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The Spinal - Cord
dr. Budhi Suwarma, SpS
FK UNJANI
The Spinal - Cord
Elongated cylindrical mass of nerve tissue
42-45 cm length (adult) Superior border of CI to upper border
L II Conus medullaris conical end of
spinal cord Cervical enlargement C III – Th II Lumbar enlargement Th IX – Th XII
Ending of Spinal - Cord
0-3rd month of fetal life = S V 5th month of fetal life = S I At the time of birth = L III Adult = L I
Divisions of the Spinal Cord
Anterior median fissure Posterior median sulcus Column / funiculi Fasciculus gracilis Gol Fasciculus cuneatus Burdach Central canal Anterior- , lateral- , posterior horn
Segments of the Spinal Cord
Segments Vertebras
Cervical 8 7
Thoracal 12 12
Lumbal 5 5
Sacral 5 5
Coccigeus - 4
Anatomic Relationships of spinal cord and bony spine (adult)
Cord segments
Vertebra bodies
Spinous processes
C8 C VI – VII C VI
Th 6 Th III – IV Th III
Th 12 Th IX Th VIII
L5 Th XI Th X
S Th XII – LI Th XII - LI
Ascending and Descending tracts of the Spinal Cord
Ascending Tracts
Anterior Column
Lateral Column Posterior Column
Ventral spinothalamic (light touch)Spino-olivary (reflex proprioception)
Dorsal & ventral spinocerebellar (rfl. proprioception)Lateral spinothalamic (pain and temperature)Spinotectal (reflex)
Fasciculus gracilis and fasciculus cuneatus (vibration, passive motion, joint and 2-point discrimination)
Descending Tracts
Anterior Column Lateral Column Posterior Column
•Ventral corticospinal (voluntary motion)•Vestibulospinal (balance rfl)•Tectospinal (audiovisual rfl)•Reticulospinal (muscle tone)
•Lateral corticospinal (voluntary motion)•Rubrospinal (muscle tone and synergy)•Olivospinal (reflex)
•Fasciculus interfascicularis & septomarginal fasciculus (association & integration)
Pain and Temperature pathway
• Axons of primary neuron synapse on secondary neurons at dorsal horn nuclei the level of entry
• Secondary axons cross midline near central -canal and run upward via lateral spinothalamic tract (spinal lemniscus) to the ncl VP thalamus tertiary neuron (thalamocortical) cortex
• Axon from face first descend through the brainstem to reach the secondary neuroncross midlinerun upward via trigeminal lemniscus to the ncl ventralis posterior (VP) thalamus
Propriception pathway
• Primary axons ascending in the dorsal columns (leg/fasciculus gracilis/Gol;arm/ fasciculus cuneatus/Burdach)
• Secondary neuron at the medullocervical dorsal column nucleicross the midline run upward via medial lemniscus termin ates ncl ventralis posterior (VP) thalamus cortex post central
Touch pathway
• One pathway through the dorsal column at the medullocervicalsecondary neuron cross the midline runs upward via medial lemniscus terminates in ncl VP thalamus
• Second pathway ,primary neuron synapse with secondary neuron cross the midline and then runs upward via ventral column (ventral spinothalamic) VP thalamus
Spinal Cord Circulation
Anterior Spinal Artery(ASA),formed by the union of VA narrowing at Th4
Lateral spinal arteries, branches from VA via intervertebral foramens low C and upper Th supply C7-Th2
Anterior medial spinal artery,prolonga tion of ASA
Spinal Cord Circulation (cont)
Intercostal aa from the aorta supply segmental branches to the cord. The largest/the great ventral radicular a/ radicularis magna/Adamkiewicz supply lower half cord
Posterior spinal a./posterolateral spinal
Syndrome Of The Spinal Cord Disorders
1. Transverse sensory motor myelopathy
2. Combined painful radicular and transverse cord syndrome (myeloradiculopathy)
3. Hemicord syndrome (Brown – Sequard)
4. Ventral cord syndrome (ASA)
5. Foramen magnum syndrome
6. Central cord syndrome (Syringomyelic)
7. Conus medullaris syndrome
8. Cauda equina syndrome
Syndrome Of The Spinal Cord Disorders (cont.)
e.g. Brown – Sequard syndrome Caused by hemisection of the
spinal cord ( tumor, traumatic, compression fracture )
Below the lesion Ipsilateral loss proprioceptive & ataxia Contralateral loss of exteroceptive Ipsilateral motor paralysis
Syndrome Of The Spinal Cord Disorders (cont.)
Transverse lesion of the spinal cord
motor, sensory, vegetatif, disturbances
below the lesion Intramedullary lesion of the spinal cord
e.g. > Syringomyelia (central cord ) loss of exteroceptive, but retains proprioceptive
in the affected parts( dissociated anesthesia ) Caused by gliosis around the central canal of
the spinal cord
Syndrome Of The Spinal Cord Disorders (cont.)
