Spinal Cord Disorders

1. Syringomyelia
   • It is the asymmetrical dilation of the central canal of the spinal cord. It causes the compression of the adjoining tracts.
   • The lateral spinothalamic tract that carries pain and temperature sensation gets affected when the syrinx gets expanded.
   • Ventral spinothalamic pathway carries crude touch and pressure, these can also get compressed on syrinx expansion.
   • Involvement of the corticospinal tract causes the development of the Babinski sign, and brisk deep tendon reflexes on the side of compression.

Causes of Syringomyelia

• Arnold Chiari malformation type 1:
  • Type 3 and type 4 are not compatible with life.
  • Type 2 is associated with myelomeningocele
• Trauma to the spinal cord
• Spinal cord tumor
• Chronic arachnoiditis
• Sequelae of transverse myelitis

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Clinical Features of Syringomyelia

• Mostly it is the young adult that will present with the following features:
  • Dissociated Sensory Loss- There will be loss of pain and temperature. Touch, proprioception, and vibration will be spared.
  • Cape-like distribution of sensory loss.
  • Areflexive weakness in the hand
  • There will be weakness in the shoulder and lower neck muscles.
  • Ipsilateral or bilateral spasticity in the leg.
  • Bladder and bowel involvement if sacral fibers are affected.
  • Facial numbness
  • Horner syndrome
  • Cough induced headache

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Diagnosis of Syringomyelia

The investigation of choice for syringomyelia is an MRI of the spine.

Treatment of Syringomyelia

• For Arnold Chiari type 1 if hydrocephalus is present then ventriculoperitoneal shunting is done.
• This surgery which can be helpful are suboccipital craniectomy, and cervical laminectomy with the placement of a dural graft.

2) Conus Medullaris Syndrome

• The progression of the disease is sudden and bilateral.
• Knee jerks are preserved but ankle reflexes are lost. 
• The perineum sensation is lost. There will be numbness to be more localized to the perineum area and that will be symmetrical and bilateral.
• Root values S2, S3, and S4 are affected therefore there will be no awareness or fullness of the bladder and no urge to urinate. The patient will be suffering from overflow incontinence. Urinary incontinence is seen early in the course of the disease.
• The patient will have a lot of lower back pain but the radical pain is less severe.
• Motor strength is typically symmetric. It is hyper-reflexive and distal paralysis of the lower limbs is less marked. Fasciculations may be present.
• Impotence can be another manifestation of conus medullaris syndrome.
• Fecal incontinence can also be present.
• The main presenting features of conus medullaris syndrome are bowel bladder issues and impotence if the patient is sexually active.

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3) Cauda Equina Syndrome

• In this disease, the presentation is slow and unilateral. Both ankle and knee jerks are affected.
• The radicular pain is more severe but the low back pain is less severe.
• The numbness here is more localized to the saddle area. It is asymmetrical and there is no sensory dissociation.
• Asymmetric Areflexic paraplegia is more marked and fascicular atrophy can be seen.
• Impotence is less frequent but if it is found then there will be sensation loss in the pubic area mainly glance penis or clitoris.
• Urinary retention will occur and it presents late in the course of disease.

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4) Subacute Combined Degeneration of the Spinal Cord

• It occurs due to the deficiency of the Vitamin B12.
• The main cause of vitamin B12 deficiency in the population is pernicious anemia or Type -A gastritis.
• The combination of lower and upper motor neuron features will be present in the patient.
• Dorsal column demyelination- There will be loss of proprioception and the patient will lose the sensation of positioning. The Rhomberg sign will be positive.
• Corticospinal pathway- The Babinski sign will be positive.
• Peripheral nerves will be involved and the patient suffers from areflexia.
• There will be the development of reversible dementia.
• The interphalangeal joints will be hyperpigmented
• Neurological features can exist in the absence of hematological features like macrocytic anemia, and hypersegmented neutrophils.
• Treatment includes IV infusion of Vitamin B12. It is done daily for seven to 10 days then weekly and then later on a monthly basis.

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5) Brown Sequard Syndrome

• It is also called hemisection of the spinal cord.
• The ipsilateral features are:
  • Proprioception loss
  • Spastic weakness due to corticospinal tract involvement.
  • There will be the development of radicular pain at the level of the lesion.
  • At the level of lesion, muscle fasciculations, and areflexia will be present.
  • Contralaterally there will be loss of pain and temperature 2 segments below the section of the spinal cord.

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6) Central Cord Syndrome

• It is caused by syringomyelia, trauma, and tumor.

The Clinical Features are:

• Due to central cervical cord involvement, arm and leg weakness features will be present.
• Dissociated sensory loss of pain and temperature in shoulders, neck, and arms will be present.
• Light touch, vibration, joint, and position sense will be preserved.
• The features are gradual in onset.

7) Anterior Cord Syndrome

• The main cause of anterior cord syndrome is anterior spinal artery thrombosis.
• The clinical features include the loss of sensory, motor, and autonomic functions. The loss of these functions corresponds to the affected level of the code.
• The onset is sudden.

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