Neurology > Spinal Pathology > Flashcards

Spinal Pathology Flashcards

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1
Q

What is a radiculopathy

A

Nerve root pathology, commonly referred to as a “pinched nerve.”

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2
Q

What are the key clinical features of radiculopathy?

A
  • Pain: Referred along the distribution of the affected nerve root (dermatomal)
    • Weakness: Lower motor neuron (LMN) pattern
    • Decreased tone
    • Loss of reflexes
    • Muscle wasting
    • Fasciculations
    • Sensory changes: Numbness, pins and needles, or dysesthesia in the dermatomal area
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3
Q

What are nerve tension signs for radiculopathy?

A
  • Straight leg raise (SLR) test: lumbar nerve roots
    • Femoral stretch test: upper lumbar nerve roots
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4
Q

What are the common causes of radiculopathy?

A
  • Prolapsed intervertebral disc: most common (lumbar > cervical > thoracic)
    • Tumours compressing nerve roots
    • Traumatic nerve root avulsion
    • Diabetic neuropathy
    • Herpes zoster infection
    • Post-viral neuritis
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5
Q

How does radiculopathy differ from peripheral neuropathy?

A

Radiculopathy: affects a specific nerve root; pain and sensory changes follow a dermatomal pattern; weakness follows myotomal distribution
• Peripheral neuropathy: usually distal symmetric sensory loss; often stocking-glove distribution

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6
Q

What is myelopathy?

A

Spinal cord pathology, often leading to upper motor neuron (UMN) signs.

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7
Q

Which part of the spinal cord is most commonly involved?

A

Cervical cord is more commonly affected than thoracic cord.

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8
Q

What are the key clinical features of myelopathy?

A

Weakness: UMN pattern
• Increased muscle tone (spasticity)
• Exaggerated tendon reflexes
• Upgoing plantar responses (Babinski sign)
• Proximal muscle weakness
• Sensory level: loss of sensation below the level of the lesion
• Bladder and/or bowel dysfunction

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9
Q

What are the typical patterns of cord injury in myelopathy?

A

Transverse myelitis: inflammation across the cord segment
• Central cord syndrome: weakness > sensory loss in upper limbs
• Anterior spinal artery syndrome: motor paralysis with loss of pain/temperature, preserved vibration/proprioception
• Brown-Sequard syndrome: ipsilateral motor and vibration loss, contralateral pain/temperature loss
• Dorsal column syndrome: loss of vibration and proprioception, preserved motor

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10
Q

How does myelopathy differ from radiculopathy?

A
  • Myelopathy: UMN signs, sensory level, bladder/bowel involvement
    • Radiculopathy: LMN signs, dermatomal sensory loss, no bladder/bowel involvement
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11
Q

What causes central cord syndrome?

A

Often cervical hyperextension injury in older patients with spondylosis
• Can be due to trauma, tumors, or syringomyelia

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12
Q

What is the classic clinical pattern of central cord syndrome ?

A
  • Motor weakness: Upper limbs > lower limbs
    • Sensory loss: Variable, often cape-like distribution (pain and temperature)
    • Bladder dysfunction: May occur
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13
Q

What is the cause of Brown-Sequard syndrome?

A

Hemisection of the spinal cord (trauma, tumor, infarct)

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14
Q

What are the key features of Brown Sequard ?

A
  • Ipsilateral: UMN weakness, increased tone, loss of vibration/proprioception
    • Contralateral: Loss of pain and temperature sensation
    • Bladder: Variable
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15
Q

What causes anterior spinal artery syndrome?

A
  • Infarction of the anterior 2/3 of the spinal cord
    • Causes include aortic surgery, thrombosis, or vasculitis
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16
Q

What are the key features of anterior cord snydrome ?

A
  • Motor paralysis: UMN below lesion
    • Loss of pain and temperature
    • Preserved vibration and proprioception (dorsal columns intact)
    • Bladder dysfunction: Common
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17
Q

What causes dorsal column syndrome?

A

Lesions affecting the posterior columns (e.g., B12 deficiency, tabes dorsalis, trauma)

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18
Q

What are the clinical features of dorsal column?

A
  • Loss of vibration and proprioception
    • Preserved pain and temperature
    • Ataxia: Positive Romberg sign
    • Motor function: Usually preserved
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19
Q

What is spinal shock?

A

A temporary loss of spinal cord function immediately after injury; not true systemic shock.

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20
Q

What are the key clinical features of spinal shock?

A
  • Flaccid paralysis below the level of injury
    • Loss of all reflexes, including deep tendon and bulbocavernosus reflex
    • Loss of sensation below the lesion
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21
Q

How long does spinal shock usually last?

