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Spinal Cord lesions

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... spread of cancer from other locations primarily the lung, ... When spinal cord injuries occur near the neck, symptoms can affect both the arms and the legs: ... – PowerPoint PPT presentation

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Title: Spinal Cord lesions


1
Spinal Cord lesions
  • Prepared by
  • Saad Al-Qahtani.
  • Presented by
  • Bandar Al-Qahtani.
  • Supervised by
  • Dr.Esam Al-Jamal.

2
Anatomy
  • Spinal cord lies within protective covering of
    vertebral column.
  • Begins just below foramen magnum of the skull.
  • Ends opposite 2nd lumbar vertebra.
  • Below L2 continue as a leash of nerve roots known
    as cauda equina.
  • Prolongation of the pia matter forms filum
    terminale.

3
Spinal cord structure
4
Spinal cord structure
  • The spinal cord consists of central core of grey
    matter containing nerve cell bodies, and outer
    layer of white matter of nerve fibers.
  • Within the grey matter, the dorsal horn contains
    sensory neurons, the ventral horn contains motor
    neurons and the lateral horn contains
    preganglionic sympathetic neurons.
  • Within the white matter run ascending and
    descending nerve fiber tracts, which link the
    spinal cord to the brain.

5
Spinal cord structure
  • The principle ascending tracts are the
    spinothalamic tracts, spinocerebellar tracts and
    dorsal columns. The coticospinal tracts is an
    important descending tract.
  • The spinal cord receives information from, and
    controls the trunk and limbs.
  • This is achieved through 31 pairs of spinal
    nerves which join the cord at intervals along its
    length and contain afferent and efferent nerve
    fibers connecting with the structures at the
    periphery.

6
Causes of spinal cord lesions
  • congenital spinal stenosis.
  • Infection TB ,abscess.
  • Trauma vertebral body fracture or facet joint
    dislocation.
  • Inflammatory Rheumatoid arthritis.
  • Disc and vertebral lesion.
  • Vascular epidural and subdural hemorrhage.
  • Tumors.

7
Spinal stenosis
  • 75 of cases of spinal stenosis occur in the low
    back ( lumbar spine).
  • Causes
  • - congenital.
  • - degenerative.
  • - trauma.

8
Congenital spinal stenosis
  • The patient is born with a narrow spinal canal
    due to abnormally formed parts of the spine.
  • This condition is most common in patients with a
    short stature, such as achondroplastic dwarves.

9
Other causes of spinal stenosis
  • aging process (most common cause ).
  • herniated discs. (fig)
  • bone and joint enlargement.
  • spondylolisthesis.
  • bone spurs.

10
Rx Spinal Stenosis
  • Initial Rx in most cases is conservative.
  • Rest.
  • Weight loss.
  • Epidural steroid injections.
  • Analgesia.
  • Anti-inflammatory agents.
  • Muscle relaxant -if needed-
  • Physiotherapy.

11
Rx spinal stenosis
  • Spine surgery
  • used when conservative treatment failed.
  • -laminectomy (removing bone behind the spinal
    cord).
  • -foramenotomy (removing bone around the spinal
    nerve).
  • -discectomy (removing the spinal disc to relieve
    pressure).
  • Complications
  • Dural tears.
  • Infections.
  • Instability of the spine.

12
Infection
  • Epidural abscess
  • Usually bacterial
  • ( staphylococcus is common).
  • Spread through
  • hematogenous route.
  • Adjacent focus.
  • Direct inoculation.

13
Risk factor for epidural abscess
  • immunodeficiency
  • AIDS.
  • Alcoholism.
  • Chronic renal failure.
  • Diabetes mellitus.
  • Intravenous drug abuse.
  • Malignancy.
  • Spinal procedure or surgery.
  • Spinal trauma.

14
Infection
  • Infection of spine
  • Uncommon
  • Either vertebral osteomyelitis Or less commonly
    intraspinal infection.
  • Causative organism
  • (staph, Strep, E.coli, TB)
  • Occasionally due to unusual organisms like
  • Salmonella or brucella.

15
Rx spinal infections
  • The goals of treatment are to relieve spinal cord
    compression and cure the infection.
  • -drain abscess.
  • -antibiotics or antimicrobial.
  • -corticosteroid.
  • -may need urgent surgical decompression by
    laminectomy.

16
Tumors
  • Tumors are classified into 3 types according to
    their site
  • -extradural ( between the meninges and spine
    bones)
  • -intradural extramedullary (within meninges)
  • -intramedullary ( inside the cord)

17
Spinal tumors
  • Most spinal tumors are extradural about 85
  • They may be primary tumors originating in the
    spine, or secondary tumors that are the result of
    the spread of cancer from other locations
    primarily the lung, breast, prostate, kidney, or
    thyroid gland.
  • Any type of tumor may occur in the spine,
    including lymphoma, leukemic tumors, myeloma, and
    others. A small percentage of spinal tumors occur
    within the nerves of the spinal cord itself, most
    often consisting of ependymomas and other
    gliomas.

