DR. RAJENDRAN S INSTITUTE OF MEDICAL EDUCATION

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1 Page 1 of 17 DR. RAJENDRAN S INSTITUTE OF MEDICAL EDUCATION SPINAL CORD DISEASES PART 2 1) Match presentation with site of lesion a. Lesion near foramen magnum A b. Conus medullaris (sacral cord) B [ No anal reflex.] c. Cauda equina C [ Radicular pain is typical.] d. Cervical cord D [ Ipsilateral Horner s syndrome may develop with cervical cord lesion at any level.] A Weakness of ipsilateral shoulder and arm, followed by weakness of ipsilateral leg, then contralateral leg, then contralateral arm, with respiratory paralysis B Saddle anesthesia, early bladder/bowel/sexual dysfunction. C Flaccid, areflexic, asymmetric paraparesis, bladder/bowel dysfunction, sensory loss below L1, pain in perineum D Horner s syndrome

2 Page 2 of 17 C3, C4 - Extensive lesions near the junction of the cervical cord and medulla are fatal due to involvement of adjacent medullary vasomotor and respiratory centers. - Upper cervical cord lesions produce quadriplegia and weakness of the diaphragm. Phrenic nerve supply is C3 to C5. Breathing is possible only by use of accessory muscles of respiration. C4, C5 - Quadriplegia with preserved respiratory function. C5, C6 - Loss of biceps and brachioradialis reflex {LMN signs at the level of lesion and UMN signs (i.e., quadriparesis) below the level of lesion}. Shoulder muscles are spared. - Triceps reflex (C6-8) is exaggerated. - Inversion of the brachioradialis reflex is typical of a lesion at C5 level. The normal components of brachioradialis reflex are flexion of the forearm, supination of the forearm and flexion of the fingers. In inversion of the brachioradialis reflex, tapping the radius to elicit the brachioradialis reflex causes exaggerated finger and hand flexion without flexion and supination of the forearm. C7 - Biceps are spared. Biceps and brachioradialis reflexes (C5, 6 segments) are preserved. - There is weakness of finger and wrist extensors. - There is loss of triceps reflex. C8 - There is paralysis of finger and wrist flexion and spastic paraparesis. - Triceps reflex is reduced or absent. - Horner s syndrome may be present. T1 to T12 - Thoracic cord lesion is best localized by sensory level. See figures below. L2 to L4 - There is paralysis of flexion and adduction of the thigh. Leg extension becomes weak at the knee, and the knee jerk is absent. S1 - Paralysis of movements of the foot and ankle, flexion at the knee, and extension of the thigh, and abolish the ankle jerk (S1).

3 Page 3 of 17 A dermatome is a portion of the skin supplied by each spinal nerve There is no C1 dermatome in many persons. When a C1 dermatome is present, it covers a small area in the central part of the neck, close to the occiput C5 dermatome is over the deltoid muscle T1 is confined to the medial side of arm The thumb, middle finger, and fifth digit are within the C6, C7, and C8 dermatomes, respectively. The nipple is at the level of T4 The umbilicus is at the level of T10

4 Page 4 of 17 2) Which is/are seen in lesions of the foramen magnum? a. "Around the clock" pattern of weakness [ Compressive lesions near the foramen magnum may produce weakness of the ipsilateral shoulder and arm followed by weakness of the ipsilateral leg, then the contralateral leg, and finally the contralateral arm ("around the clock" pattern). This may begin in any of the four limbs.] b. Suboccipital pain [ Occipital or neck pain, often increased by neck movement, is a common initial manifestation. The second cervical root innervates the posterior aspect of the scalp, which explains the pattern of radicular pain. If the compression is at the third or fourth cervical level, radicular pain may be projected to the neck or the top of the shoulder.] c. Dissociated sensory loss [ Pain and numbness affecting the same upper extremity first involved by spastic weakness is an early finding. The sensory disturbances are often of the dissociated type (i.e., loss of pain and temperature sensation with preserved tactile sensation).] d. Downbeating nystagmus [ Cranial nerve symptoms and signs may include nystagmus, often downbeating; impaired sensation over the upper face (caused by involvement of the descending tract of cranial nerve V); and dysarthria, dysphonia, and dysphagia.] e. All of the above T [ Foramen magnum and upper cervical spine tumors may cause signs of LMN weakness, atrophy, and depressed reflexes in the arms and hands. The mechanism of this LMN disturbance is uncertain but may be due to ischemia as a result of involvement of the anterior spinal artery. Magnetic resonance imaging (MRI) is the test of choice for imaging the craniocervical junction.] 3) What is/are the cause(s) of Lhermitte s sign? a. Cervical cord lesion [ Lhermitte's symptom is an electrical sensation radiating down the spine from the neck elicited by neck flexion. It usually indicates involvement of the cervical or upper thoracic (T1-T2) spine. Lhermitte's sign may be an early sign of cord compression.]