A

Typically a few days, after which reflexes gradually return (first reflex to return is usually the bulbocavernosus reflex).

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22
Q

How is spinal shock different from neurogenic shock?

A
  • Spinal shock: transient loss of cord function; hypotension not necessarily present
    • Neurogenic shock: due to loss of sympathetic tone, causing hypotension and bradycardia
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23
Q

What is cauda equina syndrome?

A

Injury to the sacral spinal roots (S1–S4) resulting in lower motor neuron deficits.

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24
Q

What are the key sensory features of CES?

A
  • Loss of sensation over the perineum (“saddle area”)
    • Loss of bladder and bowel sensation
    • Sexual dysfunction (e.g., impotence)
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25
What are the bladder features of CES?
- Loss of bladder sensation • Loss of urethral sphincter control • Overflow incontinence
26
What are the bowel features of CES?
- Loss of anal tone and sensation • Faecal incontinence
27
What are the motor features of CES?
- Weakness in distal myotomes only (e.g., ankle plantarflexion) • LMN pattern: decreased tone, wasting, fasciculations • Loss of ankle tendon reflexes
28
What are common causes of CES?
- Lumbar intervertebral disc prolapse (most common) • Sacral tumors • Trauma • Infection
29
How is CES different from spinal cord injury?
- CES affects LMN distal roots, usually below L1/L2 • Spinal cord injury affects UMN pattern, sensory level, and often spasticity
30
What is a neuropathic bladder?
A bladder dysfunction caused by spinal cord or nerve root pathology, classified as upper motor neuron (UMN) or lower motor neuron (LMN) type.
31
Which conditions cause UMN bladder?
Associated with myelopathy or spinal cord injury above sacral segments.
32
What are the key features of UMN bladder?
- Spastic, irritable, small-volume bladder • Urinary frequency and urge incontinence • Often associated constipation • Anal tone may be preserved
33
Which conditions cause LMN bladder?
Associated with radiculopathy or cauda equina syndrome.
34
What are the key features of LMN bladder?
- Absent bladder sensation • Large bladder volumes and overflow incontinence • Constipation with poor anal tone and fecal incontinence • Erectile and sexual dysfunction may occur
35
How do UMN and LMN bladder differ?
Upper - bladder tone: spastic- small volume - incontinence: urge incontinence - anal tone: often preserved - bowel: constipation Lower - bladder tone: flaccid - large volume - incontinence: overflow incontinence - anal tone: poor/ absent - bowel: constipation + fecal incontinence
36
How are causes of spinal cord compression classified?
Extradural (outside dura) • Intradural, extramedullary (inside dura but outside cord) • Intramedullary (inside spinal cord itself)
37
What are the main causes of extradural compression?
- Tumours: • Vertebral metastases (lung, breast, thyroid, renal, myeloma) • Primary vertebral tumours (osteochondroma, chordoma) • Disc prolapse: cervical or thoracic • Vertebral trauma: fractures, dislocations • Infections: tuberculosis, discitis, spondylitis, epidural abscess • Congenital: lipomas, dysraphism, spinal deformities
38
What are common intradural, extramedullary causes?
- Meningioma • Nerve sheath tumours: neurofibroma, schwannoma
39
What are intramedullary causes of spinal cord compression?
- Primary cord tumours: astrocytoma, ependymoma, syringomyelia • Trauma: cord contusion, central cord syndrome
40
Which type of compression is most common?
Extradural compression, usually from vertebral metastases or disc prolapse.
41
What is transverse myelitis?
Inflammation of the spinal cord causing complete loss of function below the level of the lesion.
42
What are the key clinical features of transverse myelitis?
- Complete loss of motor power below the level of injury * Sensory level in all modalities (touch, pain, temperature, vibration, proprioception) * Bladder and bowel dysfunction * May include spasticity or flaccidity depending on stage
43
What are the common causes of transverse myelitis?
- Traumatic spinal cord injury • Viral myelitis (e.g., post-viral, herpes viruses) • Autoimmune or idiopathic causes (less common)
44
How does transverse myelitis differ from radiculopathy or cauda equina syndrome?
Transverse myelitis affects the entire cord segment with UMN signs and sensory level, radiculopathy affects a single nerve root with LMN signs and dermatomal sensory loss, and cauda equina syndrome affects sacral roots with LMN signs, saddle anesthesia, and bladder/bowel involvement.
45
What type of sensory loss is seen in central cord syndrome?
Suspended sensory loss involving pain and temperature modalities due to damage of fibres crossing the central grey matter at the level of injury.
46
