a short slideshow on low to localise lesions of spinal cord

1. Localization
of lesions in
spinal cord

2. Definition
 Plegia – severe/complete weakness
 Paresis – mild/moderate weakness
 Monoplegia – weakness of one limb
 Paraplegia – weakness of both lower limbs
 Quadriplegia – weakness of all four limbs
 Diplegia – quadriplegia in which lower limbs
are affected more than the upper limbs

3. Spinal cord - anatomy
 It is a cylindrical column of about 43-
45cms. length extending from the
cranial border of atlas (where it
continues with medulla) to the Lower
border of L1 vertebra. It is covered by
the three layers of meninges and lies
within the vertebral column of about
70cms length.

4. Spinal cord - anatomy
 The caudal end is the Conus medullaris
containing S3, 4, 5 and Co1 segments,
from where the thread of pia matter
Filum terminale extends upto the
coccyx.
 It has 31 pairs of spinal nerves giving a
segmental picture. Due to the
differential growth of the spinal cord
and vertebral column, the bunch of
lumbo- sacral nerve roots called Cauda
equina travel down long from the lower
end of spinal cord to the inter vertebral
foramen.

5. ORGANIZATION OF
MOTOR SYSTEM

6. WEAKNESS – UMN -
LESION
1.WEAKNESS – PYRAMIDAL
2.WASTING – NONE
3.FASCICULATION – NONE
4.TONE – SPASTIC
5.TENDON REFLEX – BRISK
6.PLANTAR REFLEX – EXTENSOR

7. WEAKNESS OF LMN- LESION
1.WEAKNESS – SEGMENTAL
2.WASTING – SEVERE
3.FASCICULATION – PRESENT
4.TONE – REDUCED
5.TENDON REFLEX – REDUCED
/ABSENT
6.PLANTAR REFLEX – FLEXOR

8. Evaluation of the motor system
1. Nutrition of the muscles
2. Tone
3. Power
4. Reflexes
a) superficial
b) tendon
5. Fasciculation
6. Abnormal movement
a) Flexor spasm
b) spinal myoclonus

9. Muscles innervation-
myotomes - upper limb

10. Muscle innervation-
myotome – lower limb

11. Superficial reflexes – spinal segments
 Abdominal
Upper - D8 -10
Lower - D10-12
Cremastric - L1
Plantar - > L5, S1
Anal - S3,4
Bulbocavernous - S3,4

12. Tendon reflexes - spinal segments

13. SENSORY SYSTEM - PATHWAY

15. SENSORY DERMATOMES

16. SENSORY DERMATOME – LOWER LIMB

17. Sensory system evaluation

18. CROSS SECTION OF SPINAL CORD

19. Anatomy of a spinal segment

21. Correlation between the
spinal and vertebral
segment.
 upper dorsal - 2 segments,
 Lower dorsal - 3 segments,
D11 vertebra - L3-L4 segments
D12 vertebra - L5 segment
L1 vertebra - S1-5 and Co1 segments

23. CORD LESION ABOVE D-12
SEGMENT
1. ACUTE STATE- RETENTION
2. REFLEX BLADDER
- VAGUE SENSATION
- REFLEX EMPTYING
- SMALL BLADDER

24. AUTONOMOUS BLADDER
1. NO BLADDER SENSATION
2. DRIBBLING
3. MORE RESIDUAL URINE
CONUS LESION

25. CAUDA EQUINA
LESION
1.SAME AS IN CONUS
2. BLADDER SENSATION MAY
BE NORMAL

26. Results of spinal cord lesion
1. At the level
a) motor: segmental LMN findings
b) Sensory: segmental sensory root
findings
2. Below the level
a) motor: UMN findings
b) sensory: tract involvement findings
c) autonomic: bladder, bowel, etc.
d) others:

27. Clinical approach to localization of
spinal cord lesion
1. Does the patient has spinal cord lesion?
2. If so, localize the highest level of spinal segment
involvement by identifying the
a) motor level,
b) reflex level
c) sensory level,
d) autonomic level
3. To identify-intramedullary/extramedullary/
extramedullary-extradural,
3. Localize the corresponding vertebral level.
4. Identify the aetiology based on the history.

28. INTRAMEDULLARY LESION
 Dysesthesia and Paresthesias
 Dissociated sensory loss
 Sacral sparing present
 Spastic Paraparesis not
prominent.
 Muscle atrophy common.
 Trophic skin changes common
 Bladder bowel disturbance occur early if the lesion
is lower down.

29. EXTRAMEDULLARY LESION
 Root pain
 Segmental wasting
 Spastic paraparesis
 Bladder and bowel
symptom occur late

30. CLINICAL FEATURES – EXTRA & INTRAMEDULLARY TUMORS
Symptoms and signs Extra Medullary Intra Medullary
1. Sensory
a. Root Pain + -
b. Funicular Pain - +
c. Progression of paresthesia Ascending Descending
d.Sensory loss-Dissociative - +
e. Sensory loss-Dermatomal + -
f. Sacral sparing - +
2. Motor
a. LMN signs Segmental Diffuse
b. Appearance of UMN signs Early Late
3. Bladder Disturbances Late Early with caudal
lesions
4.Trophic Disturbances - +

31. Clinical features of extradural lesions
1. All features of
extramedullary lesions,
2. Spinal tenderness,
3. Spinal deformity,
4. Paraspinal spasm.

