Transverse myelitis

An acute transverse myelopathy can result from a variety of pathological mechanisms: Non-infective causes include MS, SLE , sarcoidosis and after vaccination. Viral infections: Echo virus, herpes zoster, EpesteinBarr virus and Cytomegalovirus. Bacterial infection: Tuberculosis & brucellosis Non-viral infective agents include scistosomiasis, mycoplasma and toxoplasma. The eatiology is not established in a substantial proportion of cases.

The clinical picture of the condition include rapid paraplegia associated with sensory level and sphincters disturbances.

Spinal cord infarction

The spinal cord is supplied by separate anterior and posterior arterial systems. The anterior aspect of the cord is supplied by the anterior spinal artery (cervical), radicular arteries (at all levels) and a particular radicular artery, that of Adamkiewicz, which is a major contributor to the lower thoracic and lumbar cord. The posterior aspect of the cord is supplied by the posterior spinal arteries, again supplemented by posterior radicular vessels.

Clinical pictures: a vascular event is typically of rapid onset resulting in a mixture of motor, sensory and sphincteric symptoms. Involvement of the anterior spinal artery, typically by atheroma or aortic dissection, produces a flaccid weakness with lower motor neurone features in some cases. Infarction of the posterior cord is less common and produces a predominant sensory deficit. Venous infarctions occur but are seldom diagnosed in life.

Investigation is of limited value, though MRI may reveal evidence of cord swelling at the relevant level. There is no specific treatment.

Conus & epiconus infarction

Spinal arteriovenous malformations

Two main forms of spinal malformation are distinguished: dural and intradural. arteriovenous (AV)

Dural AV fistulae, which are virtually confined to the thoracolumbar region, tend to present with a gradually evolving mixed motor, sensory and sphincteric syndrome in which the symptoms are frequently exacerbated by exercise. Subarachnoid haemorrhage as a presenting feature is rare.

Intradural malformations can also present insidiously but at least 50 per cent of the patients will have had a subarachnoid haemorrhage by the time of diagnosis. Investigation: MRI Arterial angiography
Multiple flow voids

Treatment: Alternative approaches include surgery, stereotactic surgery and embolization.

Subacute combined degeneration of the spinal cord. It is secondary to vitamin Bl2 deficiency. Myelin degeneration commences in the posterior columns, later involving the lateral and anterior columns. Subsequently, axonal degeneration appears. Degenerative changes can extend to the peripheral nervous system.

Clinical features Sensory symptoms are prominent from the beginning with peripheral paraesthesiae affecting the legs more than the hands. Subsequently weakness and stiffness of the legs appear, and there may be changes in mood and behaviour. Findings include predominant posterior column sensory loss, and paraplegia though often with depressed or absent ankle reflexes.

Spinal tumours
Clinical features of spinal tumours The clinical features of a spinal tumour depend on its segmental location, whether it is intramedullary or extramedullary, and its speed of growth.

Tumour types differs in adults and children. Meningiomas and neurofibromas comprise about 65% of all primary spinal tumours. Intramedullary tumours are more common in children, and Extramedullary tumours are more common in adults. The primary sites of metastatic tumours to the spine in order of frequency are lung, breast and prostate. Osteoblastic changes are more common in prostate carcinoma.

Extradural

Intradural

Adults Children % % 78 78 (metastasis) 18 04

Meningioma Schwannoma Dermoid epidermoid

Intramedullary

18

Lesions at the foramen magnum Pain in association with a foramen magnum tumour, usually a neurofibroma or meningioma is liable to be referred to the neck and occipital region of the skull. A quadriparesis appears, sometimes associated with wasting of the small hand muscles. A Horners syndrome is more likely with intramedullary than extramedullary tumours. Additional signs include disturbance of function of the eleventh and twelfth cranial nerves and down-beating nystagmus.

Cervical lesions At the level of the tumour, lower motor neurone signs appear, including wasting, weakness and fasciculation with depressed reflexes. If there is also cord compression, weakness and spasticity appear in the lower limbs together with altered sphincter function.

Extramedullary tumours are likely to produce a radicular pattern of sensory loss. Intramedullary tumours produce a disturbance of long tract sensory function, either of pain and temperature or joint position sense.

