SPINAL CORD -

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clinical anatomy

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SPINAL CORD CLINICAL ANATOMY: 

SPINAL CORD CLINICAL ANATOMY

LUMBAR PUNCTURE: 

LUMBAR PUNCTURE INDICATIONS – 1. Laboratory Diagnosis 2. Injecting Drugs 3. Inducing Anesthesia SITE – Subarachnoid space beneath L1 (L3 in infants) Till S2 (Lumbar Cistern) preferred METHOD - Patient lies on side or upright sitting with vertebral column flexed , so as to open space between two consecutive vertebrae Using aseptic precautions & local anesthesia , needle with a stylet is inserted above or below L4;depth is varying from 4 inches in adults to 1 inch in infants.

LUMBAR PUNCTURE: 

LUMBAR PUNCTURE

LUMBAR PUNCTURE: 

LUMBAR PUNCTURE As the stylet is withdrawn a few drops of blood escape indicating needle in internal vertebral plexus Maneuver so that not to much blood comes out As we reach the subarachnoid space the patient may feel discomfort in one of the dermatomes or a muscle with twitch if we reach nerve roots CSF Pressure – Measured by attaching manometer to the needle Normal – 60 to 150 mm of water By compressing IJV in neck, cerebral venous pressure rise is reflected in manometer No rise - SA space is blocked (Quickenstedt’s Sign)

LUMBAR PUNCTURE: 

LUMBAR PUNCTURE

FRACTURES & DISLOCATIONS OF VERTEBRAE: 

FRACTURES & DISLOCATIONS OF VERTEBRAE Cx Region-Common, leads to severe injury to spinal cord T Region- Common, leads to severe injury to spinal cord L Region – Uncommon , Minimal injury to Spinal Cord

HERNIATED INTERVERTEBRAL DISCS : 

HERNIATED INTERVERTEBRAL DISCS Common where mobile part joins relatively immobile part E.g. Cervico-thoracic junction, Lumbo-sacral junction Cx - Less common, 5 th & 6 th more liable to prolapse ; pain radiates to lower neck & shoulder Lum - Common , 4 th & 5 th more liable to prolapse; may press on nerve roots; If cauda equina is compressed than it leads to paraplegia or sciatica or weak plantar flexion

HERNIATED INTERVERTEBRAL DISCS : 

HERNIATED INTERVERTEBRAL DISCS

CAUDAL ANESTHESIA: 

CAUDAL ANESTHESIA Into the sacral canal through sacral hiatus Obstetricians use it for 1 st & 2 nd stage of labor (infant remains unaffected) Also used for any surgery in sacral region E.g. Anorectal surgery

Injury to The Ascending tracts Within The Spinal Cord: 

Injury to The Ascending tracts Within The Spinal Cord Lateral spinothalamic tract – Contralateral loss of pain & thermal sensations below lesion level Anterior spinothalamic tract – Contralateral loss of light touch & pressure sensations below lesion level Fasciculus Cuneatus & Gracilis –(below lesion level) - Ipsilateral loss of position & movement sensations - Ipsilateral loss of vibration sensations - Ipsilateral loss of tactile discrimination sensations - General touch is UNAFFECTED

SOMATIC AND VISCERAL PAIN: 

SOMATIC AND VISCERAL PAIN Somatic Sharp pain via fast conducting fibers Prolonged burning via slow conducting fibers Visceral Special receptor function : Baro, Chemo, Osmo, Stretch Reach CNS via sympathetic & Parasympathetic Poorly localized, associated with nausea & vomiting, tachycardia, sweating May produce referred pain

PAIN RELIEF by RHIZOTOMY or CORDOTOMY: 

PAIN RELIEF by RHIZOTOMY or CORDOTOMY - Done in terminally ill patients Posterior rhizotomy- it is division of posterior roots of spinal nerves; Pain & other sensations are lost. Cordotomy (L) – Performed in patients with severe abdominal or pelvic pain Cordotomy (Cx) – Performed in patients with intractable pain neck or thorax

TABES DORSALIS (SYPHILIS): 

TABES DORSALIS (SYPHILIS) Destruction of fibers at point of entry of posterior roots in thoracic & Lumbosacral region Stabbing pain in lower limbs Numbness & Paraesthesia in lower limbs Hypersensitivity to touch ,cold, & heat Loss of awareness that urinary bladder is full Loss of deep sensations Loss of appreciation of posture Loss of pain on parts of skin Ataxia in lower limbs Hypotonia & loss of tendon reflexes

TABES DORSALIS (SYPHILIS): 

TABES DORSALIS (SYPHILIS)

UPPER MOTOR NEURON LESION: 

UPPER MOTOR NEURON LESION PYRAMIDAL TRACT LESION: Babinski’s sign is positive Superficial abdominal reflexes are absent Cremasteric reflex Loss of performance of fine skilled voluntary movements EXTRA PYRAMIDAL TRACT LESIONS Severe paralysis Spasticity or hypertonicity Exaggerated deep tendon reflexes Clasp-knife reaction

LOWER MOTOR NEURON LESION: 

LOWER MOTOR NEURON LESION Flaccid Paralysis Atrophy Loss of reflexes Muscular fasciculations Reaction of degeneration Causes : Trauma, Infection like Poliomyelitis, Vascular disorders, Degenerative disorders, Tumors

