Spinal cord diseases
The spinal cord is part of the central nervous system. It contains the nerve pathways, taking its origin from the nerve nuclei in the brain, and its own neurons communicating with peripheral organs and other parts of the brain. Spinal cord and the rays of the nerve roots are located within the lumen of the vertebral canal. It runs from the beginning of the cervical spine and ends in the upper part of the lumbar spine in adults.
The spinal cord is located in the vertebral canal and is surrounded by epidural fat.
Some spinal cord diseases can lead to the patient's permanent neurological damage and often to their subsequent disability. Small sizes spinal cord injury can cause paralysis of arms and legs (quadriplegia), or only legs (paraplegia) with a complete absence or reduction of sensation below the injury site. Since the spinal cord is essentially similar in its cross-section like a multicore cable, then it is enough minor size damage of its for timeless appearance of neurological symptoms and patient's disability.
In disease, causing of the spinal cord compression (outside or inside), arising neurological deficits may be reversible. In such cases, it is important to remove arisen during the spinal cord compression, and do not let the time for develop neural structures lesion.
Spinal cord anatomy has a segmental structure. The spinal cord carries innervation to the limbs and trunk. From the spinal cord are depart 31 pairs of spinal nerves. This type of segmental structure and innervation facilitates of the patient diagnosis. Neurological examination is determine the localization of the pathological process in the spinal cord is allow border of sensitivity disorders, muscles paralysis or weakness in the arms or legs (paraplegia, paraparesis) and other typical syndromes.
Besides the patient's neurological examination is carried out spinal cord magnetic resonance (MRI) or computer tomography (CT) imaging. Formerly common method like myelography now moved away into the background in clinical practice due to the emergence of more accurate and safe methods of spinal cord and spine diseases study. Cerebrospinal fluid (liqvor) analysis is able to give information clarifying a diagnosis in some spinal cord diseases.
Knowledge of the spinal cord (segmental principle) and outgoing spinal nerves anatomical structure allows neurologists and neurosurgeons in practice to accurately determine the damage symptoms and syndromes. During the patient's neurological examination, descending from the top down, is necessary find the upper limit of sensation and motor activity disorders beginning. It should be remembered that the vertebrae bodies do not correspond located beneath spinal cord segments. Spinal cord injury neurological symptoms depends its damaged segment.
During the human growth, the spinal cord length lags behind the surrounding spine length.
During spinal cord formation and development, it grows more slowly than the spine. In adults, the spinal cord ends at the level of the first lumbar vertebra L1 body and the rays of the nerve roots will descend further down, for the limbs or pelvic organs innervation.
Clinical rule used in determining of spinal cord and nerve roots lesion level:
- cervical roots (except C8 nerve root) leave the spinal canal through the holes over the corresponding vertebral bodies,
- thoracic and lumbar roots leave the spinal canal under the same levels vertebrae,
- upper spinal cord’s cervical segments lie behind the vertebral bodies with the same numbers,
- lower spinal cord cervical segments lie on one segment above their corresponding vertebra,
- upper spinal cord thoracic segments lie on two segments above,
- lower spinal cord thoracic segments lie on the three segments above,
- spinal cord’s lumbar and sacral segments (the last one form tip of the spinal cord, located at the L1 vertebra level - medullary cone or conus medullaris) are located behind the ThIÕ-LI vertebrae.
For clarify the distribution of various pathological processes around the spinal cord, especially at spondylosis, it is important to accurately measure the vertebral canal's (spinal canal) sagittal diameter. Vertebral canal's (spinal canal) diameter in adults:
- cervical level - 16-22 mm,
- thoracic level - 16-22 mm,
- lumbar LI-LIII vertebrae level - about 15-23 mm,
- lumbar LIII-LV vertebrae level and below - 16-27 mm.
Depending on spinal cord injury level will be identified following neurological syndromes:
- loss of sensation below the spinal cord lesion level (sensitivity's impairment degree),
- limb's weakness, innervated by corticospinal path's descending nerve fibers on the spinal cord lesion level.
