Schedule Monday through Wednesdays- 13:30-15:20 Thursday- 10:10- 12:00 Thursdays/ Mondays- Weekly/ Biweekly Review tests

1. Schedule Monday through Wednesdays- 13:30-15:20 Thursday- 10:10- 12:00 Thursdays/ Mondays- Weekly/ Biweekly Review tests (30-45 mins) Dr. Alka Stoelinga

2. DISEASES OF THE SPINAL CORD Dr. Alka Stoelinga

3. Spinal cord Dr. Alka Stoelinga

4. Dr. Alka Stoelinga

5. Inter-vertebral discs, vertebrae and roots Dr. Alka Stoelinga

6. Cross section of spinal cord Dr. Alka Stoelinga

7. Upper motor neurons (UMN) • Are a type of first order neuron. They are unable to leave the central nervous system. • The pyramidal tract is a very important upper motor neuron tract. • The extrapyramidal tract also consists of upper motor neurons, and is multi synaptic. • As upper motor neurons must remain inside the neuraxis, they synapse with neurons of another type called lower motor neurons • LMN which can carry messages to the muscles of the rest of the body. • When children have neuromuscular problems due to UMN lesions that occur before, during, and shortly after birth they are said to have cerebral palsy. Dr. Alka Stoelinga

8. Lower motor neurons • LMN or second order neurons are Cranial and spinal nerves. • The cell bodies of these neurons are located in the brain stem, but their axons can leave the central nervous system and synapse with the muscles of the body. • All lower motor neurons are either spinal or cranial nerves. • All spinal nerves have a lower motor neuron component as they are mixed nerves. • However, not all cranial nerves have lower motor neuron components. • Some of the cranial nerves contain only sensory fibers and therefore cannot be classified as lower motor neurons. • For example, CN I, the olfactory nerve, CN II the optic nerve, and CN VIII, the auditory nerve, do not have motor components. Dr. Alka Stoelinga

9. COMPARISON BETWEEN UMN AND LMN Dr. Alka Stoelinga

10. Dr. Alka Stoelinga

11. The spinal cord and spinal roots may be affected by • Intrinsic disease of the cord • Disorders of the surrounding meninges and bones • The clinical presentation of these conditions depends on the • Anatomical level at which the cord or roots are affected • Nature of the pathological process involved Dr. Alka Stoelinga

12. Spinal cord injury Spinal cord injury occurs from either a trauma (injury) or from a disease or infection to the neural tissue within the vertebral column. Causes • Spinal cord injury is usually the result of an • Accident (for example, motor vehicle accident, fall, sports injury) • Acts of violence such as gunshot wounds. • Also caused by surgical complications or by disease (for example, polio, spina bifida, Friedreich's Ataxia). Risk Factors • Men – 80% of all spinal cord injury survivors are male • Young adults – more than half of spinal cord injuries happen to people age 16-30 • Elderly people – usually from falls • People active in sports – high-risk athletics, in particular • People with bone or joint conditions – for example arthritis, osteoporosis Dr. Alka Stoelinga

13. Clinical features: Symptoms of possible spinal cord injury include:- • Extreme pain or pressure in the neck, head, or back • Tingling or loss of sensation in the hand, fingers, feet, or toes • Partial or complete loss of control over any part of the body • Urinary or bowel urgency, incontinence, or retention • Difficulty with balance and walking • Abnormal band-like sensations in the thorax (pain, pressure) • Impaired breathing • Unusual lumps (mass) on the head or spine In addition, studies show that most spinal cord injury survivors have at least one secondary problem resulting from their injury, including: • Spasticity • Obesity • Pain • Urinary tract infection • Pressure sores Dr. Alka Stoelinga

14. Nature of the spinal cord pathology Broadly divided into two types: • Compressive • Intrinsic • Extrinsic • Non compressive • Vascular ( spinal artery occlusion) • Degenerative (MND,syringomyelia, combined degeneration) • Infections (myelitis, HIV) • Inflammatory ( multiple sclerosis) Dr. Alka Stoelinga

15. SPINAL CORD COMPRESSION Dr. Alka Stoelinga

16. Causes of spinal cord compression Dr. Alka Stoelinga

17. MRI of CS Dr. Alka Stoelinga

18. MRI of CS Dr. Alka Stoelinga

19. Clinical features-symptoms Dr. Alka Stoelinga

20. Clinical features –signs Dr. Alka Stoelinga

21. 1. Cervical cord: Above C5 • Quadriplegia UMN type • Respiratory muscles weakness • Sensory loss in all 4 limbs • Horner’s syndrome 2. Cervical cord: Below C5 • Motor weakness in upper limbs: LMN type • Segmental sensory loss in upper limb • UMN type motor weakness in lower limb • Sensory loss in lower limbs 3.Thoracic lesions: • Motor weakness: UMN type in lower limbs • Sensory: Definite sensory level in thorax • Autonomic involvement: Bladder and Bowel Dr. Alka Stoelinga

