Spinal Cord Disorders UWKS

Neurogenic Bladder, Acute Medullar Compression, and Complete Spinal

Transection

Christian Kamallan Neurology Department

Diferent

spinal cord

levels supply nerves for

diferent

regions of the body

Anatomy

of

Physiology and function

• _{Grey matter – sensory and motor}

nerve cells

• _{White matter – ascending and}

descending tracts

• _{Divided into - dorsal}

- lateral

- ventral

• Posterior column and lateral

corticospinal tract crosses over at medulla oblongata

• _{Spinothalamic tract crosses in the}

spinal cord and ascends on the opposite side

NB to understand this as it helps to understand the clinical

Dermatomes

• _{Area of skin innervated by sensory}

axons within a particular segmental nerve root

• _{Knowledge is essential in}

determining level of injury

• _{Useful in assessing improvement or}

Myotomes

• _{Segmental nerve root innervating a}

muscle

• _{Again important in determining level of}

injury

• _{Upper limbs:}

C₅ - Shoulder abduction

C ₆ - Wrist extensors

C ₇ - Elbow extensors

C ₈ - Long fnger fexors

• _{Lower Limbs :}

L₂ - Hip fexors

L_3,4 - Knee extensors L_4,5 - S₁ - Knee fexion

L₅ - Great Toe/Ankle dorsifexion S₁ - Great Toe/Ankle plantar

Anatomy review

– _{Conus medullaris:} most distal bulbous part

– _{Filum termiale:} tapering part of conus medullaris (mostly fbrous tissue)

– _{Cauda equina: distal} collection of nerve

Conus vs Cauda

– _{Conus medullaris:} most distal bulbous part

– _{Filum termiale:} tapering part of conus medullaris (mostly fbrous tissue)

– _{Cauda equina: distal} collection of nerve

Conus vs Cauda

Conus Cauda

Sudden and bilateral onset Gradual and unilateral onset

Radicular pain less prominent Radicular pain more prominent

More low back pain Less low back pain

Symmetric, distal, hyperreflexic

paresis Asymmetric, areflexic paraplegia

Symmetric, bilateral, typically

perianal area sensory loss, sensory dissociation occurs

Asymmetric, unilateral, typically

saddle area, no sensory dissociation

The real estate of cord

compression…location is key!

• _Intradural

intramedullary:

– _{astrocytomas,}

ependymomas,

hemangioblastomas

(primary spinal tumours)

• _Intradural

extramedullary:

– _Meningiomas

– _{nerve sheath tumours}

(schwannomas and neurofbromas)

• _{Epidural: metastases}

Intramedullary vs

Extramedullary

Intramedullary Extramedullary

Poorly localized burning pain Prominent radicular pain

“sacral sparing” Early sacral sensory loss

Corticospinal tract signs

appear later Early spastic weakness in legs

Usually rapid progression

Cord compression….

One of the only true

neurological emergencies…

where time is of the essence (i.e. drop everything else

Diferential Diagnosis

• _{Common causes}

– Neoplasm

– Fracture

– Cervical / lumbar stenosis

– Herniated disk

– Spinal infection/abscess

– Spinal hemorrhage

– Conus medullaris lipomas

• _Mimickers

– Anterior spinal artery infarction

– Spinal AVMs

– Multiple sclerosis / transverse myelitis

– Neurosarcoidosis

Location (Neoplasm)

Thoracic spine

60%

Lumbosacral spine

30%

Pathophysiology - Epidural

Mets

1) Hematogenous spread to bone marrow – _{Most common mechanism}

– _{Most at vertebral mass}

2) Direct invasion through intervertebral foramina from paravertebral source

– _{Second most common mechanism}

– _{Typical of lymphoma}

3) Retrograde venous spread

– _{With increased abdominal pressure, abdo/pelvis}

venous system drains via Batson paravertebral plexus to epidural venous plexus

Pathophysiology - Cord

Damage

• _Severity

– _{Mild: minor Asx indentation of thecal sac}

– _{Severe: strangulation of cord with paraplegia}

• _Progression

– _{Epidural venous plexus obstructed}  BBB

breakdown  vasogenic edema  PGD (hence utility of steroids)

– _{First WM involved}  demyelination

– _{Then GM involved}  cord ischemia / infarction

– _{Irreversible damage if prolonged compression}

What is malignant spinal cord

compression?