Conus syndrome (tumor,fract LI,etc) Saddle anesthesia Motoric intact Vegetative disturbance
Cauda syndrome(HNP,tumor,stenosis) Asymmetrical motor and sensory disturb. Vegetative disturbance ±
Syndrome Of The Spinal Cord Disorders (cont.)
Foramen magnum syndrome : Quadriparesis : around the clock pattern Headback pain,stiff neck Weakness & atrophy hands,dorsal neck Variable sensory changes Cerebellar and lower CN involvement
Neoplasm
Less frequent than brain (l5%),mostly benign,compression effect
Intramedullary (5%):lesion within cord
Extramedullary : lesion outside cord Intradural (40%) / Extra Dural (55%)
Neoplasm (Cont.)
Primary extramedullary are neurofibro- ma and meningioma (55%) ; others : sarcoma,vascular tumor,chordoma
Primary intramedullary are ependymo ma (60%),astrocytoma(25%),oligoden- droglyoma
Secondary are extradural metastasis lymphoma,Ca vertebra,Ca paraspinal
Neoplasm (Cont.)
Extramedullar Intramedullar
Pain Radicular Not characteristic
Sensibility Brown Sequard
Dissosiation of sensibility
Localization Unilateral bilateral
Examination
X-ray Vertebrae Myelografi / CTMM MRI
Trauma to The Spine and Spinal Cord
Fracture – dislocations (3)Pure fractures (1)Pure dislocations (1)
Vertebral injury C I-II, C IV-VI, Th XI-LIISatisfactorily demonstrated by CT, MRI, lateral spine X-ray
Tearing of ligaments can only inferred from the spinal displacement
Whiplash / recoil injuryExtremes of extension / flexion of the neck
Other Spinal Cord Injury
Bullet / missile Sharpnel Stab wound Spinal cord concussion
Pathology In Most Traumatic Lesions
Central part of the spinal cord with its
vascular gray matter suffers greater than
the peripheral parts
( Central cervical cord syndrome ) /
Schneider syndrome
Clinical Stage Of Spinal Cord Injury
1. Stage of spinal shock / areflexia
2. Stage of heightened reflex activity
The separation of these two stages is not
as sharp as this statement
Less complete lesion / slowly develops lesion
may result in little or no spinal shock
American Spinal Injury Association (Asia ~ Frankel Scale)
1. Complete : Motor and sensory below the lesion
2. Incomplete : Some sensory preservation below the lesion
3. Incomplete : Motor and sensory sparing, but the patient is non – functional
4. Incomplete : idem and the patient is functional (stands & walks)
5. Complete functional recovery,even reflexes may be abnormal
Inflammatory Disease Of The Spinal Cord
1. Viral myelitis (enterovirus,herpes zos ter,EBV,CMV,HSV1-2,Rabies,HTLV-1 ,AIDS,Varicella zoster)
2. Bacterial, fungal, parasitic,granuloma (TBC,abscess,lues)
3. Non infectious inflammatory type (post infectious,post vaccination,MS, lupus,paraneoplastic)
AIDS vacuolar myelopathy
1. Incidence ¼ AIDS cases
2. Symptoms and signs are obscured by neuropathy/cerebral disorders
3. Mono/hemi/asymetrical parese sen sory and sphincter disordersdeath
4. Posterior and lateral white matter resemble Subacute Combined Deg.
HTLV-1 Tropical spastic paraparesis
Slowly progressive UMN paraparesis CSF cell 10-50/mm3 lymphocyte T,
glucose and protein normal Serum : antibody HTLV-1 + MRI : thinning of the Spinal cord Neuropathology : posterior collum and
corticospinal tract are the main sites
Myelitis e.c. bacterial, fungal, parasitic and granulomatous dis.
