Unit I herbs as raw materials, biodynamic agriculture.ppt
Spinal cord disorders Anatomical Approach
1. SPINAL CORD DISORDERS
ANATOMICAL APPROACH
Dr PS Deb MD, DM
Director Neurology
Guwahati Neurological Research Institute
Assam, India
2. SPINAL CORD
Information highway between brain and body
Extends through vertebral canal from foramen magnum to L1
Each pair of spinal nerves receives sensory information and issues
motor signals to muscles and glands
Spinal cord is a component of the Central Nervous System while the
spinal nerves are part of the Peripheral Nervous System
3. SPINAL CORD FUNCTIONS
Conduction
bundles of fibers passing information up and down spinal cord
Locomotion
repetitive, coordinated actions of several muscle groups
central pattern generators are pools of neurons providing control of flexors and
extensors (walking)
Reflexes
involuntary, stereotyped responses to stimuli (remove hand from hot stove)
involves brain, spinal cord and peripheral nerves
4. SPINAL CORD - ANATOMY
Runs through the vertebral canal
Extends from foramen magnum to second
lumbar vertebra
Regions
Cervical
Thoracic
Lumbar
Sacral
Coccygeal
Gives rise to 31 pairs of spinal nerves
All are mixed nerves
Not uniform in diameter
Cervical enlargement: supplies upper
limbs
Lumbar enlargement: supplies lower limbs
Conus medullaris- tapered inferior end
Ends between L1 and L2
Cauda equina - origin of spinal nerves
extending inferiorly from conus medullaris
6. SPINAL CORD: LONGITUDINAL EXTENT
Spinal cord stretches from
foramen magnum till coccyx in
fetal life then due to growth of
spine it fall short
At 3rd fetal month up to coccyx
At birth lower border of L3
Adult spinal cord ends at lower
border of L1 body
8. COVERING OF SPINAL CORD
Connective tissue
membranes
Dura mater: outermost layer;
continuous with epineurium of
the spinal nerves
Arachnoid mater: thin and
wispy
Pia mater: bound tightly to
surface
Forms the filum terminale
anchors spinal cord to coccyx
Forms the denticulate ligaments
that attach the spinal cord to the
dura
Spaces
Epidural: external to the dura
Anesthestics injected here
Fat-fill
Subdural space: serous fluid
Subarachnoid: between pia
and arachnoid
Filled with CSF
10. SPINAL CORD TRANSVERSE SECTION
Anterior median fissure and
posterior median sulcus
deep clefts partially separating
left and right halves
Gray matter: neuron cell bodies,
dendrites, axons
Divided into horns
Posterior (dorsal) horn
Anterior (ventral) horn
Lateral horn
White matter
Myelinated axons
Divided into three columns
(funiculi)
Ventral
Dorsal
lateral
Each of these divided into
sensory or motor tracts
11. SPINAL CORD TRANSVERSE SECTION
Commissures: connections between left
and right halves
Gray with central canal in the center
White
Roots
Spinal nerves arise as rootlets then
combine to form dorsal and ventral
roots
Dorsal and ventral roots merge laterally
and form the spinal nerve
12. SPINAL CORD GRAY MATTER
Dorsal half – sensory roots and ganglia
Ventral half – motor roots
Based on the type of neurons/cell bodies located in each horn, it is
specialized further into 4 regions
Somatic sensory (SS) - axons of somatic sensory neurons
Visceral sensory (VS) - neurons of visceral sensory neur.
Visceral motor (VM) - cell bodies of visceral motor neurons
Somatic motor (SM) - cell bodies of somatic motor neurons
13. GRAY MATTER OF SPINAL CORD
Lamina I - posteromarginal nucleus
Lamina II - substantia gelatinosa of
Rolando
Lamina III, IV - nucleus proprius
Lamina V, VI
Lamina VII - intermediate gray
intermediolateral cell column (ILM)
Clarke’s column (Nucleus dorsal
intermediomedial cell column (IMM)
Lamina VIII
Lamina IX - anterior horn (motor) cell
Lamina X - gray commissure
16. WHITE MATTER OF SPINAL CORD
Divided into three funiculi (columns) – posterior, lateral, and anterior
Columns contain 3 different types of fibers (Ascend., Descend., Trans.)
