Spinal Chord Syndromes

Spinal Chord Syndromes

·        Prognosis depends on time to treatment: speed is important

·        Trauma:

o   Transfer to specialist unit within 24 hours unless medically unstable 

o   Catheterise: bladder won‟t work ® urinary retention 

o   Check underneath them before transferring. An unfelt pen or other object will cause a full thickness pressure sore during 2 hour transfer ® 3 months to heal 

o   200 per year in NZ (same as severe HI). Mainly young men ® long term disability, lots of ongoing psychological problems 

·        Extradural spinal cord compression (EDSCC)

o   Usually cancer.  Also haemorrhage (epidural haematoma) or epidural abscess

o   Key questions: where is the lesion, what is the lesion (eg weight loss, past cancer history Þ cancer)

o  If there is a clear level below which these is sensory abnormality Þ spinal chord

o  If both legs then spinal chord (usually).  Can be parasagital meningioma (very rare)

o  Are arms normal: if so T2 highest possible level

o  If there are signs of an upper motor neuron lesion in the legs then it MUST be above the cell bodies of L3 – S5 in the conus of the spinal chord, which is at T12 vertebral level Þ if UMN lesion then it is in thoracic spine or above

o  95% have pain at the site of compression ® very good indicator. Tap gently down spinal chord with tendon hammer

o  Imaging: MRI

o  If can‟t be completely sure it‟s cancer MUST biopsy (eg chronic infection)

o  Cancers:

§  Lymphoma

§  Female: breast

§  Male: lung, sometimes prostate

·        Transverse Myelitis:

o  Inflammation of spinal chord itself

o  Same symptoms as EDSCC, but no compressing signs on MRI (usually normal – NO mass lesion)

o  Usually due to a demyelinating type inflammation – can be due to MS (= 2 demyelinating lesions in the CNS at different times and different places)

o  Could also be sarcoidosis ® granulomas and inflammation (very rare to only occur in spinal chord) 

·        Corda Equina Syndrome (CES)

o  Triad: leg weakness, sensory loss, sphincter problems (usually overflow not urgency – ie LMN) 

o  Classic description: „saddle anaesthesia‟ – anaesthesia in sacral dermatomes – eg feels like cotton wool when sitting on the toilet seat. May be only symptom. Usually bilateral 

o  If due to central disc prolapse can be fixed if treated urgently Þ medical emergency 

o  95% of disc prolapses are at L4/L5 or L5/S1: but most are laterally into nerve root, not central into cauda equina

·        Acute Inflammatory Demyelinating Polyradiculopathy (AIDP)

o  = Guillian-Barre

o  = Demyelination of multiple peripheral nerves 

o  Symptoms: ascending paralysis. Affects arms, legs and respiratory. Only a portion will get to ventilatory arrest, but can deteriorate very quickly Þ test FEV1 4 hourly while normal (normal >

o   4 l), to ICU if < 2 l.  (O₂ saturation and PO₂ won‟t tell you till too late)

o  Predominantly motor problem: unlikely to be AIDP if lots of sensory symptoms

o  Signs: LMN and arreflexia (arreflexia is a classic sign)

o  Tests: 

§  Lumbar puncture: ­protein but no ­WBC

§  Nerve conduction studies: motor conduction < 30 m/sec (normal > 40 – 50 m/sec) 

o  Treatment: IV g globulin and plasmaphoresis (plasma exchange).  Heparin to prevent PE

o  Not related to Chronic Inflammatory Demyelinating Polyradiculopathy