The Spinal - Cord

dr. Budhi Suwarma, SpS

FK UNJANI

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
Ending of Spinal - Cord
0-3
rd
month of fetal life = S V
5
th
month of fetal life = S I
At the time of birth = L III
Adult = L I
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
Segments of the Spinal
Cord
Segments Vertebras
Cervical 8 7
Thoracal 12 12
Lumbal 5 5
Sacral 5 5
Coccigeus - 4
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
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)
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)
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

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
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


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
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

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
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

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

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
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
Neoplasm
Less frequent than brain (l5%),mostly
benign,compression effect

Intramedullary (5%):lesion within cord

Extramedullary : lesion outside cord
Intradural (40%) / Extra Dural (55%)


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
Neoplasm (Cont.)
Extramedullar Intramedullar
Pain Radicular Not
characteristic
Sensibility Brown
Sequard
Dissosiation of
sensibility
Localization Unilateral bilateral
Examination
X-ray Vertebrae
Myelografi / CTMM
MRI
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-LII
Satisfactorily demonstrated by CT, MRI, lateral
spine X-ray
Tearing of ligaments can only inferred from the
spinal displacement
Whiplash / recoil injury
Extremes of extension / flexion of the neck
Other Spinal Cord Injury
Bullet / missile
Sharpnel
Stab wound
Spinal cord concussion
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
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
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
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)

AIDS vacuolar myelopathy
1. Incidence 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.
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
Myelitis e.c. bacterial, fungal,
parasitic and granulomatous dis.
Leptomeningitis,pachymeningitis,absc
ess/granuloma epidural

Pial a./v.thrombosedmyelomalacia

Progressive constrictive pial fibrosis
Arachnoiditis
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
Tuberculous (TBC) Myelitis
TBC Spine Osteitis with kyphosis
(Potts dis)pus/caseous granulation
tissueepidural compression of the
cordparaplegi

TBC meningitispial arteritisspinal
cord infection
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
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
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
ASA syndrome
Sudden onset of paraparese
Bilateral loss of sensory
Dorsal collum intact

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
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
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 )

Demyelinisasi :
Multiple Sclerosis
Episodes of focal disorder of 2
nd
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
Other Myelopathy
(Primary/Secondary)
Amyotropic Lateral Sclerosis (ALS)
Progressive Muscular Atrophy (PMA)
Syringomyelia
Cervical Spondylosis
HNP

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
Progressive Muscular Atrophy
men>women,mostly symmetrical
wasting intrinsic hand musclesmore
proximal arms
Progress slower than ALS
Tendon reflex or -,signs of UMN -
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
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
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, Lhermittes sign
Compressive myelopathy
Paraparesis UMN
Unsteady gait (sensory ataxia)
Altered sphincter control
Hernia Nucleus Pulposus
Fraying of the annulus fibrosusextru
sion of disc material (# bulging)
CVI-VII(7
th
C-70%),CV-VI(6
th
C-20%),
CIV-V(5
th
C-5%),CVII-ThI(8
th
C-5%)
LV-SI(1
st
S)LIV-VLIII-IV
NCV,H reflex,X-ray photo,MRI
HNP Lumbar
3
rd
-4
th
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.
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
HNP Cervical
Neck ROM ,pain with hyperextens
ion,coughing,sneezing,flexion
7
th
C root:pain shoulder blade,pectoral,
medial axilla,posterolateral upper arm,
elbow,dors fore arm,index-midle finger
6
th
C root:pain trapezius ridge,tip shoul
der,anterior upper arm,radial fore arm,
thumb
SELESAI