• _{Occurs when cancer}

cells grow in/near to spine and press on the spinal cord & nerves

• _{Results in swelling &}

reduction in the blood supply to the spinal cord & nerve roots

• _{The symptoms are}

caused by the

Epidemiology

• _{Most common}

– _{Adults: lung, breast, prostate, lymphoma,}

sarcoma, kidney

– _{Children: Ewing’s sarcoma, neuroblastoma,}

germ cell neoplasms, Hodgkin’s lymphoma

• _{In cancer patients}

– _{likelihood of epidural spinal cord compression}

5-yrs before death = 2.5%

That being said…

all patients with new back pain and known malignancy have spinal cord compression until

Now that you’ve thought of

the Dx, focus

Hx

and

exam

on:

1) Back pain 2) Weakness 3) Refexes

4) Sensory loss

Back Pain

• _{Initial complaint in 96%}

• _{May precede neuro Sx by days or years}

(duration related to tumour growth rate);

average 7 weeks

• _{Constant, worse with coughing, sneezing,}

straining, exercise

• _{Worse when supine (as opposed to disc}

disease)

• _{May be radicular (L’hermitte sign in}

cervical lesion, “tight rope / band around chest” in thoracic lesions)

• _{Percuss / palpate chest to better localize}

Weakness

• _{Present in 80% initially (50%}

ambulatory; 35% paraparetic; 15% paraplegic)

• _{Rate of progression depends on tumour}

growth rate (30% become paraplegic in

1 week)

• _{Usu. paraplegia = cord infarction (likely}

irreversible)

• _{Pattern of weakness depends on site of}

compression

Refexes

• _{Hyperrefexia, upgoing toes (may not}

be seen in cauda equina lesions)

• _{Abdominal refexes (helpful if present}

Sensory loss

• _{Present in 78% of patients at diagnosis}

• _{“Pins and needles,” “numb”}

• _{Look for sensory level}

– _{Begin distally, then ascend (use pin, go all the}

way up to neck)

– _{Look for Brown-Sequard syndrome}

– _{Usu 1-5 levels below actual compression}

• _{Pattern as per site of compression}

• _{Above cauda equina, if intramedullary}  sparing of sacral dermatomes

Spincters

• Urinary

– Contraction of detrusor

muscle innervated by S2-3-4

– _{Initially faccid and} distended bladder 

retention

– _{Then “decentralized}

bladder” becomes active and shrinks, bladder wall hypertrophies 

incontinence, frequency

– _{Ask about urination,}

palpate bladder for fullness, bladder scan and Foley

insertion to document urine volume

http://www.accessmedicine.com/ content.aspx?

Spincters

• _{Rectal tone}

– _{External anal}

sphincter and

puborectalis muscle innervated by S3-4

– _{Loss of anal tone} 

stool incontinence

– _{Similar mechanism}

for bulbocavernosus refex

– _{DRE, anal wink,}

tugging at Foley

What to image

• _{Always image entire spine:}

– _{Spinal cord is shorter than vertebral}

spinal column; imaging LS spine means you’re not imaging the cord at all

– _{Exam is not always reliable for level of}

compression

– _{Multiple sites of deposits are frequent in}

Diagnosis

• MRI

– Test of choice

ADVANTAGES

– Non-invasive

– _{No procedural complication}

(e.g. risk of herniation with brain mets, hemorrhage with coagulopathies, neuro

deterioration with CSF retrieval)

– Visualization of spinal

parenchyma, adjacent bone and soft tissues

– Can image entire spine even if subarachnoid block present

– Needed to plan radiation and Sx

• CT

myelography

– 2nd test of choice

ADVANTAGES

– CSF can be obtained for analysis

– Safe for claustrophobic patients

– _{Safe for ferromagnetic}

implant (valves, PM, implants, shrapnel)

Treatment

• _{The obvious…}

– _{Abscess: ABX, Sx}

– _{Hematoma: correct coagulopathy, Sx}

– _{Fracture / stenosis: Sx}

• _{Goals of treatment for epidural}

metastases

– _{Pain control}

– _{Preserve or improve neurological}

Steroids (Decadron)

Initial presentation Dose recommended

Mild disease, no neurological Sx Forgo steroids

Moderate disease, minimal

neurological dysfunction, < 80% spinal block

Low dose: 10mg x1 IV

then 4mg q6h;

then taper rapidly when definitive Rx underway

Severe disease, significant neurological dyxfunction

(paraparetic, paraplegic); > 80% spinal block

High dose: 100mg x1 IV

then 24mg q6h x at least 72 hours then taper gradually when

Steroids

• _{Clearly improve neurological outcome} • _{It seems no diference b/w initial dose}

of 10mg or 100mg for mild disease

• _{Adverse efects (gastric ulcers,}

Radiotherapy

• _{RT portal: centered on spine, 2 vertebral}

bodies above and below myelographic block

• _{No diference in functional outcome or} overall survival b/w diferent dosing

regimens

• _{Protracted course had better local control}

of tumour (less recurrence within feld)

• _{Overall success depends on inherent}

Surgery

• _{Needed for tissue Dx if 1}st presentation of

cancer or if spine instability

• _{Adverse efects (wound closure, infection,}

spinal instability, nonfusion)

• _{May worsen pain}

• _{Older trials (posterior approach):}

– _{Sx + RTX = RTX alone}

• Recent trials (anterior approach):

– Sx + RTX > RTX alone

• Future direction more geared toward Sx?