Sensory impairments (hypoesthesia, paresthesia, anesthesia) may appear in one or both feet. Numbness may spread upward, simulating peripheral polyneuropathy. In the case of complete or partial corticospinal and bulbospinal pathways interruption on the same level of the spinal cord, in a patient occurs upper and / or lower limbs paralysis (paraplegia and tetraplegia). At the same time identified the symptoms of central paralysis:
- • increased muscle tone,
- • increased tendon reflexes,
- • revealed pathological Babinski's sign.
In a patient will arise motor and sensory impairments depending on the spinal cord damage level.
During the patient's examination with spinal cord injury is commonly found segmental disorders:
- sensitivity changes strip near the upper level of sensory conduction disorders (hypersensitivity or hyperpathia),
- muscular hypotonia and atrophy,
- isolated loss of tendon reflexes.
The level of sensitivity disorders (conduction type) and segmental neurological symptoms indicate about localization patient's spinal cord cross-section injury. Precise localizing sign is pain, perceived in the back's midline, especially at the thoracic level. Interscapular region pain may be the first symptom of patient's spinal cord compression. Radicular pain indicate a primary localization of spinal cord lesions in its external mass. Medullary cone lesion (conus medullaris) may causes lower back pain.
In the early stages of the cross-section spinal cord lesions in the patient's limbs can be observed decrease in muscle tone (hypotonia), and not spasticity due to spinal shock. Spinal shock can last for several weeks. Sometimes it is mistaken for an extensive segmental lesion. Later, patient's tendon and periosteal reflexes are increased. In cross-section lesions, especially due to a heart attack, paralysis often precede short clonic or myoclonic limbs convulsions. Another important symptom of cross-section spinal cord injury is malfunction of the pelvic organs, which manifests itself in a patient in the form of retention of urine and faeces.
Character of the possible motor and sensory neurological disorders depends on the spinal cord damage size.
Spinal cord compression from inside (intramedullary) or outside (extramedullary) can be manifested clinically in a similar way. Therefore, patient's neurological examination only is not enough to determine the localization of spinal cord lesions. Neurological symptoms, suggestive for localization of pathological processes around the spinal cord (extramedullary) are:
- radicular pain,
- spinal cord hemisection lesion (Brown-Sequard syndrome),
- symptoms of a lesion of peripheral motor neurons within one or two segments, often asymmetric,
- early signs of corticospinal tract involvement,
- a significant reduction of sensitivity in the sacral segments,
- early and pronounced changes in the cerebrospinal fluid (liqvor).
Neurological signs testifying in favor of the localization of pathological processes within the spinal cord (intramedullary) include:
- difficulty localized burning pain,
- dissociated loss of pain sensitivity with preserved musculoarticular sensitivity,
- preservation of sensation in the perineum and sacral segments,
- late appearing and less expressed pyramidal symptoms,
- normal or slightly altered composition of cerebrospinal fluid (liqvor).
Lesion within the spinal cord (intramedullary), accompanied by the involvement of most spinothalamic tract internal fibers, but not affecting the outermost fiber, providing the sensitivity for sacral dermatomes, will manifest itself by absence of damage signs. Will be saved perception of pain and temperature irritations in the sacral dermatomes (S3-S5 nerve roots).
Brown-Sequard syndrome indicate the symptom complex of spinal cord hemisection lesion. Brown-Sequard syndrome is clinically manifested:
- on the spinal cord affected side - paralysis of the hands and / or feet (monoplegiya, hemiplegia) muscles with loss of muscular-articular and vibration (deep) sensitivity,
- on the opposite side - loss of pain and temperature (surface) sensitivity.
Upper boundary of pain and temperature sensitivity disorders in Brown-Sequard syndrome is often determined on 1-2 segments below the spinal cord injury site, as the spinothalamic path fibers after the formation of the synapse in the dorsal horn of the spinal cord to the opposite side of funiculus, ascending upward. Segmental neurological symptoms in the form of radicular pain, muscle atrophy, tendon reflexes fading are usually one-sided.
Spinal cord blood supply provided by one anterior spinal and two posterior spinal arteries.
