Spinal cord compression

1- Highlights:

* Spinal cord compression is a neurosurgical emergency

* Absence of neurological signs supralésionnels

* There is a syndrome in spinal vertebral causes

* The lesion syndrome often precedes sub-lesional syndrome; must make the diagnosis at this stage

* Sign of the Bell: provocation of sciatic pain by pressing in the paraspinal region next disc (slipped disc).

* Brown-Sequard syndrome is pathognomonic for spinal cord injury.

* An earlier compression mainly provides motor disorders and can mimic an array of ALS.

* The study of CSF often shows albuminocytologique dissociation (increased CSF protein without hypercytose).

* Lhermitte sign: electric shock sensation browsing the spine and lower limbs during neck flexion (MS, combined degeneration of the cord; CM).

* The vertebral fracture osteoporosis respect the posterior vertebral wall and gives no spinal cord compression.

* In intramedullary causes, there is an infringement of dissociated sensitivity (damage of thermo-algesic sensitivity only) and suspended topography.

* In intramedullary causes, there is no spinal and radicular syndrome-lar.

Spinal cord compression2- Etiology:

A- brutal spinal cord compression:

* Spinal epidural hematoma

* Herniated disc: Cervical most often (syn-drome of the lumbar QDC).

* Collapsed vertebra: vertebra metastatic, myeloma or spondylitis. -> + Spinal radicular syndrome syndrome

B- slow medullary compression:

* Causes intradural extramedullary:

– Neuroma (man of 40; hourglass tumor recreated)

– Meningioma (woman after 40 years; sub-lesional syndrome predominates (syndrome Brown Sequard)

* Causes intramedullary:

– Tumours: ependymoma; astrocytoma; hemangioblastoma (Hippel-Lindau) metastasis

– Angioma marrow.

* Other causes:

– Narrow spinal canal (osteoarthritis)

– Medullary vascular malformation

3- Clinic:

A- lesional syndrome:

– Very important locator Value

– Radicular topography of Pain:

* Augmented by effort

* Uni or bilateral

* Night Paroxysm

– With hypothyroidism or anesthesia for all modes in the same territory

– Motor disorders: radi-lar peripheral paralysis and muscular atrophy with corresponding abolition of tendon reflexes.

B- Syndrome sub-lesional:

– Motor disorders:

* Driving force (painless claudication -> spastic paraparesis).

* ROT alive the lower limbs

* Cutaneous abdominal reflexes abolished and Babinski sign

* Reflex defense with triple removal of the lower limbs in advanced forms.

– Sensation Disorders: subjective (pain, paresthesia); targets (tactile sensibility, proprioception, and / or thermo-algesic)

– Sphincter disorders: urinary urgency and urinary frequency and urinary retention and overflow incontinence or incontinence.

C- spinal syndrome:

– Spinal stiffness

– Spontaneous spinal pain or caused by tapping thorns

– It is especially clear in cases vertebral

4- Topography:

A- Cervical high (C1-C4):

quadriplegia; occipital neuralgia (C1-C2); phrenic reached (C3-C4): diaphragm paralysis or hiccups; achievement of XI (SCM, trapezius); trap reached the thermoalgique sensitivity of the face (descending root of the V which stops at C2).

B- Cervical low (C5-D1):

radicular syndrome in the upper limbs (trigeminal cervicobachiale) and paraplegia

C- Dorsal:

thoraco-abdominal pain associated with a waist band anesthesia (D4: nipple D6: xiphoïde; D10: umbilicus);paraplegia.

D- Lumbosacral:

Paralysis of the quadriceps; abolished patellar; achilles alive; bilateral Babinski; sphincter disorders

E- Cone terminal:

Lesional syndrome is projected lower limbs can hide the central characters (value Babinski sign); severe sphincter disorders; reaching the L1 (psoas paralysis and sensory disturbances of the groin fold); abolition of the abdominal cutaneous reflexes and lower cremasteric reflex.

F- posterior compression:

Lesion predominantly posterior cordonale (proprioceptive ataxia) + Lhermitte’s sign

G- Side Compression:

Hémimoelle syndrome (Brown Sequard): pyramidal syndrome and cordonal rear on the same side of the cord and spinothalamic syndrome opposite side of the compression.

4- Differential Diagnosis:

– Before any medullary syndrome, eliminate spinal compression before discussing: transverse myelitis, September 1, ALS …;

A- September with medullary form:

Notions of outbreaks; values of cerebral hyperintensities on MRI T2; HyperGamma-globulinorrachie oligoclonal

B- amyotrophic lateral sclerosis:

Achievement of 2 motor neurons (sup and inf); absence of sensory disorders; importance of fasciculation; Possible bulbar signs.

C- Syringomyelia:

intramedullary cavity; dissociated sensory disturbances (thermal algesic) and dissociated; hypointense on T1

D- sclerosis combined marrow:

Associates a pyramidal syndrome and posterior cord syndrome. Imaging is normal; pernicious anemia

E- Syndrome-tail horse:

Sensorimotor impairment of lower limb peripheral type; importance of sphincter disorders; abolition of the Achilles and patellar reflexes.

F- Meningiomas of falx:

Can give a spastic paraparesis compression of 2 central lobules +++

Syndrome-tail horse:

– It is a violation of roots L2 to S5, responsible for motor and sensory innervation of the lower limbs, perineum and external genitalia and the sphincter control.

– The terminal cone of the cord ends at the lower edge of the L1 vertebra.

– It is a lesion syndrome pluriradiculaire.

– The diagnosis is clinical but additional tests are needed to etiological research (IRM +++)

– Lower back pain radiating to the legs with a plain topography or pluriradiculaire and may be unilateral or bilateral.

– Motor deficit from simple fatigue to walk to the peripheral flange type lower limb paralysis with hypotonia and atrophy

– Abolition of tendon ankle reflexes in the reach of the S1 root; patella (L4 root) and anal reflex (S3 root).

– Sensation Disorders of the perineal area (saddle anesthesia), EMB and sometimes the buttocks and legs.

– Genitourinary sphincter disorders early and constant. urinary incontinence and retention in the beginning and overflow incontinence; incapacity ; anal incontinence and constipation early.

– Negative signs: absence of central or spinal signs (no Babinski, cutaneous abdominal reflexes preserved,

– Differential diagnosis: cone reaching the terminal:

* Achievement of the iliopsoas (flexion of the thigh on the pelvis)

* Sensation Disorders in the groin folds

* Pyramidal signs (Babinski sign)

– Etiology: disc herniation (neurosurgical emergency); spinal stenosis; spinal hematoma ear or subdural