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Chronic Spinal Cord Injury (Lesi Medula Spinalis Khronis)
Darwin AmirBgn Ilmu Penyakit Saraf
Fakultas Kedokteran Universitas Andalas
The Spinal CordCervical spinal erves
Thoracic spinal nerves
Lumbar spinal nerves
Sacral spinal nerves
Conus medullaris
Cauda equina
PROYEKSI DERMATOM DIPERMUKAAN KULIT
Ascending Spinal Cord Tract
• 1st order neuron - cutaneous receptors of skin and proprioceptors spinal cord or brain stem
• 2nd order neuron - to thalamus or cerebellum
• 3rd order neuron - to somatosensory cortex of cerebrum
Conducts sensory impulses upward through 3 successive chains of neurons
Ascending Spinal Cord Tract
The Spinal CordThe Spinal Cord
spinal cord
spinal nerve
vertebra
Cross Section of Spinal CordWhite matter:Myelinated axons
forming nerve tracts
Fissure and sulcusThree columns:
◦Ventral ◦Dorsal◦Lateral
Gray matter: Neuron cell cell
bodies, dendrites, axons
‘Horns’:◦ Posterior (dorsal)◦ Anterior (ventral)◦ Lateral
Commissures:◦ Gray: Central canal ◦ White(see later for white matter
pathways)
The Nervous System
The Spinal Cord-part of the CNS found within the Spinal column
The spinal cord communicates with the sense organs and muscles below the level of the head
Bell-Magendie Law-the entering dorsal roots carry sensory information and the exiting ventral roots carry motor information to the muscles and Glands
Dorsal Root Ganglia-clusters of neurons outside the spinal cord
Nerve Pathways into the Spinal CordNerve Pathways into the Spinal Cord
sensory pathway
motor pathway
Somatic Sensory Pathway
CORTICOSPINAL TRACTS
Symptoms and Signs
Must be mastering in mind
Start by understanding anatomy and physiology of the Nervous System
Don’s forget the of CNS systematically - Anatomy of CNS
- Physiology of CNS
- Pathophysiology of the Disease
- The steps to make the diagnosis
Sensory disturbances
▪ Soft touch, pain, temperature, position, vibration impaired below the level of lesion
▪ Band like radicular pain/segmental paraesthesia at the level of lesion
▪ localised vertebral spine pain- destructive lesions
Motor disturbances
▪ Paraplegia/quadriplegia
▪ Acute-flaccid / Areflexic-spinal shock latter-hypertonic / hyper reflexic, loss of superficial reflexes, Babinski +, flexor/extensor spasm
▪ Extension of hip, knee occurs in high spinal & Incomplete lesion
• Flexion of hip , knee occur in low spinal & complete lesion
• At the level of lesion – paresis, atrophy, fasciculations,and areflexia(LMN signs) in a segmental distribution because of damage to the anterior horn cells and ventral roots
Motor disturbances
Autononomic disturbances• initially atonic, latter spastic bladder,
rectal sphincter disturbances• orthostatic hypotension• trophic skin changes• anhydrosis• impaired temperature control• vasomotor instability• sexual disturbances• I/L horner syndrome
Causes of Chronic Lesion
° Tumour
° Multiple sclerosis
° Vascular disorders
° Spinal epidural hematoma/abscess
° Auto immune disease
° Herniated intervertebral disc
° Combine degeneration of B12 Deficiences
Complete spinal cord transection(Transverse myelopathy)
Complete spinal cord transection(Transverse myelopathy)
All acsending tracts from below the level of the lesion and all descending tract from above the level of lesion interrupted. Motor, sensory, autonomic functions below the level of lesion disturbed
Causes : ° tumour ° multiple sclerosis
° vascular disorders ° spinal epidural hematoma/ ° spinal epidural abscess ° herniated intervertebral disc
° auto immune disease
Central spinal cord lesion
Spinal cord damage starts centrally and spreads centrifugally
Decussating fibers of spinothalamic tract involved initially
Thermo anaesthesia, analgesia in a ”vest like” or “suspended” bilateral distribution with preservation soft touch sensation and proprioception--- dissociation of sensory loss
Central spinal cord lesion
Forward extension of disease anterior horn cells involved segmental neurogenic atrophy, paresis, areflexia
Lateral extension I/L Horner syndrome Kypho scoliosis Spastic paralysis Dorsal extension I/L Position sense, vibratory loss
Central spinal cord lesion
Extreme venterolateral extension thermo anaesthesia, analgesia with
sacral sparing
Neuropathic arthropathy
Pain
Posterior column disease
Posterior column diseaseTabes dorsalis-tabetic neuro syphilis,
progressive locomotor ataxiaImpaired vibration and position sense, and
decreased tactile localisationLability of mechanical sensation threshold,
tactile & postural hallucinations, persistence of mechano receptor sensation, disturbances in the knowledge of extremity movement and positions (temporal & spatial disturbances)
Sensory ataxia in dark, Romberg (+)
Ataxic / stomping/ double tapping gaitPositive sink signIn tabes dorsalis lancinating pain, urinary
incontinence, Negative patellar and ankle DTR, hypotonic limb, hyper extensible joints
abdominal, laryngeal crises, impaired light touch perception, Argyll robertson
pupil, optic atrophy, ptosis, ophthalmoplegia
Posterior column disease
○ Lhermitte sign or barber chair syndrome due to increased mechano sensitivity
○ Truncal and gait ataxia : also seen in mets causing cord compression
○ Impaired conduction in dorsal spino cere -bellar tract may be a primar manifestation of epidural spinal cord compression-lower extremity dysmetria and gait ataxia.
○ Pt usually have thoracic spine compression due to selective vulnerability of spinocere bellar tract in thoracic spine to compres -sive ischemia
Posterior column disease
Hemisection of the spinal cord( Brown sequard syndrome)
Hemisection of the spinal cord( Brown sequard syndrome)
Loss of pain, temp C/L to the hemisection- interruption of crossed spino thalamic tract
Loss of proprioception – interruption of ascending fibers of posterior column
Spastic weakness due to interruption of descending cortico spinal tract
Segmental LMN signs and sensory changes at the level of lesion due to damage of the roots and anterior horn cells at the level of lesion
INNERVATION OF AUTONOMIC NERVOUSSYSTEM
Thank you BrainFor all you remember
What you forgot was my fault