1. Anatomy Spinal cord ends as conus medullaris at level of first lumbar
vertebra
lumbar and sacral
nerve roots exit below
this and form the
cauda equina 1

2. Neuroanatomy Corticospinal tracts Spinothalamic tracts
Dorsal (posterior) columns 2

3. 3

4. Corticospinal Tract Descending motor pathway
Forms the pyramid of the medulla
In the lower medulla, 90% of fibers decussate and descend as the lateral corticospinal tract
Synapse on LMN in the spinal cord
10% that do not cross descend as the ventral corticospinal tract
Damage to this part cause ipsilateral UMN findings 4

5. Spinothalmic Tract
Ascending sensory tract from skin and muscle via dorsal root ganglia to cerebral cortex
Temperature and pain sensation
Damage to this part of the spinal cord causes:
Loss of pain and temperature sensation in the contralateral side
Loss begins 1-2 segments below the level of the lesion 5

6. Dorsal (Posterior) Columns
Ascending neurons that do not synapse until they reach the medulla at which point they cross the midline to the thalamus
Transmits vibration and proprioceptive information
Damage will cause ipsilateral loss of vibration and position sense at the level of the lesion 6

7. Complete vs Incomplete
Sensory, motor or both functions are partially present below the neurologic level of injury
Some degree of recovery
Complete:
Absence of sensory and motor function below the level of injury
Loss of function to lowest sacral segment
Minimal chance of functional motor recovery 7

8. Light touch…
Transmitted through both the dorsal columns and the spinothalamic tracts
Lost entirely ONLY if both tracts are damaged 8

9. Upper vs. Lower Motor Neuron
Upper motor neuron lesion
Motor cortex internal capsule brainstem
spinal cord
Lower motor neuron lesion
Anterior horn cell nerve root plexus
peripheral nerve

10. Basic Features of Spinal Cord Disease
UMN findings below the lesion
Hyperreflexia and Babinski’s
Sensory and motor involvement that localizes to a spinal cord level
Bowel and Bladder dysfunction common
Remember that the spinal cord ends at about T12-L1

11. Motor Exam Strength - helps to localize the lesion Tone Upper cervical
Quadriplegia with impaired respiration
Lower cervical
Proximal arm strength preserved
Hand weakness and leg weakness
Thoracic
Paraplegia
Can also see paraplegia with a midline lesion in the brain
Tone
Increased distal to the lesion

12. Sensory Exam Establish a sensory level Posterior columns
Dermatomes
Nipples: T4-5
Umbilicus: T8-9
Posterior columns
Vibration
Joint position sense (proprioception)
Spinothalamic tracts
Pain
Temperature

13. Autonomic disturbances
Neurogenic bladder
Urgency, incontinence, retention
Bowel dysfunction
Constipation more frequent than incontinence
With a high cord lesion, loss of blood pressure control
Alteration in sweating

14. Total transsection
Injuries
Tumors
infection

15. Total transsection Below the lesion: first stage
Loss of motor function
Loss of sensory
Areflexion
Decreased tension of muscles

16. Total transsection Below the lesion: second stage
Normal reflexesincreased
Normal tensionincreasedspasticity

17. Total transsection Bladder: Areflexion Ischuria paradoxa
Automatic or autonomic

18. Spinal Shock
Loss of neurological function and autonomic tone below level of lesion
Loss of all reflexes
Resolves over 24-48h but may last for days 18

19. Spinal Shock Symptoms: Flaccid paralysis Loss of sensation
Bladder incontinence
Bradycardia
Hypotension
Hypothermia 19

20. Hypotension Must determine cause: Spinal cord injury Blood loss
Cardiac injury
Combination of above 20

21. Neurogenic Shock Neurogenic Shock:
Warm
Peripherally vasodilated
Bradycardic
Bradycardia may be caused by something other than neurogenic shock
Cervical spine injury may cause sympathetic denervation 21

22. 22

23. Brown-Séquard Syndrome
Hemisection of the cord
Ipsilateral loss of:
Motor function
Proprioception and vibration sense
Contralateral loss of:
Pain and temperature sensation 23

24. BSS Caused by: Prognosis: GOOD Penetrating injury
Lateral cord compression from:
Disk protrusion
Hematomas
Bone injury
Tumours
Prognosis: GOOD 24

25. 25

26. Central Cord Syndrome Older patients Preexisting central spondylosis
Hyperextension injury
Injury affects central cord>
peripheral cord
Damage to corticospinal
and spinothalamic tracts
Upper extremities>thoracic
>lower extremities>sacral 26

27. CCS Present with: Prognosis: GOOD Decreased strength
Decreased pain and temperature sensation
Upper>lower extremities
Spastic paraparesis/quadriparesis
Maintain bladder and bowel control
Prognosis: GOOD
Although fine motor recovery of the upper extremities is rare 27

28. signs
intramedullary
extramedullary
Radicular pain
unusual
common
Vertebral pain
Funicular pain
Less common
Umn Sign
+, late
+, early
Lmn sign
+++, diffuse
Unusual, segmental
Paraesthe sia progr
descending
ascending
sphincter
early
late
Trophic

29. Conus medullaris lesion
Pelvic floor weakness, early sphincter dysfunction
Autonomous neurogenic bladder
Constipation, impaired ejeculation and errection
Symmetric saddle anaesthesia
Pain
Tethered spinal cord:
numbness feet
asymmetric muscle atrophy of calf and thigh, UMN signs, bowel bladder dysfunction,foot deformities, cutaneous manifestations of spinal dysraphism

30. Cauda equina lesion Compression lumbar sacral roots below L3 vertebra
U/L early radicular pain, worse at night
Flaccid hypotonic areflexic paralysis producing peripheral paraplegia
Asymmetrical sensory loss in saddle area
KJ variable, ankle ↓↓
Sphincter dysfunction similar to conus lesion but late

31. Cauda Equina Syndrome
Peripheral nerve injury to lumbar, sacral and coccygeal nerve roots
Symptoms:
Variable motor and sensory loss in lower extremities
Bowel and bladder dysfunction
Saddle anaesthesia
Prognosis: GOOD 31

32. Conus Medullaris vs. Cauda Equina Lesion
Finding Conus CE
Pain Uncommon Common
Reflexes Increased Decreased
Bowel/bladder Common Uncommon

33. Stretch signs -Laseque -Fajersztajn-Krzemicki -Mackiewicz -Neri
-Naffziger
-Bikeles

34. Vascular syndromes of spinal cord
Anterior spinal artery syndrome:
Territory – anterior funiculi, anterior horn, base of the dorsal horn, peri ependymal area, antero medial aspect of lateral funiculi
Lower thoracic sement and conus- vulnerable
Abrupt onset of radicular pain, girdle pain
Flaccid quadriplegia, paraplegia
Bowel bladder dysfunction
Thermo anaesthesia analgesia
Position vibration light touch preserved

35. Posterior spinal artery syndrome:
Uncommon
Loss of position , proprioception, vibration
Loss of segmental reflexes
Pain , temperature – preserved
Motor function- preserved
spinal cord claudication