What physical signs should you look for that suggest chronic sensory loss in central cord syndrome?
Look for old burns and trophic changes in areas of impaired sensation.
47
How is the sensory loss in central cord syndrome commonly described?
As “cape-like”, affecting the neck, shoulders, arms, and upper thorax.
48
Why does central cord syndrome produce a “cape-like” sensory loss?
Because the cervical spinal cord is often affected, and the central cord contains fibres crossing at that level, corresponding to the upper limb and shoulder dermatomes.
49
What type of motor weakness occurs at the level of injury in central cord syndrome?
Lower motor neuron (LMN) weakness due to involvement of the anterior horn cells.
50
What clinical sign may indicate LMN involvement at the level of injury?
Wasting of hand muscles.
51
What type of motor pattern is seen below the level of injury in central cord syndrome?
Upper motor neuron (UMN) pattern spasticity
52
What are the main causes of central cord syndrome?
- Spinal cord tumours • Syringomyelia • Traumatic cord contusions
53
What type of motor loss occurs in anterior cord syndrome?
Complete loss of motor function below the level of injury, usually presenting as flaccid paralysis initially.
54
Which sensory modalities are lost in anterior cord syndrome?
Pain and temperature sensation below the level of injury.
55
Which sensory modalities are preserved in anterior cord syndrome?
Light touch and proprioception, because the dorsal columns are supplied by the posterior spinal arteries.
56
What are the main causes of anterior cord syndrome?
Anterior spinal artery thrombosis • Central disc prolapse • Trauma
57
How is Brown-Sequard syndrome often described?
“One side feels, the other side moves”.
58
Which motor deficits are seen in Brown-Sequard syndrome?
Loss of motor function on the same side as the injury due to damage to descending motor tracts.
59
Which sensory deficits are seen in Brown-Sequard syndrome?
Loss of pain and temperature sensation on the opposite side of the injury due to damage to ascending crossed fibres.
60
What are the main causes of Brown-Sequard syndrome?
- Penetrating trauma • Tumours
61
Which sensory modalities are lost in dorsal column syndrome?
Position sense (proprioception) and light touch.
62
Which motor functions are affected in dorsal column syndrome?
Motor function is usually preserved.
63
What is a classic cause of dorsal column syndrome?
Tabes dorsalis (tertiary syphilis)
64
How does acute spinal cord compression typically present?
Dramatically, with weakness below the level of injury, often flaccid at onset, associated with sensory disturbances (sensory level) and sphincter dysfunction (incontinence).
65
Is pain always present in acute spinal cord compression?
Not usually; any pain is often related to the cause of compression (e.g., metastasis, fracture, abscess), rather than the compression itself.
66
How does subacute or chronic spinal cord compression present?
Subtly, often with: • Axial spinal pain or stiffness • Subtle motor deficits: • Upper limbs: loss of dexterity, clumsiness, dropping objects, muscle wasting • Lower limbs: gait disturbances, poor balance, falling, difficulty with uneven surfaces or rising from a chair • Sensory dysfunction: numbness and tingling, often in the hands • Sphincter disturbance: urinary frequency/urgency, constipation
67
What is an important clinical warning sign for spinal cord compression?
Axial spinal pain combined with any neurological symptoms, however subtle, should prompt investigation.
68
69
What type of motor loss occurs in anterior cord syndrome?
Complete loss of motor function below the level of injury, usually presenting as flaccid paralysis initially.
70
Which sensory modalities are lost in anterior cord syndrome?
Pain and temperature sensation below the level of injury.
71
Which sensory modalities are preserved in anterior cord syndrome?
Light touch and proprioception, because the dorsal columns are supplied by the posterior spinal arteries.
72
What are the main causes of anterior cord syndrome?
- Anterior spinal artery thrombosis • Central disc prolapse • Trauma
73
How is Brown-Sequard syndrome often described?
One side feels, the other side moves”.
74
Which motor deficits are seen in Brown-Sequard syndrome?
Loss of motor function on the same side as the injury due to damage to descending motor tracts.
75
Which sensory deficits are seen in Brown-Sequard syndrome?
Loss of pain and temperature sensation on the opposite side of the injury due to damage to ascending crossed fibres.
76
What are the main causes of Brown-Sequard syndrome?
Penetrating trauma • Tumours
77
Which sensory modalities are lost in dorsal column syndrome?
Position sense (proprioception) and light touch
78
Which motor functions are affected in dorsal column syndrome?
Motor function is usually preserved.
79
What is a classic cause of dorsal column syndrome?
Tabes dorsalis (tertiary syphilis).
80
How does acute spinal cord compression typically present?