Fibers run in three directions
Ascending fibers - compose the sensory tracts
Descending fibers - compose the motor tracts
Commissural (transverse) fibers - connect opposite sides of cord
Pathways decussate (most)
Most consist of a chain of two or three neurons
Most exhibit somatotopy (precise spatial relationships)
All pathways are paired
one on each side of the spinal cord
18. CORTICOSPINAL TRACT
Originate in the precentral gyrus
of brain (aka, primary motr area)
I.e., cell body of the UMN located
in precentral gyrus
UMN synapses in the anterior
horn with LMN
Some UMN decussate in
pyramids = Lateral corticospinal
tracts
Others decussate at other levels
of s.c. = Anterior corticospinal
tracts
LMN (anterior horn motor
neurons)
Exits spinal cord via anterior root
Activates skeletal muscles
Regulates fast and fine (skilled)
movements
19. EXTRAPYRAMIDAL TRACTS
Includes all motor pathways not part of the pyramidal system
Upper motor neuron (UMN) originates in nuclei deep in cerebrum (not in cerebral
cortex)
UMN does not pass through the pyramids!
LMN is an anterior horn motor neuron
This system includes
Reticulospinal tracts – originates at reticular formation of brain; maintain balance
Rubrospinal tracts – originate in ‘red nucleus’ of midbrain; control flexor muscles
Tectospinal tracts - originate in superior colliculi and mediate head and eye
movements towards visual targets (flash of light)
Vestibulospinal Tract – muscle tone in relation to head and neck movement
Regulate:
Axial muscles that maintain balance and posture
Muscles controlling coarse movements of the proximal portions of limbs
Head, neck, and eye movement
22. ASCENDING PATHWAY
The central processes of first-order neurons branch diffusely as they enter
the spinal cord and medulla
Some branches take part in spinal cord reflexes
Others synapse with second-order neurons in the cord and medullary nuclei
The nonspecific and specific ascending pathways send impulses to the
sensory cortex
These pathways are responsible for discriminative touch (2 pt. discrimination) and
conscious proprioception (body position sense).
The spinocerebellar tracts send impulses to the cerebellum and do not
contribute to sensory perception
24. DIRECT SPINOTHALAMIC TRACT
Include the lateral and
anterior spinothalamic tracts
Lateral: transmits impulses
concerned with pain and
temp. to opposite side of
brain
Anterior: transmits impulses
concerned with crude touch
and pressure to opposite
side of brain
1st order neuron: sensory
neuron
2nd order neuron:
interneurons of dorsal horn;
synapse with 3rd order
neuron in thalamus
3rd order neuron: carry
impulse from thalamus to
postcentral gyrus
26. SPINOHTALAMIC PAIN TYPES
Fast Pain Slow Pain
Sharp, pricking Dull, burning
Group III (A) fiber Group IV (C) fiber
Short latency Slower onset
Well localized Diffuse
Short duration Long duration
Less emotional Emotional, autonomic response
Not blocked by morphine Blocked by morphine
Neospinothalamic Tract Paleospinothalamic Tract
27. 13-27
SPINORETICULAR TRACT
Pain signals from tissue injury
Decussate in spinal cord and ascend with spinothalamic fibers
End in reticular formation (medulla and pons)
3rd and 4th order neurons continue to thalamus and cerebral cortex
28. SPINOCEREBELLAR
TRACTS
Spinocerebellar Tract
Proprioceptive signals from limbs and
trunk travel up to the cerebellum
Second order nerves ascend in
ipsilateral lateral column.Transmit
info. about trunk and lower limb
muscles and tendons to cerebellum
No conscious sensation
Anterior SCbllT
(superior
cerebellar
peduncle)
anterior
spinocerebellar
tract
anterior white
commissure
posterior root
Posterior SCbllT
Inferior
cerebellar
peduncle
cuneocerebellar
tract
(upper body)
posterior
white column
posterior root
29. (A) THE DORSAL (POSTERIOR) SPINOCEREBELLAR TRACT.