Supportive

• _{Pain management (steroids usually} relieve pain, opioids help)

• _{Bedrest not helpful (except if has}

spine instability)

• _{VTE prophylaxis: heparin sc, TED} stockings, compression

Prognosis

• _{Most important Px factors: weakness at}

presentation

• _{Duration of Sx prior to presentation correlate}

with Px

• _{Sparing of sphincter and sacral sensory = good}

Px

• _{Px depends on radiosensitivity of tumour}

• _{Children overall prognosis better than adults} • _{Median survival 6 months}

– Inform patients with cancer who are at risk of MSCC

• information about the symptoms of MSCC

• _{what to do & who to contact if symptoms develop}

– Discuss with the MSCC coordinator

immediately patients with cancer who have

symptoms of spinal metastases & neurological symptoms or signs suggestive of MSCC

• view as an emergency.

– _{Discuss with the MSCC coordinator within 24}

hours patients with cancer who have symptoms suggestive of spinal metastases

Take Home Messages

• Suspect spinal cord compression in all patients with cancer and back pain, +/- weakness,

sphincter signs

• _{Goal of history and exam:}

– assess severity of neuro defcits (weakness, sensory, sphincter)

– localize lesion (pattern of weakness, sensory level)

• MRI if no contraindication, image whole spine

• Involve all relevant consultants

• No diference between high and low dose Decadron

• Act fast, prognosis directly related to duration and severity of neuro defcits

Spinal Cord Injury

Classifcation

• _{Quadriplegia :}

injury in cervical region all 4 extremities afected

• _{Paraplegia :}

injury in thoracic, lumbar or sacral segments

Injury either:

1) Complete

Complete:

i) Loss of voluntary movement of

parts innervated by segment, this is irreversible

Incomplete:

i) Some function is present below site of injury

ii) More favourable prognosis overall iii) Are recognisable patterns of injury,

Spinal Shock vs Neurogenic Shock

Spinal Shock :

• Transient refex depression of cord function below level of injury

• Initially hypertension due to release of catecholamines

• Followed by hypotension

• Flaccid paralysis

• Bowel and bladder involved

• Sometimes priaprism develops

Spinal shock

• _{Spinal shock : A period of decreased excitability of}

spinal cord at and below level of lesion (all refexes disappeared)

• _{Suppression of autonomic activity as well somatic}

activity

– _{a brief period of tachycardia and hypertension}

– _{Followed by Neurogenic shock: prolonged}

bradycardia, hypotension, reduction in cardiac output

– _{Acontractile and arefexic bladder}

• _{Absent of somatic refex activity and faccid muscle}

paralysis

– _{Sphincter = residual tone}

– _{retention (catheter / SPC / CISC)}

Spinal shock

• return of the bulbocavernosus refex (anal sphincter contraction in response to

squeezing the glans penis or tugging on

the Foley) signifes the end of spinal shock, • Bladder contraction: Last to recover

• Majority of recovery in 1st 6 months • More subtle changes up to 2 -5 years? • Refex recovery

– Refex recovery1st = striated muscle of pelvic foor

Neurogenic shock:

• _{Triad of i) hypotension}

ii) bradycardia iii) hypothermia

• More commonly in injuries above T₆

• _{Secondary to disruption of}

• _{Loss of vasomotor tone – pooling of blood}

• _{Loss of cardiac sympathetic tone –}

bradycardia

• _{Blood pressure will not be restored by fuid}

infusion alone

• _{Massive fuid administration may lead to}

overload and pulmonary edema

• _{Vasopressors may be indicated}

Types of incomplete injuries

i) Central Cord Syndrome

ii) Anterior Cord Syndrome

iii) Posterior Cord Syndrome

iv) Brown – Sequard Syndrome

i) Central Cord Syndrome :

• _{Typically in older patients} • _{Hyperextension injury}

• _{Compression of the cord anteriorly}

• _{Also associated with fracture}

dislocation and compression fractures

• _{More centrally situated cervical}

tracts tend to be more involved

hence

flaccid weakness of arms  legs

• _{Perianal sensation & some lower}

ii) Anterior cord Syndrome:

• _{Due to fexion / rotation}

• Anterior dislocation / compression fracture of a vertebral body

encroaching the ventral canal

• Corticospinal and spinothalamic

Clinically:

• _{Loss of power}

• _{Decrease in pain and sensation}

below lesion

ii) Posterior Cord Syndrome:

Hyperextension injuries

with fractures of the posterior elements of the vertebrae

Clinically:

• _{Proprioception afected – ataxia and}

faltering gait

iv) Brown – Sequard Syndrome:

• _{Hemi-section of the cord}

• _{Either due to penetrating injuries:}

i) stab wounds

ii) gunshot wounds

• _{Fractures of lateral mass of vertebrae}

Clinically:

• _{Paralysis on afected side}

(corticospinal)

• _{Loss of proprioception and fne}

discrimination (dorsal columns)

• _{Pain and temperature loss on the}

v) Cauda Equina Syndrome:

• _{Due to bony compression or disc}

protrusions in lumbar or sacral region

Clinically

• _{Non specifc symptoms – back pain}

In conclusion

Spinal Cord Injuries:

• _{Devastating event to both patient}

and family.

