Chronic Spinal Cord Injury
(Lesi Medula Spinalis Khronis)
Darwin Amir
Bgn Ilmu Penyakit Saraf
Fakultas Kedokteran Universitas Andalas
The Spinal Cord
Cervical
spinal erves
Thoracic
spinal
nerves
Conus
medullaris
Cauda equina
Lumbar
spinal nerves
Sacral spinal
nerves
PROYEKSI DERMATOM
DIPERMUKAAN KULIT
Ascending Spinal Cord Tract
Conducts sensory impulses upward
through 3 successive chains of neurons
• 1st order neuron - cutaneous receptors of
skin and proprioceptors  spinal cord or
brain stem
• 2nd order neuron - to thalamus or
cerebellum
• 3rd order neuron - to somatosensory
cortex of cerebrum
Ascending Spinal Cord Tract
The Spinal Cord
vertebra
spinal
cord
spinal
nerve
Cross Section of Spinal Cord




White matter:
Myelinated axons
forming nerve
tracts
Fissure and sulcus
Three columns:
◦ Ventral
◦ Dorsal
◦ Lateral
(see later for white matter
pathways)



Gray matter:
Neuron cell cell
bodies, dendrites,
axons
‘Horns’:
◦ Posterior (dorsal)
◦ Anterior (ventral)
◦ Lateral

Commissures:
◦ Gray: Central canal
◦ White
The Nervous System
The Spinal Cord-part of the CNS found within the
Spinal column
The spinal cord communicates with the sense
organs and muscles below the level of the head
Bell-Magendie Law-the entering dorsal roots
carry sensory information and the exiting ventral
roots carry motor information to the muscles and
Glands
Dorsal Root Ganglia-clusters of neurons outside
the spinal cord
Nerve Pathways into the Spinal Cord
sensory
pathway
motor
pathway
Somatic Sensory Pathway
Symptoms and Signs

Must be mastering in mind

Start by understanding anatomy and
physiology of the Nervous System

Don’s forget the of CNS systematically
 - Anatomy of CNS
 - Physiology of CNS
 - Pathophysiology of the Disease
 - The steps to make the diagnosis
Sensory disturbances
▪ Soft touch, pain, temperature,
position, vibration impaired below the
level of lesion
▪ Band like radicular pain/segmental
paraesthesia at the level of lesion
▪ localised vertebral spine pain-
destructive lesions
Motor disturbances
▪ Paraplegia/quadriplegia
▪ Acute-flaccid / Areflexic-spinal shock
latter-hypertonic / hyper reflexic, loss
of superficial reflexes, Babinski +,
flexor/extensor spasm
▪ Extension of hip, knee occurs in high
spinal & Incomplete lesion
Motor disturbances
• Flexion of hip , knee occur in low
spinal & complete lesion
• At the level of lesion – paresis,
atrophy, fasciculations,and
areflexia(LMN signs) in a segmental
distribution because of damage to
the anterior horn cells and ventral
roots
Autononomic disturbances
• initially
atonic, latter spastic bladder,
rectal sphincter disturbances
• orthostatic hypotension
• trophic skin changes
• anhydrosis
• impaired temperature control
• vasomotor instability
• sexual disturbances
• I/L horner syndrome
Causes of Chronic Lesion
° Tumour
° Multiple sclerosis
° Vascular disorders
° Spinal epidural hematoma/abscess
° Auto immune disease
° Herniated intervertebral disc
° Combine degeneration of B12 Deficiences
Complete spinal cord transection
(Transverse myelopathy)
Complete spinal cord transection
(Transverse myelopathy)

All acsending tracts from below the level
of the lesion and all descending tract from
above the level of lesion interrupted.
Motor, sensory, autonomic functions below
the level of lesion disturbed
 Causes :
° tumour
° multiple sclerosis
° vascular disorders ° spinal epidural hematoma/
° spinal epidural abscess
° herniated intervertebral disc
° auto immune disease
Central spinal cord lesion
 Spinal
cord damage starts centrally
and spreads centrifugally
 Decussating
fibers of spinothalamic
tract involved initially
 Thermo
anaesthesia, analgesia in a
”vest like” or “suspended” bilateral
distribution with preservation soft
touch sensation and proprioception-- dissociation of sensory loss
Central spinal cord lesion
 Forward
extension of disease anterior
horn cells involved segmental
neurogenic atrophy, paresis, areflexia
 Lateral extension
I/L Horner syndrome
Kypho scoliosis
Spastic paralysis
 Dorsal extension
I/L Position sense, vibratory loss
Central spinal cord lesion
 Extreme
venterolateral extension
thermo anaesthesia, analgesia with
sacral sparing
 Neuropathic
 Pain
arthropathy
Posterior column disease
Posterior column disease
Tabes dorsalis-tabetic neuro syphilis,
progressive locomotor ataxia
 Impaired vibration and position sense,
and decreased tactile localisation
 Lability of mechanical sensation threshold,
tactile & postural hallucinations,
persistence of mechano receptor
sensation, disturbances in the knowledge
of extremity movement and positions
(temporal & spatial disturbances)
 Sensory ataxia in dark, Romberg (+)

Posterior column disease
Ataxic / stomping/ double tapping gait
 Positive sink sign
 In tabes dorsalis lancinating pain, urinary
incontinence, Negative patellar and ankle
DTR, hypotonic limb, hyper extensible
joints
abdominal, laryngeal crises, impaired
light touch perception, Argyll robertson
pupil, optic atrophy, ptosis,
ophthalmoplegia

Posterior column disease
○ Lhermitte sign or barber chair syndrome
due to increased mechano sensitivity
○ Truncal and gait ataxia : also seen in mets
causing cord compression
○ Impaired conduction in dorsal spino cere bellar tract may be a primar manifestation
of epidural spinal cord compression-lower
extremity dysmetria and gait ataxia.
○ Pt usually have thoracic spine compression
due to selective vulnerability of spinocere
bellar tract in thoracic spine to compres sive ischemia
Hemisection of the spinal cord
( Brown sequard syndrome)
Hemisection of the spinal cord
( Brown sequard syndrome)
Loss of pain, temp C/L to the hemisectioninterruption of crossed spino thalamic tract
 Loss of proprioception – interruption of
ascending fibers of posterior column
 Spastic weakness due to interruption of
descending cortico spinal tract
 Segmental LMN signs and sensory changes
at the level of lesion due to damage of the
roots and anterior horn cells at the level
of lesion

INNERVATION OF
AUTONOMIC NERVOUS
SYSTEM
Thank you Brain
For all you remember
What you forgot was my fault
TERIMA
The KASIH
End