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1. Transverse Myelopathy

2. Combined painful radicular and transverse cord syndrome

3. Brown-séquard syndrome

4. Ventral cord syndrome

5. High cervical–foramen magnum syndrome

6. Central cord or syringomyelic syndrome

7. Syndrome of the conus medullaris

8. Syndrome of the cauda equina

What are the 8 main syndromes?

Transverse Myelopathy

a complete or almost complete sensorimotor myelopathy that involves most or all of the ascending and descending tracts

Combined painful radicular and transverse cord syndrome

• Medically referred to as myeloradiculopathy.

• It is most commonly caused by cervical or lumbar spinal stenosis (narrowing of the spinal canal, often due to age-related degenerative changes), a herniated disc, or an acute traumatic injury.

Brown-séquard syndrome

• Hemicord syndrome

• A neurological condition resulting from damage to only one side of the spinal cord, causing weakness and paralysis on the same side of the body as the injury, along with a loss of pain and temperature sensation on the opposite side

Ventral cord syndrome

• sparing posterior column function

• Also called anterior cord syndrome, it is an incomplete spinal cord injury caused by damage to the anterior two-thirds of the spinal cord, often from a stroke of the anterior spinal artery or a traumatic injury

High cervical–foramen magnum syndrome

A term for a group of symptoms resulting from compression or irritation of the brainstem, spinal cord, and nerves at the foramen magnum due to conditions like Chiari malformation, tumors, or bone abnormalities

Central cord or syringomyelia syndrome

• a spinal cord injury with a primary symptom of greater weakness in the arms than the legs

• condition where a fluid-filled cyst (syrinx) forms in the spinal cord and can cause symptoms similar to Central Cord Syndrome

Syndrome of the conus medullaris

a medical emergency resulting from compression or injury to the conus medullaris, the terminal part of the spinal cord. It is characterized by symptoms such as sudden back pain, saddle anesthesia (loss of sensation in the perineal area), and bladder and bowel dysfunction (incontinence or retention).

Syndrome of the cauda equina

a medical emergency caused by compression of the cauda equina nerve roots at the lower end of the spinal cord, leading to symptoms like severe lower back pain, leg weakness, and loss of bladder or bowel control

Spinal cord injury

Is one that causes myelopathy or damage to white matter or myelinated fiber tracts that carry signals to and from the brain. It also damages gray matter in the central part of the spine, causing segmental losses of interneurons and motorneurons.

Incidence of SCI

Highest among persons age 16-30, in whom 53.1 percent of injuries occur; more injuries occur in this age group than in all other age groups combined

Males represent 81.2 percent of all reported SCIs and 89.8 percent of all sports-related SCIs

Among both genders

auto accidents, falls and gunshots are the three leading causes of SCI, in that order.

Among males

diving accidents ranked fourth, followed by motorcycle accidents

Among females

Medical/surgical complications ranked fourth, followed by diving accidents

Auto accidents

Leading cause of SCI in the United States for people age 65 and younger

Falls

Leading cause of SCI for people 65 and older.

Sports and recreation-related SCI

Primarily affect people under age 29.

Trauma

automobile crashes, falls, gunshots, diving accidents, war injuries, etc.

Tumor

Meningiomas, ependymomas, astrocytomas, and metastatic cancer.

Ischemia

Resulting from occlusion of spinal blood vessels, including dissecting aortic aneurysms, emboli, arteriosclerosis.

Developmental disorders

Spina bifida, meningomyolcoele, and other.

Neurodegenerative diseases

Demyelinative diseases

Multiple Sclerosis

Transverse myelitis

From spinal cord stroke, inflammation, or other causes

Vascular malformations

• Arteriovenous malformation (AVM),

• Dural arteriovenous fistula (AVF)

• Spinal hemangioma

• Cavernous angioma

• Aneurysm

Sequelae of SCI

• Tissue disruption: Primary cell death, breaking of axons, etc.

