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Approach to patient with MyelopathyDr Sunil Bhatt(MD medicine)SGRR Medical college Dehradun3/6/20171

Myelopathy describes any neurological deficit related to the spinal cord.Quadriplegia, Paraplegia and sensory deficits,root pain,autonomic disturbances.When inflammatory it is known as myelitis.Disease that is vascular in nature it is known as vascular myelopathy.Cervical spondylotic myelopathy is the most common form of myelopathy.

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Spinal cord AnatomySC is a tubular extension of the central nervous systemIt starts from medulla and end at conus medullaris at lumbar levelIts fibrous extension, the filum terminale, ends at the coccyxThe adult SC is 18 inch long3/6/20173

Cut section of spinal cord3/6/20174

SC has 31 segments

SC levels relative to the vertebral bodies

3/6/20175Spinal Cord LevelCorresponding Vertebral BodyCervicalSame as cord level(C1 to C4)Lower Cervical1 level higher (C5to T4)Upper thoracic2 level higher(T3to T6)Lower thoracic 2 to 3 level higher(T7 to T9)LumbarT10 T12Sacral T12 L1

Useful markers of sensory levelT4 nippleT10 umblicusT12 Pubic symphysisLesion at T9 T10( Beevors sign)3/6/20176

Important sensory levelsC1 No supply to skinC2OcciputC5Outer aspect of shoulder tipC7The middle fingerT3AxillaT8Rib marginT10UmblicusT12Pubic symphysisL3KneeL5From outer aspect of tibia to inner aspect of footS1Little toeS3, S4, S5Concentric ring aroun anus

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Symptoms

limb weakness,loss sensation of pain and tempretureLoss of joint,position and vibration, sharp shooting back pain aggrevated by cough and sneezing. bowel and bladder incontinence.

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Time courseAcute

Subacute(2-6 weeks)

Chronic3/6/20179

Examination

Vertebral deformity

Vertebral tenderness

Motor symtoms

Sensory symptoms

Autonomic symtoms3/6/201710

COMPRESSIVE and NON COMPRESSIVE.COMPRESSIVE INTRAMEDULLARY EXTRAMEDULLARY

NON COMPRESSIVE3/6/201711

Determining the level of the Lesion1. Impairment / Loss of sensory, motor and autonomic function below a horizontal level HALLMARK of lesion of the spinal cordSensory loss due to spinothalmic / posterior column involvementMotor loss ( paraplegia/parasis, quadriplegia/parsis)Autonomic function loss in form of bladder, bowel and sexual dysfunction

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2. Segmental signs A band of hyperalgesia or hyperpathia at upper end of sensory disturbanceFasciculation or atrophy in muscles innervated by one or several segmentsA decrease or absent deep reflex Along with long tract involvement

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Sensory loss below a particular level is due to damage to spinothalamic tract on the opposite side one or two segments higher in case of a unilateral lesion.2 nd order neurons ascend for one or two level as they cross anterior to the central cannal to join the opposite STTRadicular pain or dermatomal sensory loss due to involvement of sensory roots.3/6/201715

3. limbs initially may be flacid and reflexes may be absentSpinal shock it lasts for several days to weeks3/6/201716

Features pointing to different level of spinal cord involvement3/6/201717

Foramen magnum1. Cruciate hemiparesisCortico-spinal leg fibres cross distal to upper limb fibresWeakness of ipsilateral upper limb and contralateral lower limbIn mid line ventral lesions, only crossing fibres are involved causing paraparesis3/6/201718

2. Elsberg phenomenonWeakness of ipsilateral upper limb ipsilateral lower limb contralateral lower limb and finally contralateral upper limb ( Clockwise involvement ) Can start with any limb3/6/201719

3.Suboccipital pain with radiation to neck and shouldersSometimes bilateral papilloedema due to raised intracranial pressure

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High Cervical Cord LesionSensory loss over occipital area ( C2 )

Involvement of spinal accesory nerve

Wasting of small muscles of hands

Quadriplegia with diaphragm weakness

Sensory loss (Pain & Temp) of upper portion of face along with loss of corneal reflex due involvement of spinal nucleus of V cranial nerve3/6/201721

Low Cervical CordC5 - C6 weakness in deltoid, supraspinatus,loss of power and reflexes in the biceps.

