Syndrome of transverse spinal cord injury: causes, symptoms, diagnosis

Transverse spinal cord injuries involve one or more segments and completely or partially interrupt the spinal cord. The complete intersection of the spinal cord at the cervical or thoracic level causes the following symptoms:

1. Complete, ultimately spastic, tetrapalegia or, if only the legs suffered, lower paraplegia, which in case of complete damage acquires the character of paraplegia in the flexion position;
2. Total conductive type anesthesia below the lesion;
3. Dysfunction of the pelvic organs;
4. Violation of autonomic and trophic functions (pressure sores, etc.);
5. segmental flaccid paralysis and muscle atrophy due to the involvement of the anterior horns at the level of one or more damaged segments.

More common is the syndrome of partial (partial) transverse lesion.

Symptoms are different for lesions of the spinal cord at the upper cervical level (segments C1-C4), at the level of the cervical thickening, with lesions of the thoracic spinal cord, upper lumbar (L1-L3), epiconus (L4-L5, S1-S2) and cone (S3 - S5). Isolated lesion of the cone of the spinal cord is less common than in conjunction with the damage to the horse's tail (in the latter case, severe radicular pain, flaccid paralysis of the lower extremities, anesthesia in them, disorders of urination such as delay or "true" urinary incontinence).

Damage at the level of the lower parts of the spinal cord has its clinical features. Thus, the epiconus syndrome (L4-S2) is characterized by the defeat of muscles innervated by the sacral plexus with the predominant lesion of the peroneal muscle and the relative safety of the tibial. Preserved flexion of the thigh and extension of the knee. Flaccid paralysis (varying in severity) of the muscles of the gluteal region, the back of the thigh, the lower leg and the foot (defective thigh extension and flexion of the knee, movement of the foot and fingers). Achilles reflexes drop out; knee - preserved. Sensitivity disorders are below the L4 segment. The functions of the bladder and rectum deteriorate ("autonomic bladder").

Syndrome of the cone of the spinal cord (S3 and more distal segments) is characterized by the absence of paralysis (with isolated damage to the cone); the presence of saddle anesthesia, flaccid paralysis of the bladder and paralysis of the anal sphincter, the absence of anal and bulbous-cavernous reflexes; tendon reflexes are preserved; there are no pyramid signs.

Diseases that cause damage to only one half of the spinal cord lead to the well-known syndrome of Brown-Sequard, which is not discussed in detail here (in most cases, incomplete variants of the Brown-Sekar syndrome are found).

With slowly developing lesions of the thoracic and cervical spine, it is possible to develop a syndrome of spinal automatism with protective reflexes, which can be used to determine the lower boundary of the spinal process, for example, a tumor.

The main causes of partial (partial) transverse lesion :

1. Occlusion of anterior spinal artery.
2. Pathology of the vertebrae (spine).
3. Extramedullary and intramedullary tumor (originating from the spinal cord, metastasis, sarcoma, glioma, spinal angioma, ependymoma, meningioma, neurinoma).
4. Non-tumoral compression (herniation of the intervertebral disc, epidural abscess, epidural hemorrhage (hematoma), lumbar stenosis.
5. Myelitis, epiduritis, abscess, demyelinating diseases.
6. Radiation myelopathy.
7. Trauma with a spinal cord injury (concussion) and late traumatic compression of the spinal cord.

Occlusion of anterior spinal artery

The anterior spinal artery running along the ventral surface of the spinal cord, blood supply the anterior two-thirds of the spinal cord through the numerous groove-commissural arteries that enter the spinal cord in the ventrodorzal direction. These arteries supply blood to the anterior and lateral horns of the spinal cord, spinal cord, anterior corticospinal and, most importantly, lateral corticospinal tracts.

The most important thing is the non-involvement of the hindlegs and hindquarters. Based on the anatomical data, the syndrome of the anterior spinal artery (identical to the central spinal cord syndrome) is represented by the following symptoms: central lower paraparesis (sometimes monoparesis of the foot), which in the acute phase of the disease may be sluggish (spinal shock) with areflexia, but then, later several weeks, there is a gradual increase in muscle tone by spastic type, develops hyperreflexia, clones, a symptom of Babinsky, a delay in urination, which gradually turns into an incontinence s urine (giperreflektorny bladder) decrease in pain and loss of temperature sensitivity. Unlike the disturbed pain and temperature sensitivity, the tactile sensitivity and the ability to localize the stimulus are preserved, the same concerns vibrational sensitivity. Often observed radicular pain, corresponding to the upper level of damage. Sometimes spinal cord infarction is preceded by transient ischemic spinal attacks.

The cause of occlusion may be embolism or a local atherosclerotic process. Less common cause of spinal infarction are systemic diseases (for example, nodular periarteritis). The disease begins acutely. An incomplete transverse lesion of the spinal cord occurs on the lower cervical or thoracic levels, where large feeding vessels flow into the anterior spinal artery. The age of the patients is mainly elderly (but not always). There are signs of widespread atherosclerosis. There are no abnormalities in the X-ray examination. Liquor is not changed. Sometimes, as in cerebral stroke, hematocrit is elevated.

An infarction of the posterior spinal artery does not give a picture of the transverse lesion of the spinal cord.

A rare cause of spinal cord compression syndrome is a venous infarction.

Compression of the spinal cord can be caused by spine pathology, (tumor, spondylitis, prolapse of the intervertebral disc) at which the introduction of distally modified vertebral tissues, neoplastic or inflammatory tissue into the spinal canal. In the anamnesis there may be indications of radicular pain at the level of lesion that preceded the acute development of symptoms, however such information may not be available. Quite often, the syndrome of incomplete transverse damage to the spinal cord develops without any precursors. With a neurological examination, you can only approximately determine the level of damage. The neurological examination, in general, can be relied upon in determining the transverse nature of the lesion, rather than the level of damage to the spinal cord. The reason for this is the so-called eccentric arrangement of long ascending and descending fibers. Any focus on the spinal cord in the direction from the outside to the inside will primarily affect these long fibers, so the first clinical manifestations usually occur in the anatomical regions localized below the localization level of the lesion itself.

