Neurological manifestations

Sensory disturbances

Metastatic carcinoma, lymphoma

Secondary to anticoagulation therapy

Loss of all sensory modalities below the level of the lesion, e.g. pain, temperature, light touch, position sense, and vibration.

Localized vertebral pain accentuated by vertebral palpation or percussion may occur with destructive lesions (e.g. infections and tumors), and may have some value for locating the lesion. Pain that is worse when recumbent and better when sitting or standing is common with spinal malignancies

Motor disturbances

- Paraplegia or Initially flaccid and areflexic, due to spinal shock; three tetraplegia to four weeks later, becomes hypertonic and hyperre-

flexic. Complete and lower spinal cord lesions result in flexion at the hip and the knee, whereas incomplete and high spinal cord lesions result in extension at the hip and knee

- Absent superficial abdominal and cremasteric reflexes

- Lower motor neuron Paresis, atrophy, fasciculations, and areflexia signs at the level of

Lesions Flaccid Dysarthria

I I hypesthesia

SS sensory ataxia, position sense, vibration flaccid paralysis □□ all sensory modalities □□

I I hypesthesia

SS sensory ataxia, position sense, vibration flaccid paralysis □□ all sensory modalities □□

I I spastic paralysis flaccid paralysis I I analgesia, thermoanesthesia flaccid paralysis □□ spastic paralysis □□

I I spastic paralysis flaccid paralysis I I analgesia, thermoanesthesia

□□ analgesia, thermoanesthesia flaccid paralysis □□

I I spastic paralysis I I hypesthesia 1^1 cerebellar ataxia

I I sensory ataxia, position sense, vibration spastic paralysis [

I I spastic paralysis I I hypesthesia 1^1 cerebellar ataxia

I I sensory ataxia, position sense, vibration spastic paralysis [

Friedreich Ataxia Tabes Dorsalis

I I spastic paralysis I I hypesthesia □□ sensory ataxia, position sense, vibration thermoanestesia, analgesia □□ sensory ataxia, position sense, vibration □□ spastic paralysis □□ flaccid paralysis □□ hyperesthesia OfflO

I I spastic paralysis I I hypesthesia □□ sensory ataxia, position sense, vibration thermoanestesia, analgesia □□ sensory ataxia, position sense, vibration □□ spastic paralysis □□ flaccid paralysis □□ hyperesthesia OfflO

□□ flaccid paralysis I I spastic paralysis I I all sensory modalities □□ sensory ataxia, position sense, vibration spastic paralysis □□ thermoanestesia, analgesia □□

□□ flaccid paralysis I I spastic paralysis I I all sensory modalities □□ sensory ataxia, position sense, vibration spastic paralysis □□ thermoanestesia, analgesia □□

Fig. 16i-n

Fig. 16o

Fig. 16 Syndromes of spinal cord and peripheral nerves lesions:

a Syndrome of posterior roots (C4-T6) lesion causes lancinating pain and abolition of all senory modalities in the corresponding dermatomes. Interruption of the peripheral reflex arc leads additionally to hypotonia and hypo- or areflexia. b Syndrome of the spinal ganglion (T6) following viral infections (Herpes zoster) is causing lancinating and annoying pain and paresthesias of the involved derma-tomes.

c Syndrome of the posterior columns (T8) selectively damaged by tabes dorsalis (neurosyphilis) results in impaired vibration and position sense and decreased tactile localization. Also tactile and postural hallucinations (as if walking on cotton wool), temporal and spatial disturbance of the extemities sensory gait ataxia (worse in darkness or with eyes closed), and a Roberg's sign. Patients often develop lancinating pains in the legs, urinary incontinence, and areflexia of the patellar and ankle stretch reflexes.

d Syndrome of the anterior and posterior roots and peripheral nerves (neuronal muscular dystrophy) causes abolition of all senory modalities, and flaccid paraly sis in the corresponding dermotomes and myotomes. There is also areflexia, paresthesias, and occasionally pain. The peripheral nerves appear thickened and sensitive to touch.