5 Page 5 of 17 b. Multiple sclerosis c. Cervical spondylosis d. Reaction to radiation treatment [ Lhermitte's sign is due to transient demyelination of the spinal cord following significant radiation exposure.] e. All of the above T CAUSES OF CERVICAL CORD DISEASE Cervical spondylosis Trauma Congenital disturbances of the craniocervical junction Chiari malformation Foramen magnum tumors Metastasis Meningiomas Neurofibroma Glioma Teratoma Atlantoaxial subluxation (e.g., rheumatoid arthritis) Multiple sclerosis Syrinomyelia

6 Page 6 of 17 4) Whiplash injury - False statement a. Usually due to automobile accidents [ Whiplash injury is due to trauma (usually automobile accidents) causing strain of muscles and ligaments of the cervical vertebrae. Rearend collisions are responsible for about 85% of all whiplash injuries. When an occupant of a motor vehicle is hit from behind by another vehicle, there occurs hyperextension of neck followed by flexion.] b. Due to hyperextension of neck c. Due to hyper flexion of neck [ Some clinicians use the term to also describe other types of collisions wherein the neck is subjected to different combinations of flexion, extension, and lateral motion.] d. Usually associated with fractures or disk herniation F [ False statement. This diagnosis should not be applied to patients with fractures, disk herniation, head injury, or altered consciousness.] e. Neck pain is common [ Following a whiplash injury, patients present with neck pain within 24 hours. The most common cause of the neck pain is myofascial injury. Eighty percent of patients with whiplash-type injuries also complain of headaches during the first 4 weeks after the accident.] 5) Spurling's sign a. Parkinson s disease b. Wilson disease c. Cervical disk disease [ Herniation of a lower cervical disk is a common cause of neck pain radiating to shoulder or arm. Neck movement aggravates this radicular pain. Extension and lateral rotation of the neck narrows the intervertebral foramen (see figure below) and may reproduce radicular pain (Spurling's sign). In young individuals, acute radiculopathy and ruptured cervical disk is usually due to trauma. Subacute radiculopathy is usually due to a combination of disk disease and spondylosis.]

7 Page 7 of 17 d. Down syndrome e. Prion disease

8 Page 8 of 17 6) Cervical spondylosis - True statement a. Due to osteoarthritis of the cervical spine [ It may produce neck pain that radiates into the back of the head, shoulders, or arms. It may also cause headaches in the posterior occipital region (supplied by the C2-C4 nerve roots).] b. May compress the cervical spinal cord [ Narrowing of the spinal canal by osteophytes, ossification of the posterior longitudinal ligament, or a large central disk may compress the cervical spinal cord. Combinations of radiculopathy and myelopathy also occur.] c. Lhermitte's symptom may develop [ Lhermitte's symptom indicates involvement of the cervical or upper thoracic (T1-T2) spine.] d. MRI is diagnostic [ MRI or CT myelography can show the anatomic abnormalities. EMG and nerve conduction studies can localize and assess the severity of the nerve root injury.] e. All of the above T [ Differential diagnosis include amyotrophic lateral sclerosis, multiple sclerosis, spinal cord tumors, and syringomyelia. ] 7) Not typical of spondylitic myelopathy is a. C5 nerve root compression [ Cervical spondylosis tends to affect particularly the C5 and C6 nerve roots. Early symptoms are neck and shoulder pain with stiffness. This is due compression of C5 or C6 nerve roots by bone and soft tissue overgrowth. Biceps reflex (C5-C6) is commonly reduced. Suggestive of cervical spondylosis is a depressed brachioradialis (C6) reflex with hyperactive finger flexors (C8-T1), indicating a C6 radiculoneuropathy with myelopathy. Neoplasms or other diseases at the C6 level may cause a similar clinical presentation.] b. Slowly progressive spastic paraparesis [ If there is an associated myelopathy, upper motor neuron weakness develops in one or both legs. Spastic paraparesis is due to compression of the cervical cord. Cervical spondylosis is one of the most common causes of gait difficulty in the elderly.]