C7 weakness is found in triceps, finger and wrist extensors.(radial nerve)

C8 in finger and wrist flexion are imparied.(ulnar nerve)

Horners syndrome occur lesion at any level 3/6/201722

Thoracic CordSensory level on trunk

Site of midline back pain

Paraparesi / Paraplegia of lower limb

Beevors sign positive

Bladder bowel involvement

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Lumbar cordL2-L4 weakness of Flexion and adduction of thighWeaken leg extension at kneeLoss patellar reflexSpastic paralysis belowExaggerated ankle jerk.L5-S1 paralize movement of foot and ankleWeakness of flexion at kneeWeakness of extension of the thighLoss of ankle jerks (L5,S1) 3/6/201724

Epiconus syndrome (L4 to S2)L4 to S2 segment involvement epiconusWeakness of extension (L4-L5) and external rotation of hip (L4-S1)Weakness of knee flexion, movement at ankle and toes (L4-S2)Ankle reflex is absent while knee jerk is preservedBowel and bladder empty reflexivelyImpotence after priapism3/6/201725

Conus Medullaris SyndromeLesion at vertebral level L2 affects conus medullaris.Bilateral saddle anaesthesia (S3-S5)Presentation-sudden bilateral and symmetricalLoss of anal reflexes (S4-S5) and bulbocavernosus (S2-S4)Loss of anal toneBack pain.Prominent bowel and bladder dysfunction.Preserved motor function of lower limbs including ankle jerkImpotence

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Cauda Equina SyndromeComposed of lumbar, sacral and coccygeal nerve rootsLow back and radicular pain Asymmetric leg weakness and sensory lossVariable areflexia in lower extremitiesSparing of bowel / bladder function

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Special Pattern of Spinal Cord Disease3/6/201728

Brown Sequard SyndromeHemicord lesionIpsilateral corticospinal weaknessLoss of joint position and vibration ( Posterior column)Contralateral Loss of pain and temp sensation ( Spinothalmic tract)May be present LMN type of features on ipsilateral side

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Central Cord SyndromeHyperextion injury of neck.Pain,tempreture and position sense .Motor weakness of upper limbs is more than lower limbs due spatial arrangement of fibresDeep tendon reflexes diminished or lost in upper limbs while exaggerated in lower limbsBladder / Bowel involvement is early3/6/201730

Anterior Spinal Artery Syndrome

Extensive bilateral motor, sensory and autonomic function loss Vibration and position sense are spared3/6/201731

Compressive Lesion3/6/201732

compressive lesionsBony deformity Bone tendernessGirdle like sensation Upper level of sensory loss Zone of hyperasthesiaRoot painOnset and progress-gradualAsymmetryBowel and bladder early

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Extradural LesionLocal vertebral pain and tenderness with or without radicular painCorticospinal tract involvementMyelopathy with bladder / bowel involvement laterMode of onset symmetrical .3/6/201734

Intradural extramedullaryCommonly in vicinity of dorsal rootsRadicular pain and parasthesiaPosterior column and pyramidal tract involvement spastic paresis with sensory disturbance in lower limbs and then ascendsSpinal tenderness is not commonMode of onset is asymmetrical.

Long duration of symptoms.3/6/201735

Intramedullary Radicular pain is rareDull aching painTropic changes in the skin presentSacral sparing in lower spinal cord lesionLike central canal syndromeDissociation of sensationReflexes -Less brisk ,late feature Autonomic involvement EarlyTrophic changes- CommonUMN-rareLMN- Marked with widespread atrophy,fasciculations seen

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NON COMPRESSIVE MYELOPATHY.InflammatoryPostinfectiousAutoimmuneDemyelinationParaneoplasticvaccination

toxicHereditary

Non inflammatorySpinal cord infarctionAVMVitamin b12 deficiency

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Non compressiveOnset acuteSymmetricalBladder and bowel lateAbsent bony deformityBony tenderness absentAbsent root pain Girdle sensation absentHyperasthesia absent3/6/201738

Summary3/6/201739

summaryFeatures ExtramedullaryIntramedullaryRoot painEarly and commonrareSensory deficitNo dissocitaion of sensationDissociation of sensation commonSacral sensation Lost earlySacral sparringUMN involement Early and prominentLess pronouncedLMNSegmentalMarked with widespread atrophy,fasciculations seenReflexesBrisk early featureLess brisk ,late featureAutonomic involvement Late EarlyTrophic changesUsually not marked CommonVertebral tenderness May be sensitive to local pressure No bony tendernessChanges In CSF Frequent rare

3/6/201741Thank you