Leptomeningitis,pachymeningitis,abscess/granuloma epidural
Pial a./v.thrombosedmyelomalacia
Progressive constrictive pial fibrosis Arachnoiditis
Spinal Epidural Abscess
Fever,pain at the back radicular pain. Spine percussion tenderness
Headache and Nuchal rigidity ± After several dtransverse cord lesion CSF cell < 100/mm3 (except needle pe
netrates the abscess pus),protein 100-400 mg%,glucose normal
Tuberculous (TBC) Myelitis
TBC Spine Osteitis with kyphosis (Pott’s dis)pus/caseous granulation tissueepidural compression of the cordparaplegi
TBC meningitispial arteritisspinal cord infection
Post Infectious and Post Vaccinal myelitides
Temporal relationship to viral infection/ vaccination
Asymmetric weakness and numbness Sphinteric disturbance and backache CSF mononuclear 10-100/mm3, gluco
sa normal, protein slightly raised MRI : swollen cord
Paraneoplastic Myelitis
Bronchogenic Ca,Visceral lymphoma Rapid progression long tracts signs CSF : few mononuclear,protein slight
increase No evidence of an infective-inflammato
ry/ischemic lesion No tumor cells in CSF,meningen,cord
Vascular disease Of The Spinal Cord
Infarction (myelomalacia)ASA syndr. Hemorrhage into the cord/spinal canal Vascular malformation Uncommon (1,2% compare to brain) Spinal a.not susceptible to atheroscle
rosis and emboli rarely lodge there Watershed-borderzone infarction
ASA syndrome
Sudden onset of paraparese Bilateral loss of sensory Dorsal collum intact
Hematomyeli (cord) and Hematorrhachis (spinal canal)
Hematomyeli is rare compared to ICH e.c.trauma,AVM,bleeding disease,AC)
Epidural/subdural hemorrhagecom pressive myelopathy immediate radi ologic studysurgical evacuation
Advances in the techniques of selectiv spinal angiography and microsurgery
Vascular Malformation
Venous angioma, dorsal surface lower half cord,middle age/elderly,nevus, series episodes cramplike,lancinating sciatica,worse in recumbency weak ness one/both legs
Arteriovenous angioma,dorsal surface Th and upper L or anterior C,young, slow cord compression
Nutritional Deficiency
Subacute combined degeneration Degeneration of the posterior & lateral
column Loss of proprioceptive Tetraparalysis In the advanced cases of pernicious
anemia ( vit. B12 deficiency )
Demyelinisasi : Multiple Sclerosis
Episodes of focal disorder of 2nd CN, spinal cord and brain which remit and recur over a period of many years
Long perod of latencydelay the D/ Prevalence 1/100.000 equatorial areas Diagnosa :CSF cell < 50,protein ↑,oligo
clonal IgG,evoked potential,MRI
Other Myelopathy (Primary/Secondary)
Amyotropic Lateral Sclerosis (ALS) Progressive Muscular Atrophy (PMA) Syringomyelia Cervical Spondylosis HNP
Amyotrophic Lateral Sclerosis
Incidence 0,4-1,76/100.000 population, men>women,>50 yrs old
Triad : atrophic weakness hands&fore- arms,slight spasticity arms&legs,gene- ralized hyperreflexia,absence of senso ry change
Progressive Muscular Atrophy
men>women,mostly symmetrical wasting intrinsic hand musclesmore proximal arms
Progress slower than ALS Tendon reflex ↓ or -,signs of UMN -
Progressive Bulbar Palsy
Weakness jaw,face,tongue,phraynx and larynx,difficult to pronounce r,n,l,b,m,p,f,d,t,k,g.
Bulber palsy,lower face weaken-sag, fasciculation and atrophy of tongue, bulldog reflex,pathologic laughter and crying respiratory muscles weakness
Syringomyelia
Chronic progressive degenerative cavi tation of central cord usually at C, in severe cases extending up/downward
90% associated with type I Chiari malf. Segmental weakness&atrophy hand-
arm,tendon reflex-,dissociation pain- touch sensation
Syringobulbi : face,tongue,palatum
Cervical Spondylosis
40% beyond 50 yrs,75% showed radio logic abn of C canal, painful stiff neck
Pain at the back of neck + brachialgia/ radiculopathy C, Lhermitte’s sign
Compressive myelopathy Paraparesis UMN Unsteady gait (sensory ataxia) Altered sphincter control
Hernia Nucleus Pulposus
Fraying of the annulus fibrosusextru sion of disc material (# bulging)
CVI-VII(7th C-70%),CV-VI(6th C-20%), CIV-V(5th C-5%),CVII-ThI(8th C-5%)
LV-SI(1st S)LIV-VLIII-IV NCV,H reflex,X-ray photo,MRI
HNP Lumbar
3rd-4th decade,flexion injury, trauma ? Degeneration NP,ligamentum,annulus Radiating pain,unnatural spine posture
paresthesia,weakness,tendon reflex ↓, pain over facet joint and Valleix points, limited Laseque,Bragard,Neri,Naffziger and Contra Laseque.
Failed-Back Syndrome
Have had a disc removed but still have back and leg pain (10% re-operate)
Overlooked : lateral protrusion,intradu ral herniation,extrusion original site/ another level,foraminal stenosis,facet hypertrophy,spinal stenosis,arachnoid it is,epidural scarring
HNP Cervical
Neck ROM ↓,pain ↑ with hyperextens ion,coughing,sneezing,flexion
7th C root:pain shoulder blade,pectoral, medial axilla,posterolateral upper arm, elbow,dors fore arm,index-midle finger
6th C root:pain trapezius ridge,tip shoul der,anterior upper arm,radial fore arm, thumb
SELESAI