• Injured spinal cords show progressive tissue loss

• Central hemorrhage necrosis develops over 2-3 hours,

• White matter blood flow falls by 50% by 3 hours

• Metabolism is compromised with high lactic acid levels

Neuronal apoptosis

• Peaks at 48 hours after injury in the gray matter surrounding the injury site

Neuronal apoptosis & Oligodendroglial apoptosis

Two types of Apoptosis?

Oligodendroglial apoptosis

Peaks at 10-14 days after injury in degenerating white matter tracts

1. Stage of spinal shock

2. Stage of recovery

3. Stage of reflex failure

What are the 3 stages of SCI?

Stage of spinal shock 

• Sensation and motor power localized below the vertical height of the lesion are lost.

• Stage lasts for 2 to 3 weeks in humans, and hours to days in lower animals due to a lesser degree of encephalitis

Stage of recovery 

After a period typically ranging from 2 to 3 weeks of injury, the nerves partially recover, and the return of segmental reflexes produce paraplegia-in-flexion.

Stage of reflex failure 

After a period of days the recovered reflexes again start to give way due to complete degeneration of nerve cells.

Spinal Cord Anatomy

• About 18 inches long

• Extending from the base of the brain to near the waist.

• Many of the bundles of nerve fibers that make up the spinal cord itself contain upper motor neurons (UMNs).

• Spinal nerves that branch off the spinal cord at regular intervals in the neck and back contain lower motor neurons (LMNs).

1. Cervical vertebrae (1-7), located in the neck

2. Thoracic vertebrae (1-12), in the upper back (attached to the ribcage)

3. Lumbar vertebrae (1-5), in the lower back

4. Sacral vertebrae (1-5), in the pelvis

What are the 4 sections of the spine?

The American Spinal Injury Association or ASIA

defined an international classification based on neurological levels, touch and pinprick sensations tested in each dermatome, and strength of ten key muscles on each side of the body, i.e. shoulder shrug (C4), elbow flexion (C5), wrist extension (C6), elbow extension (C7), hip flexion (L2).

Classification of SCI

Traumatic spinal cord injury is classified into five types by the American Spinal Injury Association and the International Spinal Cord Injury Classification System

Asia Class A

• Indicates a "complete" spinal cord injury where no motor or sensory function is preserved in the sacral segments S4-S5

• Since the S4-S5 segment is the lower segmental, absence of motor and sensory function indicates "complete" spinal cord injury.

Complete SCI

• Total loss of all motor and sensory function below the level of injury.

• Nearly 50 percent of all SCIs are complete.

• Both sides of the body are equally affected.

• Even with a complete SCI, the spinal cord is rarely cut or transected.

• More commonly, loss of function is caused by a contusion or bruise,compromise of blood flow to the injured part of the spinal cord.

Asia Class B

• Indicates an "incomplete" spinal cord injury where sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5.

• This is typically a transient phase and if the person recovers any motor function below the neurological level, that person essentially becomes a motor incomplete, i.e., ASIA C or D

Asia Class C

Indicates an "incomplete" spinal cord injury where motor function is preserved below the neurological level and more than half of key muscles below the neurological level have a muscle grade of less than 3.

Asia Class D

Indicates an "incomplete" spinal cord injury where motor function is preserved below the neurological level and at least half of the key muscles below the neurological level have a muscle grade of 3 or more.

Asia Class E

Indicates "normal" where motor and sensory scores are normal. Note that it is possible to have spinal cord injury and neurological deficit with completely normal motor and sensory scores.

Incomplete SCI

• Some function remains below the primary level of the injury.

• May be able to move one arm or leg more than the other, or may have more functioning on one side of the body than the other.

• Often falls into one of several patterns.

The Anterior cord syndrome

• Results from injury to the anterior part of the spinal cord, causing weakness and loss of pain and thermal sensations below the injury site

• But preservation of proprioception is usually carried out in the posterior part of the spinal cord.