• _{Huge impact on society}

• After receiving First – World care in tertiary institutions, many of our patients return to impoverished

communities

DEFINITION DEFINITION

•

refers to dysfunction of the urinary

bladder due to disease of the central

nervous system or peripheral nerves

involved in the control of micturition

(urination).

•

refers to dysfunction of the urinary

SPASTIC NEUROGENIC

BLADDER

LESIONS AT ABOVE T12 LESIONS AT ABOVE T12

INTERRUPTED AFFERENT SIGNALS INTERRUPTED AFFERENT SIGNALS

EXCITATION OF NEURONS BELOW T12 EXCITATION OF NEURONS BELOW T12

SPONTANEOUS CONTRACTION OF DM

SPONTANEOUS CONTRACTION

OF DM URINARY SPHINCTER SPASMSURINARY SPHINCTER SPASMS INTRAVESICAL VOIDING

PRESSURE

INTRAVESICAL VOIDING PRESSURE

BLADDER WALL HYPERTROPHY WITH TRABECULATION

BLADDER WALL HYPERTROPHY WITH TRABECULATION

REDUCED URINE-VOLUME CAPACITY

REDUCED URINE-VOLUME CAPACITY

UNCONTROLLED URINATION UNCONTROLLED URINATION

LESIONS AT OR BELOW S2/S4 LESIONS AT OR BELOW S2/S4

INTERRUPTED AFFERENT SIGNALS BELOW S2/S4 INTERRUPTED AFFERENT SIGNALS BELOW S2/S4

LOW OF SENSATION OF BLADDER FILLING LOW OF SENSATION OF BLADDER FILLING RELAXATION OF

DETRUSOR MUSCLE RELAXATION OF

DETRUSOR MUSCLE POOR CONTRACTION OF DETRUSOR MUSCLE POOR CONTRACTION OF

DETRUSOR MUSCLE INTRAVESICULAR PRESSURE

INTRAVESICULAR PRESSURE

BLADDER CAPACITY (2000ML) BLADDER CAPACITY (2000ML)

OVERDISTENDED BLADDER OVERDISTENDED BLADDER

BLADDER PRESSURE REACHES A BREAK THROUGH POINT

BLADDER PRESSURE REACHES A BREAK THROUGH POINT

SMALL AMOUNTS OF URINE DRIBBLE SMALL AMOUNTS OF URINE DRIBBLE

FLACCID

BLADDER

• _{A flaccid, or hypotonic, bladder ceases to contract}

fully, causing urine to dribble out of the body. Besides the complications that stem from urine dripping, rashes can occur in the area where urine pools. This

•

_{A spastic, or reflex, bladder occurs when}

the volume of urine is normal or small, but

there are involuntary contractions, causing

a person to feel the need to urinate even

when he doesn't need to release urine

Causes of Neurogenic Bladder

Causes of Neurogenic Bladder

•

_Stroke

•

_{Parkinson’s disease}

•

_{Multiple sclerosis}

•

_{Alzheimer’s disease}

•

_{Spina bifida and neural}

disorders resulting from diabetes

or alcoholism

•

_Stroke

•

_{Parkinson’s disease}

•

_{Multiple sclerosis}

•

_{Alzheimer’s disease}

•

_{Spina bifida and neural}

Symptoms of Neurogenic Bladder

Symptoms of Neurogenic Bladder

•Overactive bladder

•Frequent urination, in the daytime and at night

(nocturia)

•Stress incontinence •Urge incontinence

•Inability to urinate (urinary retention)

•Underactive bladder – bladder is unable to signal

when full

•Overactive bladder

•Frequent urination, in the daytime and at night

(nocturia)

•Stress incontinence •Urge incontinence

•Inability to urinate (urinary retention)

•Underactive bladder – bladder is unable to signal

Treatment

•Medicines that relax the bladder (oxybutynin,

tolterodine, or propantheline)

•Medicines that make certain nerves more active

(bethanechol)

•Botulinum toxin (Botox) •GABA supplements

•Antiepileptic drugs

•Medicines that relax the bladder (oxybutynin,

tolterodine, or propantheline)

•Medicines that make certain nerves more active

(bethanechol)

•Botulinum toxin (Botox) •GABA supplements