Myelopathy

Diseases affecting the spinal cord

Etiology

  • Trauma
  • Compression from: spinal stenosis, OA/degenerative disease, disc herniation, ligamentous hypertrophy, tumor (metastatic), infection (epidural abscess), or contributions from multiple processes
  • Inflammation from idiopathic/autoimmune processes (e.g. transverse myelitis)
  • Nutritional deficiencies, in particular: B12 and copper
  • Vascular malformations (e.g. AVMs within the dura or cord)
  • Primary tumors of the spinal cord (unusual)
  • Vascular insufficiency affecting the cord (e.g. interruption of artery of Adamkiewicz post AAA repair, embolic phenomenon)
  • Syringomyelia: fluid filled cavity occurring within the cord
  • Unusual infections: HIV, HTLV 1

Risk Factors

  • Degenerative compression occurs most commonly in older patients; can also occur related to trauma, disc disruption, RA, other
  • For nutrition related: sometimes idiopathic, poor diets, or post gastric surgery
  • HIV RFs for HIV related; Caribbean, Central/South America, Japan for HTLV1

Symptoms

  • Symptoms are based on level (cervical, thoracic, lumbro-sacral), region of cord affected/compressed (e.g. anterior, lateral, dorsal), whether from external or internal causes; or related to other processes if non-compressive; Rate of progression related to specifics of underlying process
  • Cervical: progressive bilateral weakness, numbness, hand clumsiness, neck pain; leg weakness and gait disturbance sometimes occurs before arms/hands (lateral cortico-spinal tracts to legs are on outside of cord relative to those traveling arms/hands), urinary and/or bowel symptoms often occur late
  • Thoracic Level: Upper extremities spared; lower extremity motor and sensory; bowel/bladder symptoms
  • Spinothalamics travel up contralateral side of cord from the region innervated; Dorsal columns travel up ipsilateral side

Physical Exam Findings

  • Symmetric spasticity, hyperreflexia, babinski, impaired sensation (Spinothalamics: pain and temperature; Dorsal columns: roprioception, vibration, pressure)
  • May be able to detect sensory level at site of involvement (e.g. numbness below umbilicus w/T-10 level lesion
  • Gait disturbance: instability, leg stiffness
  • Lhermittes sign: Shock-like sensation precipitated by neck flexion, traveling down back to legs
  • High post void residual, decrease rectal tone w/advanced disease

Tests