22. 4. Lumbar/Sacral: • Difficult to localize between two • Motor weakness of lower limbs: May be patchy 5. Conusmedullaris: • B/L sacral sensory loss • Prominent bowel and Bladder symptoms(S2,S3,S4) • Impotence • Spares motor of lower limbs 6. CaudaEquina: • Involves nerve roots descending from end of spinal cord • Severe radicular pain in lower limbs • Asymmetric lower limb weakness • Asymmetric sensory loss • Relative sparing of bowel and bladder function Dr. Alka Stoelinga

23. Investigations Dr. Alka Stoelinga

24. Management General management • Care of skin:- to avoid pressure sore • Care of bladder:-intermittent catherization, treatment of UTI and adequate fluid intake. • Care of bowel:- avoidance of constipation. • Care of limbs:-passive physiotherapy to avoid contracture. Conservative treatment • Surgical intervention and appropriate medical treatment. • If treatment is offered at early stage prognosis is relatively good • If cause of compression is malignancy (primary or metastatic) prognosis is poor. Dr. Alka Stoelinga

25. High dose of dexamethasone • Radiotherapy Radiosensitive tumors- lymphoma/ multiple myeloma • Surgical decompression Herniated disc/ epidural abscess/ hematoma Dr. Alka Stoelinga

26. Neural tube defects • Neural tube defects (NTDs) are common birth defects of the brain and spinal cord that include anencephaly and spina bifida (meningomyelocele). • Deficiency of folic acid raises the risk of neural tube defects, due to the mutation of a gene for an enzyme that concern with folic acid. • The most common causes of neural tube defects are insufficient folic acid in the mother's diet, both before she became pregnant and during the first few weeks of pregnancy. Dr. Alka Stoelinga

27. BROWN SEQUARD SYNDROME • Results from unilateral cord compression • Impaired pain and temperature sensation • Impaired light touch and vibration and position sensation • Increased tendon reflexes and extensor plantar response On the same side: • Zone of hyperesthesia at the same level • Loss of vibration, joint positions sense, fine touch • UMN type of motor weakness On opposite side: • Loss of pain, temperature sensation Dr. Alka Stoelinga

28. CENTRAL CORD SYNDROME: • Involves gray matter and crossing of Spinothalamic tract • Motor weakness • Dissociate sensory loss • E.g:Syringiomyelia,Tumors ANTERIOR 2/3rd SYNDROME: • Bilateral involvement of anterior spinal cord • Motor,sensory,Autonomic function lost • Posterior column spared • E.g: Vascular:Thrombosis of anterior spinal artery or by tumors Dr. Alka Stoelinga

29. Patterns of sensory loss Dr. Alka Stoelinga

30. NON COMPRESSIVE SPINAL CORD LESION • Vascular • Inflammatory • Transverse myelitis • Multiple Sclerosis 3.Development:Syringomyelia 4.Metabolic: Subacute combined degeneration(Deficiency of Vit B12) Dr. Alka Stoelinga

31. Clinical differentiation: Dr. Alka Stoelinga

32. CERVICAL SPONDYLOSIS Dr. Alka Stoelinga

33. Cervical Spondylosis : • Degeneration of intervertebral disc, calcification, formation of osteophytes, and fusion of the intervertebral joints. • Cervical spine is commonly involved, osteophytes or intervertebral disc may compress the nerve roots (radiculopathy) or the spinal cord (myelopathy) • In radiculopathy, there is neck pain radiating to the dermatome of the affected root, pain is aggravated by neck movements specially flexion, there may be weakness if the muscles supplied by the nerve root (LMN) Dr. Alka Stoelinga

34. Physical signs of compression of cervical roots Dr. Alka Stoelinga

35. Investigations • Plain X ray cervical spine Antero-posterior Lateral • In severe cases MRI of the cervical spine • Management of cervical radiculopathy • Analgesic • Cervical collar • Surgery if deficit is severe or conservative therapy fails. Dr. Alka Stoelinga

36. Cervical collar Dr. Alka Stoelinga

37. Cervical spondylotic myelopathy : • Progressive, gradual onset • Prone to have hyperextension injury of the cervical cord • Spastic quadriparesis with loss of sensation and ultimately, involvement of bowel and bladder. • Investigation of choice is MRI • Treatments • conservative • surgery disc resection, vertebral lamina resection.Surgery sometimes leads to acute deterioration. Dr. Alka Stoelinga

38. Lumbar disc herniation : • Common problem in middle aged and elderly. • Precipitated by trauma or lifting a heavy weights when spine is flexed. • Onset may be sudden or gradual, Constant aching pain in the lumbar region and may radiate to the buttock, thigh, calf and foot. • Pain is exacerbated by coughing or straining and may be relieved by lying flat. • SLRT (straight leg rising test) may be positive (positive Lasegue’s sign) • MRI is the investigation of choice • Management :conservative or surgery Dr. Alka Stoelinga