18
Symptoms of spinal tumors
  • Pain (in 90 of patients), numbness or sensory
    changes, motor problems and loss of muscle
    control.
  • Pain can feel as if it is coming from various
    parts of the body.
  • Numbness or sensory changes can include decreased
    skin sensitivity to temperature and progressive
    numbness or a loss of sensation, particularly in
    the legs.
  • Motor problems and loss of muscle control can
    include muscle weakness, spasticity (in which the
    muscles stay stiffly contracted), and impaired
    bladder and/or bowel control.

19
Spinal tumors
  • 17 have Multiple level involvement.
  • Metastatic lesion mostly found in Thoracic spine.
  • Myelopathy develops over days to weeks.
  • Acute SCC does occur if tumor enlarges very
    rapidly due to hemorrhage or if a vertebral body
    suddenly collapses.

20
Extradural tumors
  • The most common spinal tumor 85
  • mostly metastatic.
  • Arise from osseous element of spinal column.
  • Grow rapidly.
  • Primary Lung, Breast, prostate and kidney.
  • Compress the spinal cord by
  • Growing in epidural space
  • Causing collapse of vertebrae, distortion and
    narrowing.
  • e.g. lymphoma, hemangioma and neuroblastoma.

21
Intradural extramedullary tumors
  • Inside the dura but outside the spinal cord.
  • e.g. Meningioma, Neurinoma.
  • Arise from the dural sheath around the cord or
    showann cell sheath around the spinal root.
  • Multiple tumors in Pt. with neurofibromatosis.
  • Can grow extradurally into retropleural or
    retroperitoneal through intervertebral foramen.

22
Intradural intramedullary tumors
  • Inside the spinal cord
  • Examples Glioma, ependymoma, astrocytoma
  • Arise from glial elements of spinal cord or
    trapped ectodermal elements.
  • More common in children.
  • Astrocytoma of spinal cord is the most common
    intramedullary tumor of childhood.
  • Ependymoma of spinal cord is the most common
    intramedullary tumor of adulthood.
  • Arise from ependyma of central canal.
  • Well demarcated.

23
Investigations
  • Plain X-rays.
  • Myelography contrast material is injected into
    the thecal sac fluid surrounding the spinal cord
    and nerve root within the spinal canal
  • CT.
  • MRI ( study of choice ).

24
Rx spinal tumors
  • The goal of treatment is to reduce or prevent
    nerve damage from compression of the spinal cord,
    relieve pain and maintain the function.
  • - Surgical excision is the treatment for
    extramedullary tumors.
  • - Radiation therapy for intramedullary tumors.
  • The traditional treatment of intramedullary
    gliomas has been biopsy followed by radiation
    therapy.
  • Radiotherapy is clearly of value in
    metastatic lesions.
  • - Chemotherapy can be considered in patients with
    progression of disease after radiation therapy.

25
Spinal cord compression (SCC)
  • The act of exerting an abnormal amount of
    pressure on the spinal cord.
  • Causes and risk factors
  • - Traumatic injury.
  • - Spinal cord tumors.
  • - Spinal stenosis.
  • - Ruptured disks.
  • - Abscesses.
  • - Arteriovenous malformations.
  • - Degenerative diseases, such as arthritis.

26
Spinal cord compression
27
Clinical presentation
  • Symptoms vary depending on the cause of the
    compression, its location, severity, extent and
    rate of development but can include
  • - Back pain at the spinal site of compression.
  • - Pain or burning in other parts of the body.
  • - Difficulty breathing.
  • - Weakness in the arms, legs, or both.
  • - Numbness or tingling in the neck, shoulder,
    arms, hands, or legs.
  • - Loss of coordination or difficulty walking.
  • - Loss of fine motor skills.
  • - Loss of sexual function.
  • - Loss of bladder or bowel control.
  • - Paralysis.

28
Clinical presentation
  • - Cervical spine disease produce Quadriplegia.
  • - Thoracic spine disease produce paraplegia.
  • - TENDON REFLEXES
  • Increase below level of compression
  • Absent at the level of compression
  • Normal above the level of compression
  • - Sphincter disturbances are late feature of
    cervical and thoracic cord compression.

29
Clinical presentation
  • Cauda equina syndrome
  • is a serious condition caused by compression of
    the nerves in the lower portion of the spinal
    canal .
  • is considered a surgical emergency because if
    left untreated it can lead to permanent loss of
    bowel and bladder control and paralysis of the
    legs.

