A lecture for medical students

1. Clinical problems
related to
spinal cord
Dr. Abdul Qadeer
MBBS; (MRCS); FCPS; FICS
Assistant Prof. of Surgery

2. Lesions of nerve roots
 Compression of nerve roots may be
due to:
1. Herniated intervertebral disc
2. Tumors of vertebral column
3. Fracture dislocation of a vertebra
4. Infection of a vertebra (e.g. T.B)
5. Severe scoliosis
 The above conditions may lead to:
a. Hyperalgesia e.g. Sciatica
b. Hyperesthesia
c. Loss of sensation

3. INJURIES TO THE ASCENDING
TRACTS WITHIN THE SPINAL
CORD
1. Injury to lateral spinothalamic tract
2. Injury to anterior spinothalamic tract
3. Injury to f. gracilis & f. cuneatus

4. Injury to lateral spinothalamic
tract
 Destruction of this tract will produce:
1. Contralateral loss of pain & thermal
sensation below the level of the
lesion
2. The patient will not response to
pinprick or recognize hot & cold
objects
 The laminar arrangement of this tract
explains the reason of loss of
sensation in sacral dermatomes of
body earlier than cervical if external

5. Injury to anterior spinothalamic
tract
 Destruction of this tract will produce:
1. Contralateral loss of light touch &
pressure sensations
2. The patient will not feel the light
tpuch of a piece of cotton or pressure
from blunt object

6. Injury to f. gracilis & f.
cuneatus
 Destruction of these tracts will produce:
1. Ipsilateral loss of sense of position and
movements of the limbs below the level
of the lesion
2. With closed eyes, the patient will be
unable to tell the position of
limbs/fingers/toes
3. The patient will have impaired muscular
control

7. Injury to f. gracilis & f.
cuneatus
4. Movements will be jerky or ataxic
5. Ipsilateral loss of vibration sense
(tuning fork test)
6. Ipsilateral loss of tactile
discrimination (compass test)
7. Sense of light touch will be
unaffected

8. Tactile discrimination
 It varies from one part of the body to
other part
 ON THE FINGERS: In a normal
person, the points have to be
separated by about 3 to 4 mm before
they are recognized as separate
points
 ON THE BACK: The points have to be
separated by 65 mm or more before
they can be recognized as separate

9. Tabes dorsalis
 It is a disease caused by syphilis
 It causes selective destruction of
nerve fibers at the point of entrance of
the posterior root of the spinal cord,
especially in the lower thoracic &
lumbo-sacral regions

10. s/s of tabes dorsalis
1. Stabbing pain in lower limbs
2. Paresthesia and numbness in lower
limbs
3. Hypersensitivity of skin to touch, heat
& cold
4. Loss of sensation in lower parts of
trunk
5. Loss of awareness of fullness of
urinary bladder
6. Loss of appreciation of posture

11. s/s of tabes dorsalis (contd…)
7. Loss of deep pain sensation
8. Ataxia of lower limbs (jerky gait)
9. Hypotonia
10. Loss of tendon reflexes

12. UPPER MOTOR NEURON
LESIONS
1. Lesions of cortico-spinal tracts
(pyramidal tracts)
2. Lesions of extra-pyramidal tracts

13. S/S of lesions of cortico-spinal
tracts (pyramidal tracts)
 Babinski sign is present
 Superficial abdominal reflexes are
absent
 Cremasteric reflex is absent
 Loss of performance of fine-skilled
voluntary movements

14. S/S of lesions of extra-pyramidal
tracts
 Severe paralysis with little or no
muscle atrophy
 Spasticity or hypertonicity of the
muscles
 Exaggerated deep muscle reflexes
and clonus
 Clasp-knife reaction

15. LOWER MOTOR NEURON
LESIONS
 Will be seen by destruction of cell
bodies in the anterior gray horn or its
axon in the anterior root of the spinal
nerve. Causes may include:
1. Trauma
2. Infection e.g. poliomyelitis
3. Vascular disorders
4. Degenerative diseases
5. Neoplasms

16. S/S lower motor neuron
lesions
 Flaccid paralysis of muscles supplied
 Atrophy of muscles supplied
 Loss of reflexes of muscles supplied
 Muscular contracture in antagonist
muscles
 Reaction of degeneration i.e. muscle
response to electrical stimulation

17. Spinal shock syndrome
 It is a clinical condition that follows
acute severe damage to the spinal
cord
 All cord functions below the level of
the lesion become depressed or lost
 Sensory impairment & flaccid
paralysis occur
 Spinal reflexes are depressed due to
removal of influences from higher
centers

18. Spinal shock syndrome
(contd..)
 Severe hypotension may occur due to
loss of sympathetic vasomotor tone
 Shock persists for less than 24 hours
but in few patients it may persist for 1
to 4 weeks
 As the shock diminishes, the neurons
gain their excitability
 Hence, spasticity & exaggerated
reflexes will appear

19. Spinal shock syndrome
(contd..)
 Anal sphincter reflex will appear
 A cord lesion involving the sacral
segments will nullify the anal sphincter
test due to involvement of the nerves
supplying to anal sphincter (S2-4)