32. Clinical features of Brown-Sequard
syndrome
1. Ipsilateral
a) segmental LMN signs,
b) spastic weakness,
c) posterior column involvement,
2. Contralateral
a) spinothalamic tract
involvement signs.
Note: seen in extramedullary
lesions, penetrating injuries

33. Localization of C-V
junction bony
anomalies
1. short neck,
2. low hair line,
3. restricted neck
movements,
4. spastic
quadriparesis->C5,
5. others

34. C-V junction soft tissue (foramen
magnum) lesion
1.V1 sensory loss,
2.Horner’s syndrome
3. down beating nystagmus,
4.cerebellar findings,
5. lower cranial involvement,
6.sensory loss over C2
dermatome,
7. spastic quadriparesis >C5

35. Localization C- 5 segment lesion
1.At C5:
a) motor-LMN weakness of C5
myotome-deltoid and biceps,
b) reflex: absent
biceps DTR,
c) sensory: radicular symptoms
at-C5;
2) Below C5
a) UMN findings
b) posterior column and
spinothalamic tract
involvement.

36. Localization at D10 segment
1.At D10 level
a) weakness of lower abdominal
muscles,
b) absent lower abdominal reflex
c) sensory dematomal signs at
D10.
2. Below D10
a) UMN findings
b) posterior column and
spinothalamic tract involvement.

37. CONUS LESION (S3-Co1)
CLINICAL FEATURES
1.BLADDER INCONTINENCE
2.BOWEL INCONTINENCE
3.LOSS OF PENILE
TUMESCENCE
4. LOSS OF ANAL REFLEX
5. LOSS OF BULBOCAVERNOUS
REFLEX
6. PERIANAL SENSORY LOSS
7. NO MOTOR WEAKNESS
Localization at Conus

38. CAUDA EQUINA (L2-CO1 ROOTS) LESION
CLINICAL FEATURES
1.asymmetric LMN
signs in both lower
limbs
2.asymmetric
segmental sensory
loss in both lower
limbs
3.bladder disturbance
Localization at Cauda equina

39. Noncompressive spinal cord syndromes

40. Spinal cord syndrome-
transverse section
1.At the level
a) Motor- Segmental LMN signs.
b) sensory-segmental
root symptoms
2. Below the level
a) UMN signs-paraplegia/quadriplegia,
b) posterior column signs,
c) spinothalamic tract,
d) autonomic disturbances.
Note: trauma, transverse myelitis

41. Spinal cord syndrome-SCD
1. signs of posterior
column involvement,
2. signs of lateral
column (pyramidal
tract) involvement.
Note: additional sensory
motor peripheral
neuropathy may be
present.

42. Spinal cord syndrome-ALS
1. Signs of lateral tract (pyramidal
tract) in all four limbs,
2. Signs of anterior horn cell
(LMN) involvement,
3. absence of sensory signs.
Note: presence of LMN and
UMN signs in the same limb
symmetrically with absent sensory
signs is the characteristic feature.

43. Spinal cord syndrome-
anterior spinal artery
thrombosis
1.Signs of Lateral tract (pyramidal
tract)
signs(paraplegia/quadriplegia),
2. Signs of spinothalamic tract
involvement,
3. Bladder and bowel impairment,
4. Intact posterior column.
Note: the common vascular watershed
regions are D1-4 and L1 segment.

44. Case History
 A 32 year old lady presented with progressive
weakness of both upper and lower limbs of
two months duration without sensory,
cerebellar and bladder disturbances.
 Examination revealed moderate weakness of
all four limbs, proximal more than distal
muscles; no muscle wasting; normal tone and
DTR; no sensory disturbances.

45.  A 18 year old person presented with abrupt
onset of weakness of all four limbs of three
days duration.
 Examination revealed weakness of all four
limbs with power of grade 2, diminished tone
and tendon reflexes, plantar flexor; vibration
sense diminished over the tip of the toes.

46.  A 15 year old girl presented with shooting pain
on the right mid abdomen and weakness of
right lower limb of six months duration
without bladder bowel disturbances.
 Examination revealed spastic weakness of both
lower limbs right more than left, absent lower
abdominal reflex and diminished sensation
below umbilical region. No spinal tenderness

48.  A 48 year old person presented with progressive
weakness of all four limbs of thee months duration
without any autonomic disturbances.
 Examination revealed moderate weakness and wasting of
muscles both arm, forearm and hands; mild spastic
weakness of both lower limbs. DTR were diminished in
upper limbs and exaggerated lower limbs with extensor
plantar reflex. Pain and temperature were
disproportionately more diminished in both upper limbs.
No spinal tenderness.

50.  A 26 year old person presented with low back pain and
fever of one month and weakness of both lower limbs
as well as difficulty in initiating micturition of 12 days
duration.
 Examination revealed flail weakness of both lower
limbs (right more than left), DTR in both lower limbs
were diminished with diminished sensation over the
posterior part of right thigh and sacral region of both
sides.

52.  A52 year old person presented with numbness of
both fate and imbalance of walking and tends to
fall down while washing face of two months
duration.
 On examination there is mild weakness of both
lower limbs upper and lower abdominal reflex
absent, planter bilateral extensor.
 DTR upper limb normal and lower limb knee brisk,
anti diminished.
 Sensation all modalities diminished below ankle,
vibration was diminished upto the dorsal spine.

54. Clinical localization and MRI
imaging

55. Thank you…