39. Case • A 25 year old male was brought to Emergency department. Status- Post motor vehicle accident. • Emergency doctor does ABC management • On CNS examination • Motor • B/L Lower extremity weakness ~4/5 • B/L With hyperreflexia • Cranial nerves • Intact • Sensory • Pain and temperature- lost in lower extremities • Vibration and position- intact • Light touch- intact • What is the likely diagnosis? Why? Dr. Alka Stoelinga

40. Syringomyelia • Cavitation of spinal cord • Fluid-filled cavity (or cavities) develops near the centre of the spinal cord, usually in the cervical segments • The expanding cavity disrupts second-order spinothalamic neurons • May extend laterally to damage the anterior horn cells, and may compress the long fiber tracts. • It is assumed that the disturbed CSF dynamics cause the development of the syrinx but the mechanism is not clear. Dr. Alka Stoelinga

41. Communicating Associated with Arnold Chiari malformation • Noncommunicating secondary to spinal cord trauma Dr. Alka Stoelinga

42. Syringomyelia Dr. Alka Stoelinga

43. Clinical features • Pain in the neck or shoulder is common and patients may seek advice because of sensory loss in the upper limbs • Dissociated sensory loss (impaired pain and temperature sensation with preservation of dorsal column modalities- intact sensation of light touch) • Loss of protective sensory function leads to tropic lesions such as painless burns or ulcers on the hands • Ultimately sensory loss in all four limbs with UMN signs below the lesion and LMN sign at the level of lesion. • Investigation is MRI • Treatment is surgical. Dr. Alka Stoelinga

44. Subacute combined degeneration • Occurs with vitamin B12 deficiency • Distal paresthesias • Weakness of extremities • Spastic paresis • Ataxia • In classical case Deficit of vibration and proprioception with pyramidal signs (Plantar extension and hyperreflexia) • Investigation Serum Vitamin B12 level (Low) • Rx Vitamin B12 therapy • 250 µg to 1 mg of B12 daily • S/C or I/M injections of Vit B12 weekly for ~20 weeks followed by lifelong Dr. Alka Stoelinga

45. Anterior Spinal artery infarct • Acute flaccid paralysis which evolves into flaccid paresis over days to weeks • Loss of pain and temperature sensation • Sparing of vibration and position sense • (Posterior columns are supplied by Posterior spinal artery) Dr. Alka Stoelinga

46. Transverse myelitis:- • It affects one to five persons per million. • Transverse myelitis is an acute inflammatory condition usually secondary to viral illness or recent vaccination may be with multiple sclerosis and other inflammatory and vascular disorders (eg:-syphilis) • where there is a progressive sensory loss and weakness. • Transverse myelitis (TM) is an uncommon neurological syndrome caused by inflammation (includes swelling, pain, heat, and redness) of the spinal cord. • Characterized by weakness, back pain, and bowel and bladder dysfunction. Dr. Alka Stoelinga

47. Clinical feature: • Though non compressive, it presents as compressive myelopathy • Features depend on spinal segment involved • Commonly involved: Thoracic segments • Acute/ Subacute course • Paresthesia • Motor weakness: Paraplegia, UMN type • Sensory loss • Bladder involvement • Acute stage: Neural shock • May be difficult to differentiate with GBS • Similar symptoms may be present in multiple sclerosis Dr. Alka Stoelinga

48. Investigations: • MRI of spinal cord • Treatment: 1. Steroid: Methylprednisolone IV for 3 days Followed by Prednisolone 1mg/Kg/Day for several weeks 2. Other Rx: • Physiotherapy • Care of Bladder and bowel • Prevention of DVT Dr. Alka Stoelinga

49. Poliomyelitis: • Poliomyelitis results from a relatively selective destruction of lower motor neurons in the anterior horn cell of spinal cord by polio virus. • The disease causes Flaccid paralysis of muscles with accompanying Hyporeflexia and Hypotonicity. • Some patients may recover most function,whereas others progress to muscle atrophy and permanent disability. Dr. Alka Stoelinga

50. PARTIAL SEIZURES Simple partial seizure : • Not associated with loss of consciousness and Limited to part of the body • Denotes focal pathology in brain/involve only one hemisphere • Typically associated with structural abnormalities of brain such as scars,tumors,AV malformation or focal areas of inflammation • Can be Motor/Sensory/Autonomic/Psychomotor • In typical motor type there is clonic ( repetitive flexion and extension) movement at the rate of 2-3 Hz. • Other features of partial motor seizure are • Jacksonian March • Todd’s paralysis • Epilepsia partialis continua Dr. Alka Stoelinga