(B) THE CUNEOCEREBELLAR TRACT. SEE TEXT FOR DETAILS.
31. POST. COLUMN
Dorsal Column Tract
1. AKA Medial lemniscal pathway
2. Fibers run only in dorsal column
3. Transmit impulses from receptors in
skin and joints
4. Detect discriminative touch and
body position sense =proprioception
1st order neuron - a sensory neuron
synapses with 2nd order neuron in nucleus
gracilis and nucleus cuneatus of medulla
2nd order neuron.- an interneuron
decussate and ascend to thalamus where it
synapses with 3rd order neuron
3rd-order (thalamic neurons)
transmits impulse to somato-
sensory cortex (postcentral gyrus)
32. VASCULAR SUPPLIES OF SPINAL CORD
Posterior spinal artery Anterior spinal artery
Origin Vertebral arteries
inside the skull
Posterior inferior
cerebellar artery
Formed by the union of the 2
arteries which are arising
from the vertebral artery
inside the skull
Position Descends on the
posterior surface of
the spinal cord close
to the posterior nerve
roots
Descends on the anterior
surface of the spinal cord
within the anterior median
fissure
Supply Posterior 1/3 of the
spinal cord
Anterior 2/3 of the spinal
cord
Remark Small in the upper
thoracic region
Small in the upper and lower
thoracic segment of the
spinal cord
Risk of
ischemia
T1-T3 segments if the
segmental or radicular
arteries are occluded
T4 & L1 segments if the
segmental or radicular
arteries are occluded
34. FEATURES SUGGESTIVE OF SPINAL CORD DISEASE
System Features
Motor – weakness Acute Flaccid
Chronic Spastic
Sensory - Loss Spinothalamic Below the level contralateral
Post. Column Ipsilateral below the level
Autonomic - Loss Acute Retention, flaccid
Chronic Automatic, spastic
Reflex - Altered Acute – Loss of all reflex
Chronic Deep – exaggerated
Superficial – Altered – abdominal,
cremastic absent, plantar extensor
Other features Level of consciousness - maintained
Cognition - Normal
Cranial nerve - Normal
35. SPINAL CORD SYNDROMES
1. Nature of pathology
1. Compressive
1. Intramedullary
2. Extra medullary
1. Intradural
2. Extradural
2. Non compressive
2. Anatomical location of lesion
1. Transverse
2. Longitudinal
3. Progression and onset of symptoms
1. Acute
2. Chronic
4. Age of onset
1. Childhood
2. Adulthood
3. Elderly
36. SPINAL CORD: EXTRINSIC
Radicular involvement
Asymetric, progression in
inverted U pattern
Ipsi Lateral Hemiplegia,
contralateral spinothalamic
lesion
Ipsilateral posterior column
sensory loss
38. signs intramedullary extramedullary
Radicular pain unusual common
Vertebral pain unusual common
Funicular pain common Less common
Umn Sign +, late +, early
Lmn sign +++, diffuse Unusual,
segmental
Paraesthesia progr descending ascending
sphincter early late
Trophic common unusual
39. Extramedullary Intramedullary
Motor
a)UMN signs Common Late
b)LMN signs 1or2segments at the site of
root compression
wide (Ant horn cell)
Sensory
a)Pain Root pain Funicular pain
b)Dissociated sensory loss Absent present
c)Sacral sensation Lost Preserved
d)Joint sensation Lost Late involvement
e)Lhermitte`s sign present absent
Autonamic involvement –
Bowel and Bladder
Late Early
Intradural Extradural
Mode of onset Asymmetrical , acute,rapid
malignant
Symmetrical,slow,
progressive
benign
Vertebral No Pain and gibbus Pain and Gibbus
45. A. TRANSACTION OF CORD