9 Page 9 of 17 c. Atrophy of intrinsic hand muscles [ Dermatomal sensory loss in the arms, atrophy of intrinsic hand muscles, increased deep tendon reflexes in the legs, and extensor plantar responses are common.] d. Diminished vibration sense [ Vibratory sense is diminished in the legs. Romberg sign may be present.] e. Urinary incontinence T [ Urinary urgency or incontinence occurs in advanced cases. Diagnosis is best made by MRI. Definitive therapy consists of surgical relief of the compression. A cervical collar may be very helpful in milder cases.] DIAGNOSIS OF CERVICAL RADICULOPATHY Pain Weakness Sensory Loss Reflex Loss C5 Neck, shoulder, and Deltoid Lateral border of the Biceps interscapular region; lateral aspect of the arm Spinati Rhomboids shoulder and upper part of the arm (brachioradialis) C6 Shoulder; lateral aspect of Biceps Lateral aspect of the Brachioradialis the forearm, and the first two digits Brachioradialis Extensor carpi radialis forearm and the first two digits (biceps) C7 Interscapular region, posterior of the arm, midforearm Triceps Midforearm and middle digit Triceps Extensor carpi and digitorum Flexor carpi radialis

10 Page 10 of 17 C8 Medial aspect of the forearm Extensor carpi and Medial aspect of the Finger flexors and hand digitorum forearm and hand and the (triceps) Flexor digitorum fourth and fifth digits (sublimis and profundus) Flexor carpi ulnaris T1 Medial aspect of the arm to Intrinsic hand muscles Medial aspect of the arm to the elbow the elbow 8) Bilateral Hoffmann's signs a. UMN disease b. Anxiety c. Hyperthyroidism d. All of the above T [ Hoffmann's sign is performed by dorsiflexing the patient's wrist and then flicking the distal phalanx of the middle finger with the examiner's thumb. The patient's middle finger is thereby flexed and suddenly extended. Hoffmann's sign is present when there is reflex flexion of the patient's thumb and other fingers. Bilateral Hoffmann's sign usually is an indication of hyperactive deep tendon reflexes. Although disease of the pyramidal pathways may be responsible, healthy persons with hyperactive reflexes may have bilateral Hoffmann's signs (e.g., anxiety, hyperthyroidism, and stimulatory drugs). When Hoffmann's sign is present unilaterally, it usually signifies disease of the nervous system.]

11 Page 11 of 17 9) What is the most common site of lesion in a patient with paraparesis? a. Spinal cord T [ Most lesions of the spinal cord produce quadriparesis or paraparesis. A spinal cord lesion should be suspected in a patient with bilateral weakness, bowel or bladder control deficits, and back pain. Common causes of spinal cord compression are disk protrusion, spondylosis and acute trauma, but neoplastic and infectious causes should always be considered. Spinal cord compression resulting in paralysis should be evaluated as quickly as possible with MRI.] b. Parasagittal lesions [ An intraspinal lesion at or below the upper thoracic spinal cord level is most commonly responsible for paraparesis. Paraparesis may also result from parasagittal intracranial lesions, anterior horn cell disorders, cauda equina syndromes and peripheral neuropathies.] c. Anterior horn cell disorders [ E.g., poliovirus.] d. Cauda equina syndrome [ Cauda equina syndrome result from trauma to the low back, midline disk herniation, or intraspinal tumor.] e. Guillain-Barre syndrome [ Paraparesis may be due to a peripheral neuropathy such as Guillain-Barre syndrome.] ACUTE PARAPARESIS (Spinal cord compression resulting in paralysis should be evaluated as quickly as possible with MRI) Compressive spinal cord lesions - Disc prolapse - Vertebral involvement by malignancy or infection - Epidural tumor, abscess, or hematoma Guillain-Barre syndrome This is the most common LMN weakness that progresses over days to several weeks Spinal cord infarction {Anterior spinal artery infarction usually causes paraparesis and spinothalamic sensory loss below the level of the lesion; dorsal column function (proprioception) is preserved.} Spinal cord vascular anomaly Transverse myelitis (Postinfectious, viral infections, SLE, Sarcoidosis, Multiple sclerosis) Diseases of the cerebral hemispheres ( Parasagittal meningiomas, anterior cerebral artery ischemia, superior sagittal sinus or cortical venous thrombosis, and acute hydrocephalus)

