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New Treatments for Spinal Cord and Disc Diseases

There are many syndromes in the spinal cord. Let’s look at some of the motor syndromes. Syndrome of the cortical spinal tract, which is progressive spastic spinal paralysis, in which the cortical spinal tract are affected. So you have a spastic paralysis. When you have a combined syndrome, where the lesion is in the posterior tract - the spinal cerebellar tract - and also in the cortical spinal tract, you are going to have a spastic paralysis down here, hypoesthesia below T8, spinal cerebellar ataxia down here and here, and ataxia. This is the most common one that all of you, I’m sure, know very well. With the syndrome of any transection of the spinal cord. This usually happens with trauma, tumor. Remember the bell-shaped tumor can give this syndrome. So any transection of the cord causes anesthesia, and thermesthesia.

Let’s talk about some sensory lesions. If you have a lesion of the anterior horn, obviously you have a flaccid paralysis of the segment that is supplied by that spinal segment. Syndrome of combined lesion of the anterior horn and of the lateral pyramidal tract. What’s this called? ALS. So what you have with this is you have a flaccid paralysis of the area that is in the same dermatome where the anterior horn is affected, and below you have a spastic paralysis.

Some other syndromes that you are going to find and we are going to discuss. This is more for segmental and peripheral muscle innervation. If you have a lesion in the posterior horn, whatever segment that lesion is in, you are going to have anesthesia and thermanesthesia of that area with root distribution. So it has the distribution of the root that is affected. If the gray matter is affected, you are going to have a spastic paralysis below, a flaccid paralysis at the area where the segment is affected, and _ and thermanesthesia. Those are the cord transections.

Now we are going to talk a little about the pathology of the cord. So this is syringomyelia. And you can see the paralysis, the weakness, the atrophy due to the loss of the anterior horn cells. Remember, whenever an anterior horn segment is lesioned, there is going to be atrophy in that segment. Because the muscles are going to lose the nourishment coming from the nerve. So you are going to have weakness, atrophy, but below you are going to have spastic paralysis. Now syringomyelia can also be hydromyelia and this can be congenital. You all know the pathology for syringomyelia can be congenital, can be traumatic, can be due to tumor. Also we can have amitomyelia from trauma of the spinal cord. So many processes of the spinal cord can be due to trauma. What other pathology can give you those syndromes that I just showed you?

What do we have here? Oh, another one that you shouldn’t forget is autoimmune and is multiple sclerosis. And with multiple sclerosis you can have anything. Anywhere there is white matter you can have lesions. So, anywhere there is white matter you can have lesions and that shows you the difference between multiple sclerosis, between ALS, combined sclerosis and those are other lesions in the posterior. This could be syphilis for instance.

Oh, another thing. We said trauma, we said infection, where are we going now? Tumor. Okay. We can’t forget tumor as a pathology, etiology for spinal cord pathology. Where can the tumor be? They can be anywhere. Let’s start from the vertebral body. If the tumor is in the vertebral body, more commonly is a metastasis. What are the tumors that metastasize to the vertebral body more commonly? Breast, lungs, colon, prostate, ovarian, uterus. All those things. So this is just to remember. Usually the breast go to the thoracic and lungs too.

Let’s talk about the bell-shaped tumor. A tumor can be a meningioma, neurinoma, schwannoma, all those tumors that likes to grow on nerve can give you the typical hourglass, or bell-shaped tumor. And the hourglass tumor also starts with pain but because the whole root is involved, you also have weakness on that side. They grow very fast and they can occupy the spinal canal completely and then they push the cord on the side, so you can have a Brown-Séquard at this level. So those are the extramedullary, posterior, anterior and the hourglass.

Now here I have summarized. This again is from the Duus. Some of the symptoms of the intramedullary tumor. Intramedullary tumor differs from the extramedullary tumors because of this feature. You don’t have radicular pain. Pain is typical of the extramedullary tumor. There is _ sensory disorders so temperature and proprioception that starts early. Disorders of the bladder and the rectum appear early because bladder and rectum fibers are very medial. They are just by the central canal so anything that grows intramedullary is going to cut out those fibers. And the first thing you are going to lose is control of the sphincters.

Now another thing that they want you to know at the Boards … you know, invariably, I learned this for the Boards and two weeks later I completely forgot. And every time I have a patient I have to go back and read it again. I don’t know if it is just me. I just can’t remember it. So I hope you are luckier than I am. So this is the conus, conus medullaris. The epiconus goes from L4 to S2, the terminal conus is from S3 to C. This is the filum terminale where lipoma.

Besides tumor, the most frequent cause of conus and cauda syndrome are prolapsing of discs. This is what we are going to look at next. Before we go to the discs and other lesions of the cord, I just want to remind you that when you are going to do pediatrics - but even in adults - just remember to mention some of the congenital malformations.

The next most common thing for pathology of the spinal cord is discs. Now I was told always, during my training, that discs is a lesion of young people. Because with aging the discs lose all the juice, they become very sclerotic, but you can still have it. Certainly after age 60-65 the discs are very small, but you can still have a break of the anulus that is the external part of the disc and you can have a herniated disc. But definitely the nucleus pulposus after age 65 is very atrophic. So disc is a disease of younger people. This is usually what happens.

Just want to remind you, the most common root syndrome of intravertebral disc disease. The other thing they used to tell me when I was training, if they are going to show you a case at the orals usually it is a patient that can walk. The cases that they are going to show you in discussion, they are going to be the column and all the other things. But when you are going to examine a patient, it is usually a patient that can walk.

Cervical. C4, C5, deltoid and biceps are going to be affected. The pain is going to be in the shoulder, in the anterior arm and in the radial forearm and the reflex that is dropped is the biceps. C6 and 7 - now we are going down, so what do we have?

The last thing I want to show you is something that you might see, because as I said, those are patients that can walk, even though they might be in pain they can walk. They are not comatose. And older people, they like to go to doctors so they are the ones that are going to be volunteering to be examined. Cervical spondylosis is very common, much more common than you might think. I do geriatric neurology - if you are wondering what is my specialty - I do geriatric neurology and I see a lot of this.

Hyperreflexia, Babinski is positive, and the Hoffman sign is also positive. Your patient has a spastic gait disorder and they have bladder symptoms. This is very difficult to sort out in older people. You know what is the positive Babinski for somebody who doesn’t have a foot? How do you do Babinski if the patient is an amputee? What you do is you is you stroke on the stump and you look at the tensor fascia lata. If you see a contraction, that’s the equivalent to a Babinski of a patient who has a foot. So a patient with spondylotic myopathy, they do have a spastic disorder, bladder symptoms and sensations. Sensory are not usually very involved.