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LOCALISATION OF THE LEVEL OF LESION IN A
COMPRESSIVE MYELOPATHY
SPINAL CORD
31 segments
Embryological developmentgrowth of cord lags behind mature spinal cord ends at L1
Upper quadriplegia + weakness of diaphragm
C4-C5 Quadriplegia
C5-C6 Biceps
Cervical cord
C7 extensors
C8 flexion
Nipples T4 Umbilicus T10
SENSORY LEVEL
Disturbance of bladder & bowel habits
Thoracic cord
L2-L4 Paralysis of flexion & adduction of thigh + weakening of leg extension at knee+ patellar reflex lost
L5-S1 Mvmnts of foot & ankle + flexion & knee + extension of thigh + ankle jerk LOST
Lumbar cord
B/L saddle anaesthesia [S3-S5]
Bladder & Bowel dysfunction
Impotence
Bulbocavernosus & anal reflexes absent
Muscle strength preserved
Conus medullaris
Low back& radicular pain
Asymmetrical leg weakness , sensory loss,areflexia in lower extremities
Sparing of bowel & bladder function
Cauda equina
1) Distribution of root pain
ask for specific dermatomes involved
due to the involvement of posterior nerve roots
2) Upper border of sensory loss
examine the patient from below upwards for demonstration of upper border of sensory loss
Due to the affection of spinothalamic tract
3) Girdle like sensation / sense of constriction at the level of lesion
due to the involvement of posterior column
4) Zone of hyperaesthesia/ hyperalgesia
localise the level of lesion one segment below
Due to compression of posterior nerve roots
5) Analysis of abdominal reflex
[ upper abdominal reflex (T7-T9) intact - loss of middle (T9-T11) & lower (T11-T12) ones - site of lesion is probably at T10 spinal segment ]
6) Atrophy of the muscles in a segmental distribution
Due to involvement of anterior horn cells
7) Loss of deep reflexes if the particular segment is innvolved
brisk below the involved segment
8) Analysis of BEEVOR’S SIGN
when the patient attempts to lift his head up from the pillow, against resistance
Rectus abdominis
useful in deciding the level of thoracic spoinal cord lesions
9) Deformity / any swelling in the vertebra
10) Tenderness in the verterbra
11) Area of sweating
Lack of sweating below the level
12) level can also be localised by X-Ray of the spine, Myelography, CT Scan / MRI
DETERMINATION OF SPINAL SEGMENTS IN RELATION TO VERTEBRA…
Cervical vertebra
add 1
T1 - T6
Add 2
T7 – T9
Add 3
T 10
overlies L 1 & L 2 segments
T 11
overlies L 3 & L4 Segments
T 12
Arch overlies L 5 segment
L I arch overlies sacral & coccygeal segments
In the case of non-compressive myelopathy , the question of localisation of the level of lesion does not arise
Synopsis Of Bladder Dysfunction In Neurological Diseases NEUROGENIC BLADDER
UB receives nerve supply from sympathetic- L 1,2,3 [ NERVE OF FILLING ] & Parasympathetic- S 2,3,4 [NERVE OF EVACUATION]
SPINAL BLADDER
A) Incomplete lesion
Precipitancy involvement of inhibitory fibres [multiple sclerosis]
Hesitancy facilitatory fibres involved [incomplete cord compression]
B) Complete lesion
1-Retention of urine wt overflow incontinence
commonly seen in ‘neural shock stage’ of a/c transverse myelitis
evacuation of bladder is usually
incomplete
2-Automatic Bladder
evacuation complete
commonly seen when the neuronal shock stage is over& evacuation occurs by local reflex arc
frequency, urgency &urge incontinence
C) Lesion in the local reflex arc
1- sensory paralytic bladder
loss of awareness of fullness of bladder large volume of urine collects in the
bladder wt huge residual volume
2- motor paralytic bladder
inability to initiate & continue micturition
seen in trauma, pelvic neoplasm
3- Autonomous bladder-
common in cauda equina lesions, pelvic malignancy, spina bifida
no sensation of bladder fullness, bt
having continuous dribbling
THANK YOU…..
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