12 Page 12 of 17 CHRONIC PARAPARESIS (OVER WEEKS OR MONTHS) Degenerative disease of the spine Hereditary degenerative diseases Intraparenchymal spinal cord tumor Multiple sclerosis Subacute combined degeneration Motor system disease Syringomyelia Tropical spastic paraparesis Paraneoplastic syndromes Parasagittal meningiomas Chronic hydrocephalus CAUDA EQUINA SYNDROME Trauma to the low back Midline disk herniation Intraspinal tumor; although sphincters are affected, hip flexion is often spared, as is sensation over the anterolateral thighs. Rarely, paraparesis is caused by a rapidly evolving anterior horn cell disease (such as poliovirus or West Nile virus infection), peripheral neuropathy (such as Guillain-Barré syndrome; Chap. 380) or myopathy (Chap. 382). In such cases, electrophysiologic studies are diagnostically helpful and refocus the subsequent evaluation. RECURRENT EPISODES OF PARAPARESIS Multiple sclerosis Vascular malformations of the spinal cord

13 Page 13 of 17 ACUTE QUADRIPARESIS Guillain-Barre syndrome This is the most common LMN weakness that progresses over days to several weeks Cerebral anoxia Hypotension Brainstem or cervical cord ischemia Trauma Systemic metabolic abnormalities and electrolyte disturbances Toxins Periodic paralyses 10) Early sacral sensory loss is typical of a. Extramedullary lesions T [ In extramedullary lesions (90%), radicular pain is usually prominent. There is early sacral sensory loss (damage to lateral spinothalamic tract). This is due to lamination of the spinothalamic tract with the sacral fibers being outermost. Spastic weakness in the legs (damage to corticospinal tract) also appears early. See 2 figures below.] b. Intramedullary lesions [ Intramedullary lesions (10%) usually produce poorly localized burning pain rather than radicular pain. Sensation in the perineal and sacral areas ( sacral sparing ) is usually present normally in the early stages. Corticospinal tract signs appear later. Intramedullary diseases presents with tract dysfunction (not with nerve root pain). Extramedullary compression presents with nerve root pain (radicular pain).] c. Both d. None

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15 Page 15 of 17 ACUTE AND SUBACUTE SPINAL CORD DISEASES Compressive myelopathies Neoplastic Spinal cord compression Spinal epidural abscess Epidural hematoma Hematomyelia

16 Page 16 of 17 Noncompressive myelopathies (Acute transverse myelopathies) Spinal cord infarction Acute transverse myelopathies Infectious myelitis (Herpes zoster is the most common viral cause of acute myelitis) Postinfectious myelitis or postvaccinial myelitis Multiple sclerosis CHRONIC SPINAL CORD DISEASES Spondylitic myelopathy Vascular malformations Retrovirus-associated myelopathies Syringomyelia Multiple sclerosis Subacute combined degeneration (vitamin b12 deficiency) Tabes dorsalis Familial spastic paraplegia Primary lateral sclerosis Lathyrism

17 Page 17 of 17 Chronic paraneoplastic myelopathy Radiation injury For rest of the 37 questions with explanatory answers, click premium content > Neurology.