6. the spinal - cord
DESCRIPTION
asdjkTRANSCRIPT
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The Spinal - Cord
dr. Budhi Suwarma, SpS
FK UNJANI
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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
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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
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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
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Segments of the Spinal Cord
Segments Vertebras
Cervical 8 7
Thoracal 12 12
Lumbal 5 5
Sacral 5 5
Coccigeus - 4
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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
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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)
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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)
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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
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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
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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
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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
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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
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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
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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
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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
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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 ±
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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
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Neoplasm
Less frequent than brain (l5%),mostly benign,compression effect
Intramedullary (5%):lesion within cord
Extramedullary : lesion outside cord Intradural (40%) / Extra Dural (55%)
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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
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Neoplasm (Cont.)
Extramedullar Intramedullar
Pain Radicular Not characteristic
Sensibility Brown Sequard
Dissosiation of sensibility
Localization Unilateral bilateral
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Examination
X-ray Vertebrae Myelografi / CTMM MRI
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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
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Other Spinal Cord Injury
Bullet / missile Sharpnel Stab wound Spinal cord concussion
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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
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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
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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
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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)
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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.
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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
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Myelitis e.c. bacterial, fungal, parasitic and granulomatous dis.
Leptomeningitis,pachymeningitis,abscess/granuloma epidural
Pial a./v.thrombosedmyelomalacia
Progressive constrictive pial fibrosis Arachnoiditis
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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
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Tuberculous (TBC) Myelitis
TBC Spine Osteitis with kyphosis (Pott’s dis)pus/caseous granulation tissueepidural compression of the cordparaplegi
TBC meningitispial arteritisspinal cord infection
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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
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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
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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
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ASA syndrome
Sudden onset of paraparese Bilateral loss of sensory Dorsal collum intact
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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
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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
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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 )
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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
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Other Myelopathy (Primary/Secondary)
Amyotropic Lateral Sclerosis (ALS) Progressive Muscular Atrophy (PMA) Syringomyelia Cervical Spondylosis HNP
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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
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Progressive Muscular Atrophy
men>women,mostly symmetrical wasting intrinsic hand musclesmore proximal arms
Progress slower than ALS Tendon reflex ↓ or -,signs of UMN -
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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
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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
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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
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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
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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.
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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
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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
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SELESAI