30
Investigation
  • X ray.
  • CT scan.
  • MRI.
  • Myelogram.
  • Biopsy.
  • Bone scan.
  • Blood and spinal fluid studies.

31
Rx spinal cord compression
  • Acute cord compression is a 'surgical' emergency.
  • In those with malignant disease radiotherapy may
    be treatment of choice.
  • In general, tumor, infection and disc disease
    produces anterior compression.
  • Surgical decompression should be achieved through
    an anterior approach.

32
Spinal trauma
  • Spinal cord trauma is damage to the spinal cord.
    It may result from direct injury to the cord
    itself or indirectly from damage to surrounding
    bones, tissues, or blood vessels.
  • Symptoms
  • Symptoms vary depending on the location of the
    injury.
  • Spinal cord injury causes weakness and
    sensory loss at and below the point
    of the injury.
  • we can divide spinal trauma into 3 levels
    according to its location in the spinal cord (
    cervical - thoracic Lumbosacral ).

33
Cervical injuries
  • - When spinal cord injuries occur near the neck,
    symptoms can affect both the arms and the legs
  • Breathing difficulties (from paralysis of the
    breathing muscles).
  • Loss of normal bowel and bladder control (may
    include constipation, incontinence, bladder
    spasms).
  • Numbness.
  • Sensory changes.
  • Spasticity (increased muscle tone).
  • Pain.
  • Weakness, paralysis.

34
Thoracic injuries
  • - When spinal injuries occur at chest level,
    symptoms can affect the legs
  • Breathing difficulties (from paralysis of the
    breathing muscles)
  • Loss of normal bowel and bladder control (may
    include constipation, incontinence, bladder
    spasms).
  • Numbness.
  • Sensory changes.
  • Spasticity (increased muscle tone).
  • Pain.
  • Weakness, paralysis.
  • Injuries to the cervical or high-thoracic spinal
    cord may also result in blood pressure problems,
    abnormal sweating, and trouble maintaining normal
    body temperature.

35
Lumbosacral injuries
  • - When spinal injuries occur at the lower-back
    level, varying degrees of symptoms can affect the
    legs
  • Loss of normal bowel and bladder control (may
    include constipation, incontinence, bladder
    spasms).
  • Numbness.
  • Pain.
  • Sensory changes.
  • Spasticity (increased muscle tone).
  • Weakness and paralysis.

36
Investigations
  • A CT scan or MRI of the spine may show the
    location and extent of the damage and reveal
    problems such as blood clots (hematomas).
  • Myelogram (an x-ray of the spine after injection
    of dye) may be necessary in rare cases.
  • Somatosensory evoked potential (SSEP) testing or
    magnetic stimulation may show if nerve signals
    can pass through the spinal cord.
  • Spine x-rays may show fracture or damage to the
    bones of the spine.

37
Rx Spinal trauma
  • ABC
  • Spine Immobilization to prevent further injury to
    the spinal cord.
  • In cervical injuries higher than C5, intubation
    and respiratory support are usually needed.
  • Corticosteroids, rest, analgesics and muscle
    relaxant.
  • Surgery (decompression laminectomy ).
  • Extensive physical therapy and other
    rehabilitation interventions are often required
    after the acute injury has healed.

38
Disc prolapse
  • Rupture of the disc or prolapse as it is usually
    called, can press on the spinal cord and its
    nerve roots leading to pain, numbness and
    weakness and may also affect the control of bowel
    and urinary bladder.
  • Dx X-ray, CT scan or MRI.

39
Rx Disc Prolapse
  • Initial Rx in most cases is conservative.
  • Rest.
  • Analgesia.
  • Anti-inflammatory agents.
  • Muscle relaxant -if needed-.
  • Physiotherapy.

40
Rx Disc Prolapse
  • laminectomy, involves excision of a portion of
    the lamina and removal of the protruding disk.
  • spinal fusion, may be necessary to overcome
    segmental instability.
  • Laminectomy and spinal fusion are sometimes
    performed concurrently to stabilize the spine.
  • Microdiskectomy, can also be used to remove
    fragments of nucleus pulposus.
  • Chemonucleolysis Injection of the enzyme
    chymopapain into the herniated disk produces a
    loss of water and proteoglycans from the disk,
    thereby reducing both the disks size and the
    pressure in the nerve root.

41
Spondylolisthesis
  • Spondylolisthesis
  • is a condition in which the there is a defect
    in a portion of the spine, causing vertebra to
    slip to one side of the body.

42
Rx Spondylolisthesis
  • Non-surgical treatment may include one or a
    combination of
  • - NSAIDs (e.g. ibuprofen, COX-2 inhibitors)
  • - Oral steroids
  • - Physical therapy
  • - Manual manipulation (e.g. chiropractic
    manipulation).
  • Spinal fusion surgery.

43
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