Phys · neurological
Spinal Cord Disease
Also known as spinal cord compression · myelopathy · malignant spinal cord compression · MSCC · cord syndrome · Brown-Sequard syndrome · anterior cord syndrome · central cord syndrome · syringomyelia · transverse myelitis · subacute combined degeneration · cauda equina syndrome
Consultant-physician-depth guide to spinal cord anatomy, the cord syndromes (complete transection, anterior cord, Brown-Sequard, central cord, posterior column), malignant spinal cord compression with the Patchell criteria, cauda equina syndrome, syringomyelia, transverse myelitis and B12 deficiency subacute combined degeneration — for FRACP DWE and DCE preparation.
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Red flags
- Back pain plus any limb neurological deficit is malignant spinal cord compression until proven otherwise — give dexamethasone 16 mg and image within 24 hours
- Acute urinary retention with saddle anaesthesia is cauda equina syndrome — emergency MRI and surgical decompression within 24 to 48 hours
- Loss of ambulation in MSCC predicts permanent non-ambulation — time is cord
- A normal serum B12 does NOT exclude subacute combined degeneration — check methylmalonic acid and homocysteine, and ask about nitrous oxide use
- Never give folate alone to a B12-deficient patient — it can precipitate or worsen irreversible subacute combined degeneration
Spinal Cord Disease
The answer first
Spinal cord disease is an anatomical diagnosis. The examination alone tells you where the lesion is before any scan. The two questions that determine everything are: where is the level? and is it compressive or not? [1]
The emergencies are three:
- Malignant spinal cord compression (MSCC) — the most common cause in adults. Back pain plus any limb deficit is compression until proven otherwise. Give dexamethasone 16 mg and arrange emergency MRI whole spine within 24 hours.
- Cauda equina syndrome — bilateral leg pain, saddle anaesthesia, sphincter disturbance. Emergency MRI and surgical decompression within 24 to 48 hours.
- Any acute myelopathy that is progressing — compressive causes must be excluded before inflammatory or vascular causes are treated. [1]
The organising principle is the tract map. Know which tract carries which modality, and you can name the syndrome from the bedside: a sensory level with UMN signs below is a cord lesion; dissociated sensory loss (pain and temperature lost, touch preserved) is a central cord lesion; ipsilateral motor and proprioception loss with contralateral pain and temperature loss is Brown-Sequard. [1]
References6ShowHide
- [1]Patchell RA, Tibbs PA, Regine WF, et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial Lancet, 2005.PMID 16112300
- [2]Vecht CJ, Haaxma-Reiche H, van Putten WLJ, et al. Initial bolus of conventional versus high-dose dexamethasone in metastatic spinal cord compression Neurology, 1989.PMID 2771077
- [3]Transverse Myelitis Consortium Working Group Proposed diagnostic criteria and nosology of acute transverse myelitis Neurology, 2002.PMID 12236201
- [4]Wingerchuk DM, Banwell B, Bennett JL, et al. International consensus diagnostic criteria for neuromyelitis optica spectrum disorders Neurology, 2015.PMID 26092914
- [5]Healton EB, Savage DG, Brust JCM, Garrett TJ, Lindenbaum J Neurologic aspects of cobalamin deficiency Medicine (Baltimore), 1991.PMID 1648656
- [6]Garakani A, Jaffe RJ, Savla D, et al. Neurologic, psychiatric, and other medical manifestations of nitrous oxide abuse: A systematic review of the case literature Am J Addict, 2016.PMID 27037733