Spinal Cord Compression

Spinal Cord Compression

Surgical Students’ Society of Melbourne PresentationFelicity Victoria Connon

Spinal Cord CompressionCervico-medullary junction Conus medullaris +/- cauda equinae

Lesions are:•Extradural (80%)•Intradural, extramedullary (15%)•Intramedullary (5%)

http://myradnotes.wordpress.com/category/tumor/ http://indyspinemd.com/Images/normalAnat/coloredSpine.jpg

Causes of Spinal Cord Compression

• Acute• Subacute• Chronic

LOCATIONExtradural Intradural,

ExtramedullaryIntramedullary

AETIOLOGY

Tumour MetastasesMyeloma, Leukaemia

LymphomaChordoma

1° VB tumour

MeningiomaSchwannoma

IC seeding (medulloblastoma,

ependymoma)

GliomaMetastases

Degenerative Disc prolapseOP/OA/spondylolithesis

Ligamentum flava hypertrophy

Infection Extradural abscessVB (eg. TB)

  Abscess

Haematoma Extradural haematoma (trauma)

AVM AVMHaematoma

Developmental Arachnoid cyst Arachnoid cyst Syrinx

Presentation - Pain• Subacute

Chronic• Pain

• Muscles • Bone • Segment/central• Nerve root

http://www.dheerajbojwani.com/images/spinal-nerve.jpg http://www.patient.co.uk/images/OM1314b.jpg

Presentation – Altered Sensation and Power

  Brown-Sequard Syndrome/Hemisection

Syringomyelia/Central cord

Posterior Column

Spinal Cord

Lateral Compressive Lesion Central Cord LesionPosterior Compressive

LesionTracts Affected Corticospinal

Dorsal column Spinothalamic

1. Spinothalamic2. Interomediolateral

columns (autonomic)3. Corticospinal

Dorsal Column +/- Corticospinal & Autonomic

Motor Deficit Ipsilateral weaknessLMN at level of lesion

UMN below

Bilateral weaknessLMN at level of lesion

UMN below

Ipsilateral/Bilateral weakness

LMN at level of lesion+/- UMN below

Sensory Deficit Ipsilateral loss of vibration, proprioception and fine

touchContralateral loss of pain

and temperature

Bilateral pain and temperature

Cervical - Cape distribution extending downwards

Sacral sparing

Bilateral loss of vibration and proprioception

Bladder and Bowel Usually unaffected Late Late incontinence

Presentation – Altered Sensation and Power

  Complete Anterior Syndrome Cauda Equinae

Spinal Cord 

Anterior Compressive Lesion

Tracts Affected SpinothalamicCorticospinal

Lumbar and Sacral nerve roots

Motor Deficit Bilateral weakness LMN at level of lesion

UMN below

Bilateral weaknessLMN at level of lesion

UMN below

Ipsilateral or bilateral LMN

Sensory Deficit All modalities to level of lesion

Bilateral loss of pain and temperature

Lumbar nerve and S1 dermatome distribution (all modalities)

S2-5 Saddle anaesthesia

Bladder and Bowel 1. Initiation2. Retention

3. IncontinenceConstipation+/- Priapism

Retention Loss of motor and sensory bladder control + detrusor paralysis

(overflow incontinence)Impotence

Faecal incontinence

http://rezidentiat.3x.ro/eng/lombalgiaeng.files/image010.gif

Investigations• MRI

• Definitive Ix • Spinal X-rays

• Erosion, destruction, collapse

• Scalloping, IV space

• Myelography• CT (intrathecal

contrast)http://www.urmc.rochester.edu/smd/Rad/neurocases/Case34/Fig3.jpg

http://www.ortho.pe.kr/upload/ank_spond02.jpg

Management – Neurosurgical Emergency

Conservative• Rest• Weight loss• Epidural steroid

injections• Analgesia, anti-

inflammatories• Muscle relaxants• Physiotherapy

Specific• Malignancy

• Extramedullary/Vertebral

• Laminectomy (post.)• Vertebrectomy +

fusion (ant.)• XRT, chemo

• Intramedullary:• Macroscopic excision• XRT

• + Dexamethasone

Management• Spinal canal stenosis

• Laminectomy• Discectomy• Foramenectomy• ACDF

• Abscess• Drainage +/-

decompression• Antibiotics

• AVM• Dural: nidus excision or

venous obliteration• Intradural

http://img.springerimages.com/Images/Springer/PUB=Springer-Verlag-Berlin-Heidelberg/JOU=00586/VOL=2009.18/ISU=S2/ART=2009_895/MediaObjects/WATER_586_2009_895_Fig2_HTML.jpg

References• Essential Neurosurgery, Kaye, 3rd ed.,2005,

Blackwell Publishing• Neurology and Neurosurgery Illustrated, Lindsay

& Bone, 4th ed., 2004, Churchill Livingstone• www.uptodate.com

• Treatment and prognosis of neoplastic epidural spinal cord compression, including cauda equinae. Schiff et al, 2010

• Anatomy and localisation of spinal cord disorders, Eisen et al, 2010