Etiology
Trauma
Demyelination
Vascular
Tumor
Infection
Radiation
46. CLINICAL FEATURES
At the level of lesion
Band like radicular pain or
Segmental paraesthesia
Lower motor signs
Localised vertebral spine pain- destructive lesions
Below the level of lesion
Sensory loss (all modalities)
Motor loss (Paraplegia, Quadriplegia)
Arflexia -> hypereflexia
Bladder bowel involvement
47. STAGES OF ACUTE CORD SYNDROME (RIDDOCH)
Stage of spinal shock
Motor autonaumic areflexia for 1-6weeks
Sometimes last longer or permanent with minimal recovery
Mechanism
Release of supraspinal control
Vascular
Stage of hightended activity
Below the lesion
Tendon hyperreflexia
Babinski sign
Flexor spasm
Reflex bladder bowl mass reflex
Increased by infection and nociceptive stimuli
Above the lesion
Autonaumic dysreflexia- Disinhibited sympathetic adrenal and medullary discharge->
sweating flussing hypertension, bradycardia
48. B. CENTRAL CORD SYNDROME
Etiologies
1. Trauma: Especially with
1. Cervical arthritis
2. Older patients
3. Spondylitic myelopathy
2. Syringomyelia
3. Neoplasm:
1. Metastatic, Glioma, lymphoma
49. CLINICAL FEATURES
Sensory loss
Pain & temperature (crossing fiber of spinothalamic tract) > Thermo
anaesthesia, analgesia in a ”vest like” or “suspended” bilateral
distribution with preservation soft touch sensation and proprioception--
- dissociation of sensory loss
Sparing: Sacral
Weakness: Arms > legs (Man in Barrel)
May occur in absence of spinal fracture
50. PROGRESSION OF CENTRAL CORD
Forward extension of disease
anterior horn cells inv- segmental neurogenic atrophy, paresis,
areflexia
Lateral extension
I/L horner syndrome
kypho scoliosis
spastic paralysis
Dorsal extension
I/L position sense, vibratory loss
Extreme venterolateral extension
thermo anaesthesia, analgesia with sacral sparing
Neuropathic arthropathy
Pain
51. C. ANTERIOR CORD SYNDROME
Etiology:
Anterior spinal artery territory ischemia
Disc: osteophytes
Clinical Feature
Loss: Motor function Legs > Arm (Corticospinal tract)
Pain & temperature sensation loss with preservation: Position sense
(Dissociated anesthesia)
52. D. ANTERIOR HORN CELL SYNDROME
Aterior horn cell, cranial motor
nuclei involved
Autosomal recessive spinomuscular
atrophy
Diffuse weakness and atrophy,
fasciculations of trunk and
extremities
Muscle tone& DTR ↓
Sensation intact
53. COMBINED ANTERIOR HORN CELL AND PYRAMIDAL TRACT
DISEASE
Progressive diffuse LMN signs with
UMN dysfunction
Striated muscles except pelvic floor
mucles affected
U/L, muscles of hands and foot are
involved
Sparing rectal and urethral sphincter
Bulbar and pseudobulbar inv super
imposed
54. E. POSTERIOR CORD SYNDROME
Etiology
Posterior spinal artery damage
Diffuse atherosclerosis: Deficient collateral perfusion
B12 deficiency
Lipoma
Ligamentum flavum hypertrophy
Bimondo’s post column degeneration
Tabes dorsalis
Clinical Features
Loss: Position sense
Relative preservation: Motor, pain & temperature
Prognosis: Better than anterior syndrome
55. F. POSTERO LATERAL COLUMN DISEASE
Etiology
SACD- B12 def
Vacuolar myelopathy- AIDS-HTLV
1, tropical spastic paraparesis
Cervical spondylosis
Clinical
paraesthesia,
diffficulty with gait , balance,
loss of vibration and
proprioception, sensory ataxia,
rombergs +,
bladder atony,