Dramatically, with weakness below the level of injury, often flaccid at onset, associated with sensory disturbances (sensory level) and sphincter dysfunction (incontinence).
81
Is pain always present in acute spinal cord compression?
Not usually; any pain is often related to the cause of compression (e.g., metastasis, fracture, abscess), rather than the compression itself
82
How does subacute or chronic spinal cord compression present?
Subtly, often with: • Axial spinal pain or stiffness • Subtle motor deficits: • Upper limbs: loss of dexterity, clumsiness, dropping objects, muscle wasting • Lower limbs: gait disturbances, poor balance, falling, difficulty with uneven surfaces or rising from a chair • Sensory dysfunction: numbness and tingling, often in the hands • Sphincter disturbance: urinary frequency/urgency, constipation
83
What is an important clinical warning sign for spinal cord compression?
Axial spinal pain combined with any neurological symptoms, however subtle, should prompt investigation.
84
What is the role of spinal X-rays in cord compression?
X-rays can show most causes of extradural cord compression, such as fractures or bony lesions.
85
What is the investigation of choice for spinal cord dysfunction or compression?
MRI scan – provides excellent imaging of neural tissue and paravertebral soft tissues (discs, ligaments, muscles).
86
What are the limitations of MRI in spinal cord compression?
Expensive and time-consuming.
87
When is CT scan useful in cord compression?
CT shows bony pathology very well but has poor visualization of intradural structures unless combined with myelography.
88
What is the role of a myelogram in spinal cord compression?
Largely replaced by MRI, but useful with metal artifact from spinal instrumentation; carries a small risk of worsening neurological deficit.
89
Does bone scan have a major role in spinal cord compression?
Secondary role only; largely superseded by MRI.
90
Is spinal cord compression a medical or surgical emergency?
It is a surgical emergency; requires urgent investigation and referral.
91
What supportive measures should be implemented while managing spinal cord compression?
Pressure care, bladder decompression, and spinal precautions (log roll, traction, temporary splinting).
92
What are the main goals of surgery in spinal cord compression?
- Decompression of the cord • Reduction of displaced structures • Spinal stabilization • Rehabilitation
93
How does prognosis differ between complete and incomplete spinal cord injuries?
- Complete injury: very poor recovery; check perineal/anal sensation as it may be the last remnant of cord function. • Incomplete injury: better prognosis; recovery depends on: • Rate of cord compromise (slow is better than fast) • Consistency of compressing agent (soft disc better than bone fragments) • Energy of distorting force (low-velocity better than high-velocity) • Duration and severity of neurological deficit • Patient factors (age, diabetes, vasculopathy)
94
What acute condition can mimic spinal cord compression?
Acute spinal trauma, usually obvious, but may be missed in unconscious patients.
95
How can minor trauma lead to cord compression symptoms?
In patients with pre-existing spinal stenosis (usually cervical), hyperextension injury may cause a central cord pattern of weakness.
96
Which neoplastic conditions can cause spinal cord compression?
Extradural: vertebral metastases (rapid onset) • Intradural: spinal cord tumours (slower onset, may show central cord pattern
97
How do peripheral neuromuscular disorders differ from cord compression?
- Guillain-Barré syndrome: rapidly ascending weakness, areflexia, usually normal sensation • Amyotrophic lateral sclerosis (ALS): wasting and fasciculations in upper limbs, lower limb spasticity, sensation preserved • Myopathies: proximal > distal weakness, may be due to hypercalcemia or steroids in cancer
98
Which infections can mimic cord compression?
- Extradural: TB spondylitis, pyogenic discitis • Intradural: TB myelitis, HIV myelitis
99
What cortical lesions can mimic cord compression?
Bilateral parasagittal motor strip lesions, e.g., meningioma or trauma over the vertex (“cortical paraplegia”).
100
Which systemic or autoimmune disorders can mimic cord compression?
- Normal pressure hydrocephalus • Acute idiopathic transverse myelitis • Multiple sclerosis • Devic syndrome (neuromyelitis optica)
101
What congenital or developmental conditions can mimic cord compression?
Tethered cord • Split cord malformation • Chiari malformation and syringomyelia
102
Which metabolic or vascular conditions mimic cord compression?
- Subacute combined degeneration (B12 deficiency) • Anterior spinal artery thrombosis (produces anterior cord pattern) • Spinal AVM or dural AV fistula
103
What psychiatric or non-organic conditions can mimic cord compression?
Hysteria or malingering.
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