20. Destructive spinal cord
syndromes
 After disappearance of spinal shock,
one of the following syndromes may
appear
1. Complete cord transaction syndrome
2. Anterior cord syndrome
3. Central cord syndrome
4. Brown-Sequard syndrome or
hemisection of the cord
5. Cauda equina syndrome

22. Complete spinal cord transection

23. Complete cord transaction
syndrome
 Following clinical features after the
period of spinal shock will appear
1. Bilateral LMN paralysis & muscular
atrophy in the segment of the lesion
2. Bilateral spastic paralysis below the
level of the lesion (bilateral Babinski
sign is present)
3. Bilateral loss of superficial abdominal
& cremasteric reflexes

24. Complete cord transaction
syndrome
4. Bilateral loss of all sensations below
the level of the lesion
5. Bladder & bowel functions are not
under voluntary control because all
the descending autonomic fibers are
destroyed

25. Anterior cord syndrome

26. Anterior cord syndrome
 Following clinical features will appear
after the period of spinal shock
1. Bilateral lower motor neuron
paralysis in the segment of the lesion
and muscular atrophy (due to
involvement of anterior gray columns
or anterior motor roots)

27. Anterior cord syndrome
2. Bilateral spastic paralysis below the
level of the lesion (due to
involvement of anterior corticospinal
tracts on both sides)
3. Bilateral loss of pain, temperature &
light touch sensation (due to
interruption of anterior & lateral
spinothalamic tracts on both sides)

28. Anterior cord syndrome
4. Tactile discrimination and vibratory &
proprioceptive sensations are
preserved because posterior white
columns on both sides are
undamaged

30. Central cord syndrome
 Following clinical features will appear
after the period of spinal shock
1. Bilateral LMN paralysis in the
segment of the lesion & muscular
atrophy (dur to damage to anterior
gray columns & nerve roots)

31. Central cord syndrome
2. Bilateral spastic paralysis below the
level of the lesion with characteristic
sacral sparing
3. Lower limb fibers are affected less
than upper limb fibers (refer laminar
organization)
4. Bilateral loss of pain, temperature,
light touch & pressure sensation
below the level of the lesion with
sacral sparing

32. Central cord syndrome

34. Brown-Sequard Syndrome

35. Brown-Sequard syndrome
(Hemisection of the cord)
 Incomplete hemisection is common
 Complete hemisection is rare
 Following clinical features will appear
after the period of spinal shock
1. Ipsilateral LMN paralysis in the
segment of the lesion & muscular
atrophy (due to involvement of
anterior gray columns / roots)

36. Brown-Sequard syndrome
(Hemisection of the cord)
2. Ipsilateral spastic paralysis below the
level of the lesion
3. Ipsilateral Babinski sign is present
4. Ipsilateral loss of superficial
abdominal reflexes & cremasteric
reflexes occur (all the above signs
occur due to loss of corticospinal
tracts on the side of the lesion)

37. Brown-Sequard syndrome
(Hemisection of the cord)
5. Ipsilateral band of cutaneous
anesthesia (due to destruction of
posterior root & its entrance)
6. Ipsilateral loss of tactile
discimination, vibratory &
proprioceptive sensation below the
level of the lesion (due to destruction
of the posterior white columns)

38. Brown-Sequard syndrome
(Hemisection of the cord)
7. Contralateral loss of pain &
temperature sensation below the
level of the lesion (due to destruction
of lateral spinothalamic tracts)
8. Contralateral but not complete loss
of tactile sensation below the level of
the lesion (due to destruction of
crossed anterior spinothalamic tracts
on the side of the lesion)

39. Brown-Sequard Syndrome

41. Cauda equina syndrome

42. Cauda equina syndrome
 Causes may be:
1. Tumors
2. Trauma
3. Spinal stenosis
4. Inflammation

43. Cauda equina syndrome
 S/S may be:
1. Paraplegia
2. Urinary retention (due to detrusor
muscle weakness
3. Decreased anal tone ± anal
incontinence
4. Sexual dysfunction
5. Saddle anesthesia
6. Sciatica
7. Absent ankle reflex

44. Syringomyelia

45. Syringomyelia
 It is the condition in which a cyst (syrinx)
may develop within the spinal cord
 It may lead to:
1. Pain
2. Paralysis
3. Weakness
4. Stiffness in the back, shoulders,
extremities
5. Loss of feeling extremes of heat or cold

46. Syringomyelia

47. S/S in syringomyelia
 Loss of pain & temperature in the
dermatomes of affected segments
(shawl-like distribution) due to affected
lateral spinothalamic tract
 Normal tactile discrimination, vibratory
& proprioceptive senses
 LMN weakness in small muscles of
hand
 Bilateral spastic paralysis of both legs
 Positive Babinski sign

48. Poliomyelitis
 It is an acute viral infection of the
neurons of anterior gray columns of the
spinal cord and the motor nuclei of the
cranial nerves
 It leads to paralysis and wasting of the
muscles
 Lower limb is more affected than upper
 May involve respiratory muscles &/or
diaphragm leading to respiratory
problems

49. THE END