reflexes lost or hypo active –
super imposed peripheral
neuropathy
56. G. ANTERIOR HORN CELL SYNDROME
Aterior horn cell, cranial motor
nuclei involved
Autosomal recessive
spinomuscular atrophy
Diffuse weakness and atrophy,
fasciculations of trunk and
extremities
Muscle tone& DTR ↓
Sensation intact
57. H. COMBINED ANTERIOR HORN CELL AND PYRAMIDAL
TRACT DISEASE
Progressive diffuse LMN signs
with UMN dysfunction
Striated muscles except pelvic
floor mucles affected
U/L, muscles of hands and foot
are involved
Sparing rectal and urethral
sphincter
Bulbar and pseudobulbar inv
super imposed
58. I. BROWN-SÉQUARD: HEMICORD INJURY
Etiologies
Tumor: Dumbbell
Facet; Luschka joint
Trauma: Penetrating
Radiation
Decompression sickness
Clinical Features
Ipsilateral loss
Weakness
Position sense
Contralateral loss
Pain & temperature
60. FORAMEN MAGNUM SYNDROME & LESIONS OF UPPER
CERVICAL CORD:
Sub occipital pain in C2 distribution, neck stiffness, electric shock like sensation
sub occipital paraesthesia, syringo myelic type of sensory dissociation, finger tip
numbness and tingling
Spastic tetraparesis, long tract sensory findings, lower cranial nerve palsy
“around the clock presentation of UMN type of weakness
foramen magnum lesion- down beat nystagmus, papilloedema ,cerebelar ataxia
causes: tumour,cx spondylosis, basilar invagination in pagets disease , syrinx,
C1C2 subluxation, chiari, MS
61. Pyramidal tract decussates at cervicomedullary jn- lesion at
this place causes HEMIPLEGIA CRUCIATA, onion skin
pattern of facial sensory loss, respiratory insufficiency,
bladder dysfunction
Compressive lesion of C1-C5 cord segment may compromise
the cranial nerve 11
C3-C5 lesion produces diaphragmatic paralysis
High cervical cord lesion- respiratory arrest
62. Lesions of C5-C6:
LMN signs at corresponding segment level. UMN sign below the lesion, LMN paresis
of arm associated with spastic para paresis of lower extremities.
C5 level:
Diaphragmatic function compromised
BJ&BRJ –ve
TJ & FFR ++++
Inversion of brachio radialis reflex
Sensory loss entire body below neck and anterior shoulder
C6 level:
BJ,BRJ,TJ –ve & FFR ++++
Sensory loss samme as that of C5 lesion sparing the lateral part of arm
63. Lesion at C7:
Diaphragm fn normal
Paresis of flexors and extensors of wrist and fingers
BJ,BRJ-Normal, FFR++++
Paradoxical triceps jerk
Sensory loss at /below 3rd 4th finger
Lesion at C8 T1:
Weakness of small muscles of hands with spastic paraparesis
C8 inv- TJ &FFR-ve
T1 inv-TJ –Normal, FFR-ve
U/L or B/l horner syndrome
Sensory loss starts from fifth digit
64. Lesion of thoracic segment level:
Root pain , paraesthesia mimicking intercostal neuralgia
Segmental LMN paralysis
Paraplegia and sensory loss below a thoracic level
Bladder, bowel sexual dysfunction
Lesion above T5- orthostatic hypotension, episodic autonomic
dysreflexia
Lesion at T10- +ve Beevors sign
Lesion at T6- abdominal reflex –ve
Lesion at T10 – upper, middle part +ve
Lesion at T12- abdominal reflex intact
65. Lesion at L1:
All muscles of lower extremities – weak
Lower abd musc- Internal oblique, tr abd weak
Sensory loss – both lower limbs up to groin, to a level above buttocks
Chronic lesion- patellar++++, ankle++++
Lesion at L2:
Spastic paraparesis
Cremasteric reflex↓↓, patellar reflex ↓↓
