Chronic Spinal Cord Injury - PowerPoint Presentation

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Chronic Spinal Cord Injury (Lesi Medula Spinalis Khronis)

Darwin Amir

Bgn Ilmu Penyakit Saraf

Fakultas Kedokteran Universitas Andalas

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The Spinal Cord

Cervical spinal

erves

Thoracic spinal nerves

Lumbar spinal nerves

Sacral spinal nerves

Conus

medullaris

Cauda

equina

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PROYEKSI DERMATOM DIPERMUKAAN KULIT

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Ascending Spinal Cord Tract

1

st

order

neuron

- cutaneous receptors of skin and proprioceptors

 spinal cord or brain stem

2nd order

neuron - to thalamus or cerebellum

3

rd order neuron

- to somatosensory cortex of cerebrum

Conducts sensory impulses upward through 3 successive chains of n

eurons

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Ascending Spinal Cord Tract

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The Spinal Cord

spinal cord

spinal nerve

vertebra

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Cross Section of Spinal Cord

White matter:

Myelinated

axons forming nerve tracts

Fissure and sulcus

Three columns:Ventral DorsalLateral

Gray matter:

Neuron cell

cell bodies, dendrites, axons‘Horns’:

Posterior (dorsal)Anterior (ventral)

LateralCommissures:

Gray: Central canal White

(see later for white

matter pathways)

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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

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Nerve Pathways into the Spinal Cord

sensory pathway

motor pathway

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Somatic Sensory Pathway

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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

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Sensory disturbances

▪

Soft touch, pain, temperature, position, vibration impaired below the level of lesion

▪ B

and like radicular pain/segmental paraesthesia at the level of lesion

▪ localised vertebral spine pain- destructive lesions

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Motor disturbances

▪

P

araplegia/quadriplegia

▪ A

cute-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

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• F

lexion

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

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Autononomic disturbances

initially

atonic

, latter spastic bladder, rectal sphincter disturbances

orthostatic hypotensiontrophic

skin changesanhydrosisimpaired temperature control

vasomotor instabilitysexual disturbances

I/L horner syndrome

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Causes of Chronic Lesion

°

T

umour

° Multiple sclerosis

° Vascular disorders

° Spinal epidural hematoma/abscess

° Auto immune disease

° Herniated

intervertebral disc

° Combine degeneration of B12 Deficiences

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Complete spinal cord

transection

(Transverse

myelopathy

)

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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 disturbedCauses :

° tumour

° multiple sclerosis ° vascular disorders

° spinal epidural hematoma/

° spinal epidural abscess

° herniated intervertebral disc

° auto immune disease

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Central spinal cord lesion

Spinal cord damage starts centrally and

spre

a

ds centrifugallyDecussating fibers of spinothalamic

tract involved initiallyThermo anaesthesia, analgesia in a ”vest like” or “suspended” bilateral distribution with preservation soft touch sensation and

proprioception--- dissociation of sensory loss

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Central spinal cord lesion

Forward extension of disease

anterior horn cells involved

segmental neurogenic atrophy, paresis, areflexia

Lateral extension I/L H

orner syndrome

Kypho scoliosis

Spastic paralysis

Dorsal extension

I/L Position sense, vibratory loss

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Central spinal cord lesion

Extreme

venterolateral

extension

thermo anaesthesia, analgesia with sacral sparing

Neuropathic arthropathy

Pain

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Posterior column disease

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Posterior column disease

Tabes

dorsalis-tabetic

neuro syphilis, progressive locomotor ataxia

Impaired 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

(+)

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Ataxic / stomping/ double tapping gait

Positive sink sign

In

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

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○

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

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Hemisection

of the spinal cord

( Brown

sequard

syndrome)

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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 tractSegmental 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

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INNERVATION OF AUTONOMIC NERVOUS

SYSTEM

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Thank you Brain

For all you remember

What you forgot was my fault

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The End

TERIMA KASIH