Beruflich Dokumente
Kultur Dokumente
Christian Kamallan
Neurology Department
UWKS
Anatomy of the
spine
Different spinal
cord levels supply
nerves for different
regions of the
body
Physiology and function
• Grey matter – sensory and motor nerve cells
• Upper limbs:
C5 - Shoulder abduction
C6 - Wrist extensors
C7 - Elbow extensors
C8 - Long finger flexors
T1 - Small hand muscles
• Lower Limbs :
L2 - Hip flexors
L3,4 - Knee extensors
L4,5 - S1 - Knee flexion
L5 - Great Toe/Ankle dorsiflexion
S1 - Great Toe/Ankle plantar flexion
Anatomy review
• Spinal cord ends at L1-L2
• Terminology
– Conus medullaris: most
distal bulbous part
– Filum termiale: tapering
part of conus medullaris
(mostly fibrous tissue)
– Cauda equina: distal
collection of nerve roots
http://en.wikipedia.org/wiki/Filum_terminale
Conus vs Cauda
• Spinal cord ends at L1-L2
• Terminology
– Conus medullaris: most
distal bulbous part
– Filum termiale: tapering
part of conus medullaris
(mostly fibrous tissue)
– Cauda equina: distal
collection of nerve roots
http://en.wikipedia.org/wiki/Filum_terminale
Conus vs Cauda
Conus Cauda
Sudden and bilateral onset Gradual and unilateral onset
• Intradural extramedullary:
– Meningiomas
– nerve sheath tumours
(schwannomas and
neurofibromas)
• Epidural: metastases
http://www.emory.edu/ANATOMY/AnatomyManual/back.html
Intramedullary vs Extramedullary
Intramedullary Extramedullary
• Mimickers
– Anterior spinal artery infarction
– Spinal AVMs
– Multiple sclerosis / transverse myelitis
– Neurosarcoidosis
– Plexopathy
Location (Neoplasm)
• Progression
– Epidural venous plexus obstructed BBB breakdown
vasogenic edema PGD (hence utility of steroids)
– First WM involved demyelination
– Then GM involved cord ischemia / infarction
– Irreversible damage if prolonged compression with cord
infarction (> 1 week)
What is malignant spinal cord
compression?
• Occurs when cancer cells grow
in/near to spine and press on the
spinal cord & nerves
• In cancer patients
– likelihood of epidural spinal cord compression 5-yrs
before death = 2.5%
– Vertebral metastases >>> ESCC
That being said…
• Rectal tone
– External anal sphincter
and puborectalis muscle
innervated by S3-4
– Loss of anal tone stool
incontinence
– Similar mechanism for
bulbocavernosus reflex
– DRE, anal wink, tugging at
Foley http://www.netterimages.com/image/12555.htm
What to image
• Always image entire spine:
– Spinal cord is shorter than vertebral spinal
column; imaging LS spine means you’re not
imaging the cord at all
– Exam is not always reliable for level of
compression
– Multiple sites of deposits are frequent in epidural
spinal cord metastases (1/3 of patients)
Diagnosis
• MRI • CT myelography
– Test of choice – 2nd test of choice
ADVANTAGES ADVANTAGES
– Non-invasive – CSF can be obtained for
– No procedural complication (e.g. risk of analysis
herniation with brain mets, – Safe for claustrophobic
hemorrhage with coagulopathies, patients
neuro deterioration with CSF retrieval) – Safe for ferromagnetic implant
– Visualization of spinal parenchyma, (valves, PM, implants,
adjacent bone and soft tissues shrapnel)
– Can image entire spine even if – No movement artifact
subarachnoid block present
– Needed to plan radiation and Sx
Treatment
• The obvious…
– Abscess: ABX, Sx
– Hematoma: correct coagulopathy, Sx
– Fracture / stenosis: Sx
• Goals of treatment for epidural metastases
– Pain control
– Preserve or improve neurological function
Steroids (Decadron)
Initial presentation Dose recommended
• Paraplegia :
injury in thoracic, lumbar or sacral segments
2 extremities affected
Injury either:
1) Complete
2) Incomplete
Complete:
i) Loss of voluntary movement of parts
innervated by segment, this is irreversible
ii) Loss of sensation
iii) Spinal shock
Incomplete:
Spinal Shock :
Clinically:
• Proprioception affected – ataxia and
faltering gait
• Usually good power and sensation
iv) Brown – Sequard Syndrome:
• Hemi-section of the cord
• Either due to penetrating injuries:
i) stab wounds
ii) gunshot wounds
• Fractures of lateral mass of vertebrae
Clinically:
• Paralysis on affected side (corticospinal)
• Loss of proprioception and fine discrimination
(dorsal columns)
• Pain and temperature loss on the opposite
side below the lesion (spinothalamic)
v) Cauda Equina Syndrome:
• Due to bony compression or disc protrusions
in lumbar or sacral region
Clinically
• Non specific symptoms – back pain
- bowel and bladder dysfunction
- leg numbness and weakness
- saddle parasthesia
In conclusion
Spinal Cord Injuries:
• Devastating event to both patient and
family.
• Huge impact on society
• After receiving First – World care in
tertiary institutions, many of our patients
return to impoverished communities
• Here they face huge challenges in terms of
survival
NEUROGENIC BLADDER
DEFINITION
SPONTANEOUS CONTRACTION
URINARY SPHINCTER SPASMS
OF DM
INTRAVESICAL VOIDING
UNCONTROLLED URINATION
PRESSURE
BLADDER WALL HYPERTROPHY
WITH TRABECULATION
REDUCED URINE-VOLUME
CAPACITY FREQUENT URINATION
FLACCID NEUROGENIC
BLADDER
LESIONS AT OR BELOW S2/S4
INTERRUPTED AFFERENT SIGNALS BELOW S2/S4
INTRAVESICULAR PRESSURE
OVERDISTENDED BLADDER
BLADDER PRESSURE REACHES A RESIDUAL
BREAK THROUGH POINT
URINE
SMALL AMOUNTS OF URINE DRIBBLE RETENTION
FLACCID BLADDER
•Stroke
•Parkinson’s disease
•Multiple sclerosis
•Alzheimer’s disease
•Spina bifida and neural
disorders resulting from diabetes
or alcoholism
Symptoms of Neurogenic Bladder
•Overactive bladder
•Frequent urination, in the daytime and at night
(nocturia)
•Stress incontinence
•Urge incontinence
•Inability to urinate (urinary retention)
•Underactive bladder – bladder is unable to signal
when full
Treatment