• Infarction in anterior 2/3 of cord

• Flaccid paraplegia below the level of the lesion

• Dissociated sensory loss

• loss of pain/temp below the level of lesion

• intact proprioception and vibration

• dorsal columns spared--> supplied by the posterior spinal artery

• Occurs in watershed distribution (~T4)

• Associated with atherosclerosis, hypotension, dissecting aneurysm, or repair of aortic aneurysms

Ipsilateral findings below level of injury

• UMN signs

• Loss of proprioception, vibration

Ipsilateral findings at level of injury

paresthesias and radicular pain

Contralateral findings

• loss of pain and temperature extending to ~2

• dermatomes below level of injury

Tabes Dorsalis

Results from injury to the posterior part of the spinal cord, usually from infection diseases such as syphilis, causing loss of touch and proprioceptive sensation.

Clinical of Brown-Sequard Syndrome

• Ipsilateral findings below level of injury

• Ipsilateral findings at level of injury

• Contralateral findings

Tabes Dorsalis

• Degeneration of posterior columns

• Develops 10-20 years after syphilis

• Posterior roots are affected in addition to the posterior columns

1. “lightning” pains

2. ataxia

3. bladder disturbance

What are the classic triad of symptoms for Tabes Dorsalis?

Signs of Tabes Dorsalis

• loss of proprioception (sensory ataxia)

• areflexia

• argyll-robertson pupils

• only react to accomodation, not to light

Conus medullaris syndrome

Results from injury to the tip of the spinal cord, located at L1 vertebra.

Cauda equina syndrome

is, strictly speaking, not really spinal cord injury but injury to the spinal roots below the L1 vertebra.

Spinal Concussion

• These can be complete or incomplete, spinal cord dysfunction is transient, generally resolving within one or two days.

• Football players are especially susceptible to spinal concussions and spinal cord contusions.

• Numbness, tingling, electric shock-like sensations, and burning in the extremities.

• Fracture-dislocations with ligamentous tears may be present in this syndrome.

Penetrating SCI

• Gunshot wounds - common

• Require neurosurgical decompression

• May need to be immobilized with a collar or brace for several weeks

• Surgery to remove the bullet does not yield much benefit and may create additional risks, including infection, cerebrospinal fluid leak, and bleeding.

Symptoms of SCI

• Extreme pain or pressure in the neck, head, or back

• Tingling or loss of sensation in the hand, fingers, feet, or toes

• Partial or complete loss of control over any part of the body

• Urinary or bowel urgency, incontinence, or retention

• Difficulty with balance and walking

• Abnormal band-like sensations in the thorax - pain, pressure

• Impaired breathing after injury

• Unusual lumps on the head or spine

Complications of SCI

• Pneumonia

• Decubitus ulcers

• GI hemorrhage

• Thrombophlebitis

• Pulmonary embolism

• Arrhythmia

• Wound infection

• AMI

Pneumonia & Decubitus ulcers

Most common complications of SCI?

Surgical Advances

• Decompression and stabilization of spine.

• Management of syringomyelic cysts.

• Peripheral nerve bridging.

• Implanting avulsed roots or nerves into the spinal cord.

Some Recent Approachesto Spinal Injury

• Biochemical to overcome inhibitory factors.

• Cellular approaches to provide a substrate for axonal regeneration or as cell replacement therapy.

• Management of the inflammatory response.

Laminectomy

Central Cord Syndrome (Syringomyelia)

• Associated with greater loss of upper limb function compared to lower limbs.

• Usually results from trauma

• Damage to the large nerve fibers that carry information directly from the cerebral cortex to the spinal cord.

• Paralysis and/or loss of fine control of movements in the arms and hands, with far less impairment of leg movements. Sensory loss below the site of the SCI and loss of bladder control may also occur, with the overall amount and type of functional loss related to the severity of damage to the nerves of the spinal cord.

Clinical of Syringomyelia

• Dissociated sensory loss

• Loss of pain & temperature in a cape-like distribution with other sensory modalities spared

• frequent burns/injuries to the arm (pt can’t feel pain)

• Segmental paresis w/LMN signs

• Horner’s (if the lesion is in the thoracic cord)

• Sacral sparing

Brown-Séquard syndrome

Results from injury to one side with the spinal cord, causing weakness and loss of proprioception on the side of the injury and loss of pain and thermal sensation of the other side.