Certain useful information can be obtained from laboratory studies (eg, ESR). Other necessary diagnostic tests may not be available at the time of admission (eg, examination of bone metabolism indices).

To clarify the diagnosis, more research is needed. Traditional methods are radiography and neuroimaging in the mode of bone visualization, which allows to reveal destructive changes in the vertebra due to local effects on them of the neoplasm or inflammatory process. In the absence of changes in radiography or neuroimaging, spinal scintigraphy is diagnostic. Scintigraphic research performs the role of the search method when the level of lesion of the spinal column can not be established. When determining the level of damage to the degree of compression of the spinal cord and extraspinal effect, judging by the results of myelography combined with CT.

Extramedullary or intramedullary tumor

To detect extramedullary intradural volumetric processes, the most informative myelography in combination with CT or MRI The spinal column in such cases is often intact, while at the same time there is compression of the spinal cord. The advantage of myelography is its ability to clearly visualize the localization of the pathological process, in addition, simultaneously it is possible to take the liquor for the study and get the diagnostically valuable information. The spectrum of extramedullary pathological processes is wide: from neurinoma or meningioma (usually located on the posterolateral surface of the spinal cord and requiring surgical intervention) to the lymphoma that best succumbs to radiotherapy, and the arachnoid cyst.

Intramedullary tumors of the spinal cord are rare. To the fore in the clinical picture comes not pain, but paresthesia, paraparesis and urination disorders. With this symptomatology, if there are any assumptions about neurological pathology, then the spinal form of multiple sclerosis is suspected first of all. However, there is no multifaceted or flow with exacerbations and remissions in this condition. The progressive course of spinal pathology involving different systems (sensory, motor, vegetative) should be the basis for the search for a volumetric process.

Non-tumoral compression of the spinal cord

Abaissement of a herniated intervertebral disk at the cervical level usually leads to the syndrome of Brown-Sekar, but it is possible to form and the syndrome of the anterior spinal artery. For the loss of hernia does not require any extraordinary impact: in most cases this occurs in completely unremarkable situations, for example - when stretching (stretching) in the supine position. Among the additional methods of research, the method of choice is neuroimaging.

Epidural abscess is characterized by a syndrome of incomplete transverse lesion of the spinal cord of a progredient nature: local, almost intolerable pain and tension of the interested part of the spinal column; local soreness; and inflammatory changes in blood. In this situation, there is no time for additional studies, except for radiography and myelography. Urgent surgical intervention is necessary.

Epiduritis requires a differential diagnosis with myelitis. The crucial diagnostic value is MRI or myelography. Lumbar puncture with suspicion of epiduritis is absolutely contraindicated.

Acute development of the syndrome of transverse spinal cord injury in a patient receiving anticoagulants is most likely due to hemorrhage into the epidural space (epidural hematoma). Such patients should immediately inject antagonists of anticoagulants, because in this situation it is necessary to carry out neurovisualization studies and myelography and urgent surgical intervention.

Myelitis and multiple sclerosis

A more or less complete transverse lesion of the spinal cord occurs with inflammatory (viral, paraneplastic, demyelinating, necrotizing, postvaccinal, mycoplasmic, syphilitic, tubercular, sarcoid, idiopathic myelitis) process in the spinal cord. In other words, both the viral and other etiology of myelitis are possible; often it arises as a post-infection immune reaction, manifested in the form of multifocal perivenic demyelination. This condition is sometimes not easy to differentiate from multiple sclerosis. A characteristic sign of the latter is the syndrome of atactic paraparesis. However, atactic syndrome in the acute stage may be absent.

Myelitis occurs acutely or subacute, often against the background of general infectious symptoms. There are pains and paresthesias in the innervation zone of the affected roots; they are joined tetraplegia or lower paraplegia (paraparesis), which in the acute period are languid in nature. Characteristic violations of the functions of the pelvic organs, trophic disorders (bedsores). The functions of the rear pillars are not always violated.

Clarification of the etiology of myelitis requires a complex of clinical and paraclinical studies, including the study of cerebrospinal fluid, MRI of the spinal cord, evoked potentials of different modalities (including visual), serological diagnosis of viral infection, including HIV infection. Approximately half the cases of isolated inflammation of the spinal cord can not be identified.

Radiation Myelopathy

Radiation myelopathy can develop delayed (in 6-15 months) after radiation therapy of tumors in the region of the thorax and neck. Peripheral nerves are more resistant to this damage. Gradually, paresthesia and dysesthesia appear in the feet and the phenomenon of Lermitt; then develops weakness in one or both legs with pyramidal signs and symptoms of involving spinotalamic tracts. There is a picture of transverse myelopathy or Brown-Sekar syndrome. Liquor does not show significant abnormalities, except for a slight increase in protein content. MRI helps to see vascular foci of reduced density in the parenchyma of the spinal cord.

Spinal trauma and late traumatic spinal cord compression

Diagnosis of acute spinal cord injury does not cause difficulties, since there is a corresponding anamnestic information. If the trauma occurred many years ago, the patient may forget to inform the doctor about it, since he does not suspect that this trauma can be the cause of the existing progressive spinal symptoms. Therefore, chronic vascular myelopathy due to compression of the vertebra without the help of radiography can be difficult to diagnose.

Other (rare) causes of spinal cord compression syndrome: cicatrical-adhesive processes, hematomyelia, haemorrhagis, spinal syphilis (gumma), cysticuricosis, cysts.