Clinical guidelines to extramedullary lesion

differentiate

intramedullary and

Radicular pain

Extramedullary common early

Intramedullary unusual

Vertebral pain Segmental pain Bilateral paresthesia Dissociated sensory

UMN signs LMN signs

common less common Ascending Uncommon

unusual common descending pattern Common

late early bilateral Prominent & diffuse unusual & if present segmental

Sphincteric

late

early

Thoracic lesions
Radicular pain is common with meningioma neurofibroma. A spastic paraparesis with a sensory level on the trunk to pain or temperature which tends to be slightly below the level of compression.

Conus and cauda equina lesions

Cauda equina lesion produce a flaccid paraparesis, with areflexia, segmental sensory loss and a severe disturbance of sexual and sphincter function. Conus lesions which extend into the epiconus produce a mixture of upper and lower motor neurone signs, with reflex abnormalities determined by the site of the tumour.

Spinal cord clinical syndrome The clinical picture with cord compression tends to follow three patterns. A transverse cord lesion disrupts all cord function below that level, with an appropriate sensory level, and a motor deficit involving either both upper and lower limbs, or the lower limbs alone, according to whether the cervical or thoracic cord is compressed.

A hemicord syndrome (Brown Squard) Usually seen with extrinsic cord compression, but can also develop with intramedullary tumours. Typically, ipsilateral to the compression, there is a pyramidal deficit along with posterior column signs, with contralateral loss of spinothalamic function.

Central cord syndrome Intramedullary tumours can lead to a suspended level of pure spinothalamic loss with pyramidal signs below the site of the lesion.

Specific tumours
Intramedullary tumours Astrocytomas predominate in the cervical and thoracic segments of the cord and are usually of low grade malignancy and slow growing. Some are sufficiently demarcated to allow surgical removal. Ependymomas predominate in the filum terminale and are most often seen in middle-aged adults. The tumours are usually well defined and easily separable surgically. Intramedullary metastases Bronchogenic carcinoma is the usual source. In many cases, cerebral metastases coexist.

Tumours of the spinal meninges Meningioma Usually occur in the thoracic region and predominate in women. Spread is principally within the intradural space. Typically, symptoms evolve gradually, usually over months. Metastatic carcinoma and lymphoma are liable to involve both the spinal and cranial meninges.

Nerve sheath tumours Most Schwannomas are isolated tumours arising from the dorsal root. Multiple tumours are usually a manifestation of Von Recklinghausens disease. The peak incidence in the fourth and fifth decades of life. Most remain confined to the intradural space, but some pass through an intervertebral foramen, forming a dumb-bell shaped mass.

Tumours of the epidural space and spine Metastatic carcinoma The most common sources for extradural metastases are the breast, bronchus, prostate and kidney. About two-thirds occur in the thoracic region. Local or referred pain is the usual presenting complaint followed by evidence of spinal cord involvement. Other the epidural include Lymphoma, leukaemia and Multiple myeloma . Chordomas usually arise in the sacral region.

Investigation of spinal tumours Plain X-ray Plain X-rays of the spine are of no value in the diagnosis of intramedullary tumours, unless the tumour is calcified or has eroded an intervertebral foramen.

When the tumour has extended outside the vertebral canal, plain X-rays are likely to detect a paravertebral mass

CT myelography allows better definition of cord expansion.

MRI has proved of great value in the diagnosis of spinal tumour. For intramedullary tumours, MRI defines their exact extent, indicates if they are cystic, and establishes whether there is an associated syringomyelia.

Congenital disorders Neural tube defects Failure of cranial neural tube closure results in different types of anomalies.

Spina bifida occulta In this condition the two halves of the vertebral arch fail to fuse. The lumbosacral junction is often involved. The defect, which is asymptomatic, is sometimes declared by a dimple or tuft of hair on the overlying skin surface.

Spina bifida cystica Meningocoele: Protrusion of the meninges, and their contained CSF, through a vertebral defect. Myelomeningocoele: Protrusion of the meninges, spinal cord or roots. These defects, which appear most commonly in the lumbar region, are found in about 1:1000 births.