Ankle jerk ++++
Sensation in upper anterior aspect preserved
66. Lesion at L3:
Some preservation of hip flexion, adduction
KJ ↓↓, ankle++++
Sensation upper anterior aspect of thigh normal
Lesion at L4:
Better hip flexion, adduction
Able to stand stabilising knee
KJ↓↓ , ankle++++
Sensation normal in anterior aspect of thigh, superomedial aspect of knee
Lesion at L5:
Normal hip flexion, adduction
KJ- normal, ankle++++ pt extends knee against resistance
Sensation normal in antr aspect of thigh, medial aspect of legs ankle and sole
67. Lesion at S1:
Weakness of triceps surae, flexors of foot, and small muscles of foot
Ankle reflex↓↓, KJ-normal
Sensory loss- sole, heel, outer aspect of foot and ankle, medial aspect of calf, posterior
thigh, outer aspect of saddle area also anaesthetic
S2 lesion:
Triceps surae spared, flexors of toes, small muscles of foot weakness
Ankle jerk ↓↓
Sensory loss- upper part of dorsal aspect of calf, dorsolateral aspect of thigh and
saddle area
68. ROOT SYNDROMES
Root Sensation Index Muscle Reflex Comments
C3/4
Pain or hypalgesia in
shoulders
Paresis of diaphragm,
occasionally rhomboids
None
C3 anterior diaphragm,
C4 posterior diaphragm
C5
Pain or hypalgesia laterally
over upper arm and shoulders
Paresis of deltoid,
supraspin-atus, infra-
spinatus, rhomboids
Diminished
biceps reflex
Common causes include
brachial neuritis, upper
plexus injury, cervical
spondylosis
C6
Pain or hypalgesia of radial
forearm, thumb, and index
finger
Paresis of biceps,
brachialis, brachiorad-ialis,
Extensor carpi radialis
Diminished
biceps,
brachiorad ialis
reflex
Common causes include
spondylosis, acute disc
lesion (20%)
C7
Pain or hypalgesia over
triceps, mid- forearm and
middle finger
Paresis of triceps,
latissimus dorsi, pectoralis
major, ext. carpi ulnaris ,
flex. carpi radialis
Diminished or
absent triceps
reflex
Common causes
includes acute disc
lesions (70%),
spondylosis, DDX
includes CTS (triceps
reflex present)
C8
Pain or hypalgesia over ulnar
forearm, 4th/5th digits
Paresis of flex. dig. sup. &
profundus, flex. poll.
longus, flex. carpi ulnaris
Diminished
finger jerk
(Hoffmans or
Tromner)
Caused rarely by
spondylosis or acute
disc lesion; DDX
includes ulnar nerve
palsy
69. ROOT SYNDROMES
Root Sensation Index Muscle Reflex Comments
T1
Pain or hypalgesia from axilla to
olecranon
Paresis of all small
hand muscles and
hypothenar wasting
None
Common causes
include outlet
syndrome, pancoast
tumor, metastatic Ca of
deep cervical nodes
L3
Pain or hypalgesia across upper
anterior thigh
Paresis of quadriceps
femoris
Patellar reflex
decreased or
absent
DDX includes femoral
nerve palsy
L4
Pain or hypalgesia from lateral
thigh, over patella to medial calf and
inner foot
Paresis of quadriceps
femoris, and tibialis
anterior
Patellar reflex
diminished
5% lumbar discs, DDX
includes femoral nerve
palsy
L5
Pain or hypalgesia from postero-
lateral thigh to lateral calf to dorsum
of foot
Paresis of EHL, occ
EDB
Posterior tibial
reflex decreased;
useful only if
elicitable on other
side
40% lumbar discs; DDX
includes peroneal
nerve palsy
S1
Pain or hypalgesia from posterior
thigh down to lateral aspect and
sole of foot
Paresis of triceps
surae, hamstrings,
gluteus maximus
Achilles tendon
reflex decreased
45% lumbar discs