Spinal Cord Lesions

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management

Definition

Spinal cord lesions refer to structural or functional abnormalities affecting the spinal cord, leading to varying degrees of motor, sensory, and autonomic dysfunction depending on the level and extent of involvement.

Aetiology

1. Traumatic Causes:

  • Spinal fractures (e.g., due to road traffic accidents, falls).
  • Penetrating injuries (gunshot wounds, stab wounds).
  • Post-surgical or iatrogenic injury.

2. Neoplastic Causes:

  • Primary spinal tumours (e.g., meningiomas, ependymomas, gliomas).
  • Metastatic disease (e.g., lung, breast, prostate cancer).

3. Inflammatory/Autoimmune Causes:

  • Multiple sclerosis.
  • Neuromyelitis optica (NMO, Devic’s disease).
  • Transverse myelitis.
  • Sarcoidosis.

4. Infectious Causes:

  • Spinal epidural abscess.
  • Pott’s disease (spinal tuberculosis).
  • Viral myelitis (e.g., HIV, herpes zoster, polio).

5. Vascular Causes:

  • Spinal cord infarction.
  • Arteriovenous malformations (AVMs).

Pathophysiology

  • Disruption of neural pathways in the spinal cord leads to motor, sensory, and autonomic dysfunction.
  • Ischaemia, inflammation, or direct compression may cause reversible or irreversible damage.
  • Lesion location determines clinical presentation (e.g., cervical lesions cause quadriplegia, thoracic lesions cause paraplegia).

Risk factors

  • History of malignancy.
  • Autoimmune diseases (e.g., MS, sarcoidosis).
  • Spinal trauma or recent surgery.
  • IV drug use (risk of spinal infections).
  • Vascular risk factors (e.g., diabetes, hypertension for spinal infarcts).

Signs and symptoms

Motor Impairment:

  • Weakness or paralysis below the level of the lesion.
  • Hyperreflexia and spasticity (if upper motor neuron lesion).
  • Flaccid paralysis (if lower motor neuron lesion).

Sensory Impairment:

  • Numbness, paraesthesia, or loss of sensation.
  • Dermatomal distribution suggests specific spinal level involvement.

Autonomic Dysfunction:

  • Bladder dysfunction (retention or incontinence).
  • Bowel dysfunction (constipation, faecal incontinence).
  • Sexual dysfunction.
  • Loss of temperature regulation.

Specific Spinal Cord Syndromes:

  • Brown-Séquard syndrome: ipsilateral motor loss, contralateral pain and temperature loss.
  • Anterior cord syndrome: loss of pain, temperature, and motor function below lesion (preserved proprioception).
  • Posterior cord syndrome: loss of proprioception and vibration sense.
  • Central cord syndrome: weakness in arms > legs, variable sensory loss.
  • Cauda equina syndrome (urgent referral): saddle anaesthesia, bladder/bowel dysfunction, lower limb weakness.

Investigations

  • MRI spine: first-line for identifying cord compression, inflammation, or tumour.
  • CT spine: useful for fractures if MRI is contraindicated.
  • CSF analysis (via lumbar puncture):
    • Raised protein in inflammatory conditions (e.g., MS, infections).
    • Oligoclonal bands suggest multiple sclerosis.
  • Blood tests:
    • FBC, CRP, ESR (inflammatory or infective causes).
    • Autoimmune screen (e.g., ANA, ANCA for vasculitis).
    • Serum vitamin B12 (deficiency can cause subacute combined degeneration of the cord).

Management

1. Emergency Management (If Acute Spinal Cord Lesion Suspected):

  • Urgent neurosurgical referral if spinal cord compression suspected.
  • High-dose steroids (dexamethasone 16 mg STAT) for MS relapse or spinal cord compression.
  • Bladder catheterisation if urinary retention.

2. Specific Treatment Based on Cause:

For Traumatic Lesions:
  • Spinal immobilisation and surgical stabilisation if needed.
For Malignant Lesions (Metastatic Spinal Cord Compression - MSCC):
  • Radiotherapy for radiosensitive tumours.
  • Surgical decompression if tumour causing significant compression.
For Autoimmune or Inflammatory Causes:
  • High-dose IV methylprednisolone for multiple sclerosis or transverse myelitis.
  • Immunosuppressants (e.g., azathioprine, rituximab for neuromyelitis optica).
For Infectious Causes:
  • IV antibiotics for bacterial infections (e.g., epidural abscess, TB).
  • Antivirals if viral aetiology suspected.

3. Rehabilitation and Supportive Care:

  • Physiotherapy to optimise function.
  • Occupational therapy for mobility aids and lifestyle adaptations.
  • Pain management (neuropathic pain agents like gabapentin, amitriptyline).
  • Bladder and bowel management as required.
NeurologymypanotesSpinal Cord Lesions