e Syndrome of the central spinal cord (C4-T4), as in syringomyelia, hydromyelia, and intramedullary cord tumors, where the central cord damage spreads centrif-ugallyto involve the surrounding spinal cord structures. Characteristically this results in bilateral "vest-like" thermoanesthesia and analgesia with preservation of soft touch sensation and proprioception (i.e., dissociation of sensory loss). Anterior extension with involvement of the anterior horns results in segmental neurogenic atrophy, paresis, and areflexia. Dorsal extension involves the dorsal columns causing ipsilateral position sense and vibration loss. Lateral extension causes ipsi-lateral Horner's syndrome (C8-T2 lesions), kyphoscoliosis, and spastic paralysis below the level of damage. Ventrolateral extension affects the spinithalamic tract resulting in thermoanesthesia and analgesia below the spinal cord lesion with sacral sparing due to its lamination (cervical sensation medial, and sacral lateral). f Syndrome of combined lesions in anterior horns and lateral pyramidal tract (amyotrophic lateral sclerosis or motor neuron disease) syndrome causes lower motor neuron signs (muscular atrophy, flaccid paresis, and fasciculation) superimposed on the symptoms and signs of upper motor neuron disease (spastic paresis and extensor plantar responses). If the nuclei of the medullary cranial nerves are involved, there will be explosive dysarthria dysphagia (bulbar or pseudobulbar paralysis).

g Syndrome of the posterior horns (C5 - C8) causes ipsilateral segmental sensory loss, essentially of pain and temperature, but due to absence of damage to the spinothalamic tracts there is preservation of pain and temperature sensation below the level of damage. Spontaneous attacks of pain may develop in the analgesic area.

h Syndrome of the anterior horns (C7-C8) where the anterior horns are selectively involved in acute poliomyelitis and in progressive spinal muscular atrophies resulting in diffuse weakness, atrophy, and fasciculations in muscles of the extremities and the trunk, reduction of muscle tone and hypo- or areflexia of muscle stretch reflexes.

i Syndrome of combined lesions in posterior tracts, spinocerebellar tracts and eventually the pyramidal tracts (Friedreich's ataxia). The disease commences with loss of position sense, discrimination, and stereognosis, leading to ataxia and Romberg's sign. Pain and temperature sensations are involved to a lesser extent. Later, spastic paresis appears indicating degeneration of the pyramidal tracts. j Syndrome of the corticospinal tracts (progressive spastic spinal paralysis) presents initially with heaviness if the legs, progressing to spastic paresis, spastic gait, and hyperreflexia. Spastic paresis of the arms develops later in the course of the disease.

k Syndrome of posterolateral column (T6) (subacute combined degeneration) due to selective damage from vitamin B12 deficiency or vacuolar myelopathy of AIDS or extrinsic cord compression, resulting in paresthesias of the feet, loss of proprioception and vibration sense and sensory ataxia. Bilateral spasticity, hyperreflexia, and bilateral extensor toe signs. Hypo- or areflexia due to peripheral neuropathy.

l Syndrome of hemisection of the spinal cord (Brown-Sequard syndrome) is characteristically produced by extramedullary lesions and contralateral to the hemisection, ipsilateral loss of propriception below the level of the lesion, ipsilateral spastic weakness and segmental lower motor neuron and sensory signs at the level of the lesion due to damage of the roots and anterior horn cells at this level.

m Syndrome of complete spinal cord transection (transverse myelitis) causes impairment of all sensory modalities (light touch, position sense, vibration, temperature, and pain) below the level of the lesion. Paraplegia or tetraplegia below the level of the lesion, initially flaccid and areflexic due to spinal shock but progressively hypertonic and hyperreflexic. Segmental lower motor neuron signs (paresis, atrophy, fasciculations, and areflexia). Urinary and anal spincter dysfunction, sexual dysfunction, anhidrosis, skin changes, and vasomotor instability. n The anterior spinal artery syndrome presents with an abrupt radicular girdle pain, loss of motor function (flaccid paraplegia), bilateral thermoanesthesia and analgesia, bladder and bowel dysfunction. Position sense, vibration, and light touch are intact.

o Characteristic sensory deficits found in various spinal cord lesions in comparison to peripheral neuropathy: (1) Advanced intraaxial lesion of thoracic cord at T3-T6 (sacral sparing). (2) Cauda equina lesion. (3) Stocking-glove pattern of sensory loss of an advanced stage of peripheral neuropathy. (4) Organic sensory loss follows an anatomic distribution on the left side of the face, upper and lower extremities. Functional facial anesthesia includes the angle of the mandible and may stop at the hair line; functional loss of upper extremity sensation usually cuts off transversely at the wrist, elbow, or shoulder; functional loss of lower extemity sensation cuts off at the inguinal line ventrally, or at a joint or the gluteal fold dor-sally, or it may cut off transversely at any lower level.

Autonomic disturbances below the level of the lesion

- Urinary and rectal sphincter dysfunction

- Anhidrosis

- Trophic skin changes

- Temperature control impairment

- Vasomotor instability

- Sexual dysfunction

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