, astrocytoma
• Arise from glial elements of spinal cord or
  trapped ectodermal elements.
• More common in children.
• Astrocytoma of spinal cord is the most common
  intramedullary tumor of childhood.
• Ependymoma of spinal cord is the most common
  intramedullary tumor of adulthood.
• Arise from ependyma of central canal.
• Well demarcated.

23
Investigations

• Plain X-rays.
• Myelography contrast material is injected into
  the thecal sac fluid surrounding the spinal cord
  and nerve root within the spinal canal
• CT.
• MRI ( study of choice ).

24
Rx spinal tumors

• The goal of treatment is to reduce or prevent
  nerve damage from compression of the spinal cord,
  relieve pain and maintain the function.
• - Surgical excision is the treatment for
  extramedullary tumors.
• - Radiation therapy for intramedullary tumors.
• The traditional treatment of intramedullary
  gliomas has been biopsy followed by radiation
  therapy.
• Radiotherapy is clearly of value in
  metastatic lesions.
• - Chemotherapy can be considered in patients with
  progression of disease after radiation therapy.

25
Spinal cord compression (SCC)

• The act of exerting an abnormal amount of
  pressure on the spinal cord.
• Causes and risk factors
• - Traumatic injury.
• - Spinal cord tumors.
• - Spinal stenosis.
• - Ruptured disks.
• - Abscesses.
• - Arteriovenous malformations.
• - Degenerative diseases, such as arthritis.

26
Spinal cord compression
27
Clinical presentation

• Symptoms vary depending on the cause of the
  compression, its location, severity, extent and
  rate of development but can include
• - Back pain at the spinal site of compression.
• - Pain or burning in other parts of the body.
• - Difficulty breathing.
• - Weakness in the arms, legs, or both.
• - Numbness or tingling in the neck, shoulder,
  arms, hands, or legs.
• - Loss of coordination or difficulty walking.
• - Loss of fine motor skills.
• - Loss of sexual function.
• - Loss of bladder or bowel control.
• - Paralysis.

28
Clinical presentation

• - Cervical spine disease produce Quadriplegia.
• - Thoracic spine disease produce paraplegia.
• - TENDON REFLEXES
• Increase below level of compression
• Absent at the level of compression
• Normal above the level of compression
• - Sphincter disturbances are late feature of
  cervical and thoracic cord compression.

29
Clinical presentation

• Cauda equina syndrome
• is a serious condition caused by compression of
  the nerves in the lower portion of the spinal
  canal .
• is considered a surgical emergency because if
  left untreated it can lead to permanent loss of
  bowel and bladder control and paralysis of the
  legs.

30
Investigation

• X ray.
• CT scan.
• MRI.
• Myelogram.
• Biopsy.
• Bone scan.
• Blood and spinal fluid studies.

31
Rx spinal cord compression

• Acute cord compression is a 'surgical' emergency.
• In those with malignant disease radiotherapy may
  be treatment of choice.
• In general, tumor, infection and disc disease
  produces anterior compression.
• Surgical decompression should be achieved through
  an anterior approach.

32
Spinal trauma

• Spinal cord trauma is damage to the spinal cord.
  It may result from direct injury to the cord
  itself or indirectly from damage to surrounding
  bones, tissues, or blood vessels.
• Symptoms
• Symptoms vary depending on the location of the
  injury.
• Spinal cord injury causes weakness and
  sensory loss at and below the point
  of the injury.
• we can divide spinal trauma into 3 levels
  according to its location in the spinal cord (
  cervical - thoracic Lumbosacral ).

33
Cervical injuries

• - When spinal cord injuries occur near the neck,
  symptoms can affect both the arms and the legs
• Breathing difficulties (from paralysis of the
  breathing muscles).
• Loss of normal bowel and bladder control (may
  include constipation, incontinence, bladder
  spasms).
• Numbness.
• Sensory changes.
• Spasticity (increased muscle tone).
• Pain.
• Weakness, paralysis.

34
Thoracic injuries

• - When spinal injuries occur at chest level,
  symptoms can affect the legs
• Breathing difficulties (from paralysis of the
  breathing muscles)
• Loss of normal bowel and bladder control (may
  include constipation, incontinence, bladder
  spasms).
• Numbness.
• Sensory changes.
• Spasticity (increased muscle tone).
• Pain.
• Weakness, paralysis.
• Injuries to the cervical or high-thoracic spinal
  cord may also result in blood pressure problems,
  abnormal sweating, and trouble maintaining normal
  body temperature.

35
Lumbosacral injuries

• - When spinal injuries occur at the lower-back
  level, varying degrees of symptoms can affect the
  legs
• Loss of normal bowel and bladder control (may
  include constipation, incontinence, bladder
  spasms).
• Numbness.
• Pain.
• Sensory changes.
• Spasticity (increased muscle tone).
• Weakness and paralysis.

36
Investigations

• A CT scan or MRI of the spine may show the
  location and extent of the damage and reveal
  problems such as blood clots (hematomas).
• Myelogram (an x-ray of the spine after injection
  of dye) may be necessary in rare cases.
• Somatosensory evoked potential (SSEP) testing or
  magnetic stimulation may show if nerve signals
  can pass through the spinal cord.
• Spine x-rays may show fracture or damage to the
  bones of the spine.

37
Rx Spinal trauma

• ABC
• Spine Immobilization to prevent further injury to
  the spinal cord.
• In cervical injuries higher than C5, intubation
  and respiratory support are usually needed.
• Corticosteroids, rest, analgesics and muscle
  relaxant.
• Surgery (decompression laminectomy ).
• Extensive physical therapy and other
  rehabilitation interventions are often required
  after the acute injury has healed.

38
Disc prolapse

• Rupture of the disc or prolapse as it is usually
  called, can press on the spinal cord and its
  nerve roots leading to pain, numbness and
  weakness and may also affect the control of bowel
  and urinary bladder.
• Dx X-ray, CT scan or MRI.

39
Rx Disc Prolapse

• Initial Rx in most cases is conservative.
• Rest.
• Analgesia.
• Anti-inflammatory agents.
• Muscle relaxant -if needed-.
• Physiotherapy.

40
Rx Disc Prolapse

• laminectomy, involves excision of a portion of
  the lamina and removal of the protruding disk.
• spinal fusion, may be necessary to overcome
  segmental instability.
• Laminectomy and spinal fusion are sometimes
  performed concurrently to stabilize the spine.
• Microdiskectomy, can also be used to remove
  fragments of nucleus pulposus.
• Chemonucleolysis Injection of the enzyme
  chymopapain into the herniated disk produces a
  loss of water and proteoglycans from the disk,
  thereby reducing both the disks size and the
  pressure in the nerve root.

41
Spondylolisthesis

• Spondylolisthesis
• is a condition in which the there is a defect
  in a portion of the spine, causing vertebra to
  slip to one side of the body.

42
Rx Spondylolisthesis

• Non-surgical treatment may include one or a
  combination of
• - NSAIDs (e.g. ibuprofen, COX-2 inhibitors)
• - Oral steroids
• - Physical therapy
• - Manual manipulation (e.g. chiropractic
  manipulation).
• Spinal fusion surgery.

43
Thank you