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EBMG

Diseases of the Spinal Cord

Essentials

  • The most important thing to assess is whether symptoms originating from the spinal cord are caused by an injury or a disease.
    • Symptoms caused by an injury appear acutely, and the cause is usually known Acute Treatment of Traumatic Spinal Cord Injuries. The patient should be referred for emergency treatment.
    • Symptoms caused by diseases usually develop more slowly, and the urgency varies.
  • When the symptoms have been localized as originating from the spinal cord, the aim should be to determine the level of possible lesion.
  • The majority of spinal cord diseases are caused by local changes, a smaller number of them are disseminated, i.e. diffuse.
  • In diffuse spinal cord diseases there is no sensory level, but in spinal cord compression originating from an injury or disease it can often be found and it guides the diagnostics especially in acute situations.

Symptoms and determining the level of a spinal cord lesion

  • When a lesion of the upper motor neurone progresses slowly, it is manifested as spastic paraparesis or tetraparesis. Typical symptoms include
    • increase of the muscle tonus (spasticity) Spasticity
    • heightened tendon reflexes
    • positive Babinski's sign.
  • Exclude diseases of the brain area. Spinal cord diseases do not affect cranial nerves, consciousness or higher mental functions (speech, cognition).
  • It is most important to distinguish between paraparesis and tetraparesis, i.e. whether there are symptoms or signs also in the upper extremities in addition to the lower extremities. If not, the lesion is below the Th1 segment.
  • Try to determine the sensory level. In diffuse spinal cord diseases there is no sensory level, but in spinal cord compression originating from an injury or disease it can usually be found.
    • The lesion in the cord is usually higher than the sensory level.
    • Tenderness to percussion of the spine may localize a vertebral injury.
    • Saddle block anaesthesia suggests a lesion in the conus medullaris.
  • The function of the bladder is controlled by micturition reflex. The bladder empties often and the reflex causes an urge-type incontinence or, depending on the level of injury, also retention may occur.
  • Lesions in the lumbar spine do not cause compression of the medullary cord but a lesion of the lower motor neurone because the spinal cord ends on the L1 level.
  • An x-ray of the spine may reveal fractures, spondylosis or erosions (metastases). A normal spine x-ray does not rule out spinal cord compression, so it should not be taken when suspecting a disease originating from the spinal cord.
  • MRI of the vertebral canal is the primary method to determine the level when suspecting diseases or injuries of the spinal cord.

Infectious and inflammatory diseases

Myelitis

  • Causes in the order of frequency
  • Can be diffuse, transverse (lesion in the area of a few intervertebral spaces, symptoms come from below this level) or ascending.
  • The clinical picture includes weakening of the lower extremities, a sensory level and bladder paresis.
  • Investigations: CSF analysis (pleocytosis; possible causative agent detected in bacterial culture) and an MRI scan of the spinal cord (reveals inflammatory changes)
  • Treatment is initiated before the possible causative agent can be determined from the CSF sample. Empirical treatment consists of a combination of doxycycline, acyclovir and methylprednisolone.

Abscesses

  • Epidural
    • Bacterial aetiology, e.g. Staphylococcus aureus or tuberculosis
    • Severe back pain is the initial symptom, followed by progressive paraparesis and ascending sensory level.
    • Antimicrobial treatment is combined with surgical treatment; laminectomy and drainage of the abscess are to be performed without delay.
  • Intradural
    • Caused by e.g. protozoa
    • Symptoms and treatment are the same as in epidural abscesses.

Vascular lesions

Haematomas

  • Epidural
    • Caused by arteriovenous malformations or haemorrhagic disorders
    • Symptoms include motor weakness and sensory loss below the level of the haematoma.
    • Treated as a surgical emergency
  • Intramedullary
    • Symptoms and treatment are the same as in epidural haematomas.

Infarction of the arteria spinalis anterior

  • Often a consequence of an aortic disease (dissection, atherosclerosis)
  • The symptoms develop within a few hours and include severe neck and back pain, bilateral paralysis, loss of sensitivity to pain and temperature below the lesion as well as weakness of the sphincter muscles.
  • Treatment is symptomatic.

Other spinal cord diseases

  • Diffuse spinal cord lesion caused by vitamin B12 deficiency
    • Symptoms are symmetrical and progress slowly. The initial symptoms include sensory losses of the upper and lower extremities. Later on, a walking impairment and loss of vibration sense develop.
    • Treatment consists of permanent vitamin B12 substitution.
  • Medullar injury caused by radiotherapy
    • Early symptoms (3 to 6 months after radiotherapy) include paraesthesias of the upper and lower extremities.
    • Late symptoms (12 to 15 months after radiotherapy) include at first paraesthesias, then muscle weakness.
  • Syringomyelia
    • Central cavity in the spinal cord, usually in the cervical region
    • Aetiology: post traumatic, tumour-related or congenital
    • Symptoms include weakening of the upper extremities together with muscular wasting as well as impairment of sensitivity to pain and temperature.
    • The patient often also has pains in the skull base or in the neck.
    • The disease is chronic but progresses very slowly.
    • May be associated with Chiari malformation
    • Possible treatment is surgical.
  • Malignancies
    • Metastases of tumours or spreading along the leptomeninges (leptomeningeal spreading)
    • Especially melanoma, breast cancer, glioblastoma and lymphoma