TYPES OF PARALYSIS: 

TYPES OF PARALYSIS

TYPES OF PARALYSIS: 

TYPES OF PARALYSIS

MUSCULAR SIGNS & SYMPTOMS: 

MUSCULAR SIGNS & SYMPTOMS Hypotonia – Decreased or Absent muscle tone Hypertonia – Increased (Spasticity or rigidity) muscle tone Tremors – Rhythmic involuntary movements due to contraction of opposing muscle groups E.g. Parkinsonism & Thyrotoxicosis Spasms – Sudden involuntary contractions of large group of muscles Athetosis – Continuous ,slow, involuntary , dysrhythmic movements; in some patient disappears during sleep (lesions of corpus striatum)

MUSCULAR SIGNS & SYMPTOMS: 

MUSCULAR SIGNS & SYMPTOMS Chorea – Quick, brief, sudden, jerky, continuous movements disoriented in time and space Dystonia – Bizarre postures (Lesions of lentiform nucleus) Myoclonus – Sudden contractions of isolated muscle or part of muscle Hemiballismus – Rare form of involuntary movements of one muscle on one side of the body, usually proximal extremity muscles ; flying in all directions (sub-thalamic nuclei involvement)

SPINAL SHOCK SYNDROME: 

SPINAL SHOCK SYNDROME Acute severe damage to the spinal cord All the cord functions below the lesion are lost, sensory impairment & flaccid paralysis High level – severe hypotension as loss of sympathetic vasomotor tone occurs In 24 hours to 4 weeks time signs regress as neurons recover Absent anal sphincter reflex (S2-4)

COMPLETE CORD TRANSACTION: 

COMPLETE CORD TRANSACTION Bilateral LMN paralysis ,muscular atrophy in segment of lesion Bilateral spastic paralysis below lesion level Babinski’s sign positive Abdominal cremasteric reflexes are lost due to interruptions of corticospinal tracts Bilateral loss of sensations below lesion level Bladder & bowel functions are no longer under voluntary control

ANTERIOR CORD SYNDROME: 

ANTERIOR CORD SYNDROME Bilateral LMN paralysis & muscular atrophy at the segment level Bilateral spastic paralysis below lesion level Bilateral loss of pain, temperature, light touch below lesion level Tactile discrimination, vibratory & proprioceptive sensations are preserved CAUSES: Contusion due to # vertebrae or PID or injury to spinal cord

CENTRAL CORD SYNDROME: 

CENTRAL CORD SYNDROME Bilateral LMN paralysis & muscular atrophy at segmental level Bilateral spastic paralysis below lesion level with characteristic “sacral sparing” Bilateral loss of pain, temperature, light touch & pressure below lesion level with “sacral sparing” CAUSE : Hyperextension of cervical spine

BROWN SEQUARD SYNDROME: 

BROWN SEQUARD SYNDROME Ipsilateral LMN paralysis & muscular atrophy at segmental level Ipsilateral spastic paralysis below lesion level , Babinski’s sign positive Ipsilateral loss of superficial abdominal & cremasteric reflex Ipsilateral band of cutaneous anesthesia Ipsilateral loss of tactile discrimination, vibratory & proprioceptive sensations below lesion level Conteralteral loss of pain & sensations below lesion level Contralateral incomplete loss of tactile sensations below lesion level

SYRINGOMYELIA: 

SYRINGOMYELIA Loss of pain & temperature in dermatomes related to affected segments on both sides (shawl like distribution) LMN weakness in small muscles of hand Bilateral spastic paralysis of both legs Exaggerated deep tendon reflexes Babinski’s sign is positive Horner’s syndrome ( ptosis , meiosis, anhydrosis ) CAUSE : Congenital anomaly

POLIOMYELITIS: 

POLIOMYELITIS CAUSE : Acute viral infection of the neurons of anterior gray horn of the spinal cord & motor nuclei of the cranial nerves Due to death of motor neurons paralysis & wasting of muscles takes place Lower limbs are more affected

MULTIPLE SCLEROSIS: 

MULTIPLE SCLEROSIS CNS disorder causing de- myelination of ascending & descending tracts Seen in Young adults Unknown cause Due to loss of myelin conduction of nerve impulse is hampered & finally stopped Chronic disease with exacerbations & remissions Signs - Weakness of limbs - Ataxia - Spastic paralysis

AMYOTROPHIC LATERAL SCLEROSIS (Lou Gehrig’s disease): 

AMYOTROPHIC LATERAL SCLEROSIS (Lou Gehrig’s disease) Corticospinal tracts & motor neurons of anterior column Familial & Inherited Unknown cause Late middle age occurrence Fatal in 2 to 6 years LMN signs of progressive muscular atrophy, paresis, fasciculations , along with UMN disorder of paresis,spasticity & positive babinski’s sign Cranial nerve nuclei may be involved

PARKINSON’S DISORDER: 

PARKINSON’S DISORDER Neuronal degeneration in substantia nigra & globus pallidus , putamen & caudate nucleus Degeneration of nigrostriate fibers leads to decreased dopamine secretion; leading to hypersensitivity of dopamine receptors SIGNS: Tremors, cogwheel rigidity, difficulty in initiating voluntary movement