Spinal Cord Lesions Overview

Spinal Cord Lesions

• Central Lumbar Stenosis: Narrowing of the lumbar spinal column, compressing the spinal cord. Ligaments and facet joints overgrow, causing calcification and compression. Affects all dermatomes and myotomes below the affected area.
• Symptoms (Lumbar): Gradual numbness/paraesthesia, burning/crampy pain in calves, potentially thigh muscles if stenosis is higher. Pain often aggravated by walking and extension, relieved by flexion. May affect balance (steppage gait, wide-based gait), and lead to weakness. Possible acute inflammatory "flare-ups".
• Signs (Lumbar): Lower motor neuron signs at lesion level (flaccid weakness, hyporeflexia); spastic weakness, hyporeflexia below the level. Aggravation of leg pain with standing and extension, but not sitting. Possible positive Babinski, balance impairment, steppage gait, wide-based gait. Reduced height/kyphosis, hypertonic muscles in lumbar region/reduced lumbar extension, and reduced lateral flexion.
• Testing (Lumbar): Sensory testing (SMRs, toe/finger proprioception, vibration), reflexes, and ROM. Reduced sensation at affected dermatomes.
• Central Cervical Stenosis: Neck pain, limited ROM due to degeneration. Subtle loss of hand dexterity/strength (e.g., buttons, writing, texting). Subtle balance problems, gait clumsiness, and needing handrails for stairs (early signs). Paraesthesia and weakness in upper extremities. Radicular pain possible if nerve root is involved (Cervical spondylotic myelopathy).
• Signs (Cervical): Similar to lumbar stenosis, with possible lower motor neuron signs at the level of the lesion, and upper motor neuron signs below. Important to observe and palpate for loss of height, kyphosis in the cervical spine, and hypertonic muscles related to that area. Possible positive Babinski / Chaddock/ balance issues. Sensory and muscle changes to limbs are possible.

Syringomyelia

• Definition: Fluid-filled cavity (syrinx) in the spinal cord. Can extend to the brainstem (syringobulbia).
• Causes: CSF blockage (e.g., Arnold-Chiari malformation), post-traumatic injury, spinal infection (abscess, transverse myelitis), intramedullary tumors, idiopathic.
• Onset: Typically in the 30s, slower progression over years, often more acute if syringobulbia.
• Symptoms: Dissociated sensory loss (e.g., shawl-like distribution), neurogenic pain in neck/shoulders (deep, aching and often severe). Muscle atrophy, especially hands, progressing proximally. Possible claw hand, dysphagia, nystagmus (syringobulbia).
• Signs: Dissociated sensory loss (e.g., pinprick deficit, intact touch), diminished arm reflexes, spasticity (lower limbs), hyperreflexia (lower limbs), and possible clonus, Babinski. Cranial nerve testing if syringobulbia is suspected.

Cauda Equina

• Definition: Compression of the cauda equina.
• Causes: Tumors, trauma/spondylolisthesis, infection, ankylosing spondylitis (late) lumbar central stenosis (rare), disc herniation.
• Symptoms: Saddle anesthesia (can you feel it when you wipe yourself after stool?), Bowel and bladder disturbances (difficulty initiating/stopping urination, retention, overflow incontinence), bowel incontinence, sometimes constipation. Unilateral or bilateral sciatica, low back pain, leg weakness, sensory deficits, and reduced/absent leg reflexes.
• Signs: Sensory (dermatomal changes), muscle (myotomal weakness), and reflex (hypo/areflexia) changes.
• Treatment: Immediate referral to A&E. Surgical decompression is vital.

Spinal Infection (Vertebral Osteomyelitis/Discitis)

• Definition: Infectious disease of the spine (vertebrae, intervertebral discs, adjacent paraspinal tissue)
• Causes:
  • Vertebral osteomyelitis: Bacterial or fungal infection entering the bloodstream. Common for IV drug users, post trauma/surgery, infections elsewhere in the body.
  • Discitis: Rare, fast spread via bloodstream. Common in children and older adults.
• Symptoms: Localized spinal pain, insidious pain progression, increased pain with movement. Fever, chills, malaise, weight loss (may be associated with systemic infections). Possible pathological fracture and nerve root compression in later stages.
• Signs: Fever, severe pain on palpation/percussion, pain on ROM, nuchal/neck rigidity (meningism). Possible para-spinal spasm, SMR if radiculopathy, variable reflexes (absent to clonus, Babinski possible).
• Treatment: Antibiotics/antifungals, possible surgical decompression/abscess drainage.

Multiple Sclerosis

• Definition: Immune-mediated inflammatory disease destroying myelin and axons. Relapsing/remitting pattern.
• Causes: Unknown, likely genetic predisposition and environmental triggers.
• Types:
  • Relapsing-remitting (85%): Episodes of neurological dysfunction with recovery.
  • Primary progressive (15%): Gradual progression from onset.
• Symptoms: Variable symptoms depending on brain/cord areas affected. Early symptoms may include visual problems (optic neuritis), cranial nerve involvement (diplopia, facial sensation loss), gait disturbance, trunk or extremity weakness, Lhermitte's phenomenon (cervical cord), and spinal cord lesions leading to sensory/motor symptoms.
• Signs: Possible problems (UMN type) with movement, motor signs/muscle weakness, positive Babinski/Chaddock, possible ankle clonus.
• Treatment: Lifestyle modifications (sleep, exercise), Disease-Modifying Antirheumatic Drugs (DMARDs), symptomatic medications.