If the spinal cord lesion site are localisedin in central part (intramedullary) or affects superficially, it will mostly damage the neurons of gray matter and segmental conductors that produce their decussation at this level. This observed in contusion during spinal trauma, syringomyelia, tumors and vascular lesions in the anterior spinal artery basin. In case of cervical spinal cord central lesion often occur:
- arm weakness more expressed than the legs weakness,
- dissociative sensitivity disorder (analgesia, i.e. the loss of pain sensitivity with the distribution in the "cushion shoulders" form and the lower neck, without anesthesia, i.e. loss of tactile sensations and preservation vibration sensitivity).
Spinal cord cone lesions site, localized on LI vertebral body level or lower, compress the spinal nerves (part of cauda equina). This causes peripheral asymmetric paraparesis with areflexia. Spinal cord and its nerve roots lesion on this level is accompanied by dysfunction of the pelvic organs (bladder and bowel dysfunction). The distribution of sensory disorders in the patient's skin resembles the saddle outline, reaches LII level and corresponds to zones of innervation of the nerve roots entering into a cauda equina. Achilles and knee reflexes in these patients reduced or absent. Most patients reported about pain, extending to the perineum or thigh.
If pathological processes localized in the spinal cord cone area pain exhibits much weaker than in patients with lesions of the cauda equina, and the bowel's and bladder's malfunction occur earlier. Achilles reflexes fade away. Compression processes can cover the cauda equina and spinal cord cone simultaneously, causing a combined of peripheral motor neuron's syndrome with increased reflexes and the emergence of a pathological Babinski sign (reflex).
If the spinal cord affected at the level of foramen magnum in patients occurs upper extremity (shoulder, hand) muscle weakness, after which comes arms and legs weakness on the opposite side. Abnormal mass of this localization sometimes provide pain in the neck and nape, extending to the head and shoulders. Another evidence of the high cervical level (to segment ThI) lesion is Horner's syndrome.
Some vertebral spine diseases can cause sudden myelopathy without previous symptoms (like spinal stroke). These include epidural hemorrhage, hematomyelia, spinal cord infarction, intervertebral disc's nucleus pulposus herniation (prolapse, extrusion), and vertebral subluxation.
Chronic myelopathy occur in the following vertebral spine or spinal cord diseases:
- Lumbar spinal stenosis,
- Degenerative and hereditary myelopathy
- Meningovascular syphillis (tabes).
If you have any questions on the diagnosis or treatment of spinal cord diseases, you can ask them to our neurosurgeon or neurologist:
- Ankylosing spondylitis (Bechterew's disease)
- Back pain in pregnancy
- Coccydynia (sore tailbone)
- Compression fracture of the spine
- Degenerative and hereditary myelopathy
- Epiduritis and spinal abscess
- Low back pain, pain in leg, Sherman Mau diseases
- Lumbago, sciatica and lumbodynia
- Lumbar disc disease (herniated disc, bulging disc)
- Meningovascular syphilis or syphilitic myelopathy (tabes dorsalis)
- Cervicocranial syndrome and whiplash neck injury
- Neck pain, shoulder pain
- Non-compressive oncological myelopathy
- Osteochondrosis and its symptoms
- Osteochondrosis of the thoracic spine, intercostal neuralgia
- Osteoporosis (vertebral body)
- Rules of disability patients care with arms and legs muscles paralysis (paraplegia, quadriplegia)
- Sacroiliac joint osteoarthritis
- Sacroiliac joint pain (sacroiliac joint dysfunction syndrome)
- Sacrum pain
- Scoliosis spine, stoop
- Syringomyelia, siringobulbia
- Spinal cord and spine congenital defects (Klippel–Feil syndrome, cervical rib, spina bifida, meningocele, meningomylocele, diastematomyelia, sacralization, lumbarization, spondylolisthesis)
- Spinal cord compression
- Spinal cord diseases
- Spinal cord and spinal canal epidural space hemangiomas
- Spinal cord infarction (ischemic stroke)
- Spinal stenosis, lumbar and cervical osteophytes
- Spondylitis (osteomyelitic, tuberculosis, etc.)
- Spondyloarthrosis (osteoarthritis of the intervertebral joints)
- Spondylolisthesis (displacement and spinal instability)
- Vertebral hemangioma (vertebral angioma)
- Vertebral subluxation and dislocation