How to treat the spinal cord. Spinal cord diseases. Complications of spine and spinal cord injuries

In case of spinal cord injuries, the primary task is to begin treatment as early as possible so that the affected segments nerve tissue began to recover as soon as possible. If treatment is started untimely or incorrectly, irreversible changes in the tissue of the spinal cord may occur, and therefore motor functions and sensitivity in different parts of the body will never be fully restored.

Modern methods for diagnosing spinal cord injuries

During the first medical examination of the patient, it is very important to identify which structures of the spinal cord are damaged. The specialist checks whether the sensitivity of individual parts of the body is impaired, assesses the victim’s ability to perform movements, and the strength of the muscles of the limbs.

An X-ray of the neck and back will help determine whether the patient has a spinal fracture or displacement of the vertebrae relative to each other. The image will also show a tumor – if present, arthritis or an infectious process. After all, these diseases can also cause compression and damage to the spinal cord.

Myelography

This method is X-ray examination using a contrast agent.

Pneumomyelography

Diagnosis, which is based on x-ray examination with the introduction of air.

CT scan

This diagnostic method will help identify those changes and damage to the spine and spinal cord that are not visible on an x-ray.

This diagnostic method is more informative, as it allows not only to diagnose injuries to the spine and spinal cord, but also to examine the intervertebral discs, surrounding tissues, ligaments, and nerve pathways.

Spinal tap

A study that allows you to determine the pressure of the cerebrospinal fluid, its condition - color, composition, presence of blood impurities. Having taken the cerebrospinal fluid for examination, specialists will perform serological and biochemical reactions.

General principles for treating spinal cord injuries – when is surgery required?

First aid

This stage is extremely important for injuries of the spine and spinal cord, when proper immobilization of the victim allows you to stabilize the spine and avoid additional damage to the spinal cord structures when transporting the patient.

A victim of a traumatic incident with signs of spinal cord injury should be carefully placed on a rigid board for transport, well secured. Before transporting the victim, you can give painkillers intramuscular injections (Promedol 2% - 2 ml)

During transportation, it is necessary to monitor breathing and monitor cardiovascular activity.

Treatment of spinal cord concussions

The patient is prescribed bed rest. The doctor prescribes vitamins and painkillers. If the victim has a dysfunction of urination, his bladder is emptied using a catheter. It is necessary to prevent bedsores by turning the patient over every 2-3 hours. When the patient's condition improves, massage and physical therapy are prescribed.

Treatment of spinal cord contusion

If, as a result of a spinal cord contusion, the patient has no positive dynamics of the condition for a long time, surgery is required to eliminate scar formations in place. Where were the hemorrhages?

Treatment of spinal cord injuries resulting from fractures and spinal injuries

The position of a patient with a spinal cord injury should be horizontal, on an anti-decubitus mattress or on a hard board with a thin foam rubber mattress. It is necessary to often turn the patient, straighten his bed, and straighten the sheets. For cervical injuries, the patient should be positioned on his back; for lumbar and thoracic injuries, the best position is on the stomach to prevent bedsores.

In case of spinal cord injury in the cervical region The main task of specialists is to monitor the functions of breathing and heartbeat. To do this, electrical stimulation of the diaphragm is used and artificial ventilation is performed. Despite a full range of measures, treatment for these injuries has little chance of success.
For fractures, dislocations of the vertebrae To eliminate all causes of spinal cord compression and spinal column deformation, surgical treatment is performed in the vast majority of cases. The dislocated vertebra is realigned and, if necessary, fixed using special devices. In case of fractures, bone fragments that compress and damage the spinal cord are removed from the wound, and the spine is stabilized using special spinal systems. Contraindications to surgical treatment are disruption of the functioning of vital systems (respiratory, cardiovascular), severe traumatic shock.
IN late period spinal cord injuries dysfunctions of the pelvic organs often occur, as well as a number of syndromes (spastic, pain, adhesions) that need correction. Microneurosurgical methods are used to treat these disorders.
For example, in case of pain syndrome, microneurosurgical operations are performed taking into account the localization of spinal cord injuries - these are selective rhizotomy, cordotomy, commissurotomy and others.
Spastic syndrome after spinal cord injury currently treated using hypothermia and myotonolytics. Surgical treatment of spastic syndrome consists of performing a number of interventions - these are, first of all, longitudinal frontal myelotomy, bilateral longitudinal myelotomy and others.
If urinary function is impaired, a permanent catheter is inserted into the patient's urethra to drain urine. A catheter is also inserted into the urethra in patients with spinal cord injuries in the acute period of injury, and in patients with severe traumatic shock. To prevent urinary tract infection, rinse daily Bladder a solution of furatsilin (in a ratio of 1 to 5000) with antibiotics.

Recovery after spinal cord injury

For injuries to the spinal cord and spinal column, additional treatment may be needed if one or more typical frequent complications:

The most important task in the treatment of patients with spinal cord injury, after measures to stabilize the spine and eliminate life-threatening factors, is to restore the functions of the affected organs and systems, body parts, and limbs. As a rule, possible restoration of functions of damaged limbs, organs and parts of the body occurs within 6 months after the traumatic incident. If any functions are not restored within 12 months, there is Great chance that they will never be able to recover.

To restore patients after spinal cord injury, they use:

Spinal cord diseases often lead to irreversible neurological damage and persistent and severe disability. Pathological foci that are small in size cause the occurrence of tetraplegia, paraplegia and impaired sensitivity downward from the lesion, since through a small area cross section The spinal cord contains almost all efferent motor and afferent sensory pathways. Many diseases, especially those accompanied by compression of the spinal cord from the outside, are reversible, and therefore acute lesions of the spinal cord should be considered the most critical emergency conditions in neurology.

The spinal cord has a segmental structure and innervates the limbs and trunk. 31 pairs of spinal nerves arise from it, making anatomical diagnosis relatively simple. The localization of the pathological process in the spinal cord can be determined by the border of sensory disorders, paraplegia and other typical syndromes. Therefore, for diseases of the spinal cord, a thorough examination of the patient is required using additional laboratory tests, including nuclear magnetic resonance imaging, CT, myelography, CSF analysis and somatosensory evoked potential testing. Due to the ease of implementation and better resolution, CT and NMR are replacing standard myelography. NMR provides especially valuable information about the internal structure of the spinal cord.

Ratio anatomical structure spinal column and spinal cord with clinical symptoms

The universal organization of the spinal cord along a somatic principle makes it quite easy to identify syndromes caused by damage to the spinal cord and spinal nerves (see Chapters 3, 15, 18). The longitudinal localization of the pathological focus is established along the uppermost border of the sensitive and motor dysfunction. Meanwhile, the relationship between the vertebral bodies (or their surface landmarks, the spinous processes) and the spinal cord segments located underneath them complicates the anatomical interpretation of the symptoms of spinal cord diseases. Spinal cord syndromes are described according to the segment involved rather than the adjacent vertebra. During embryonic development, the spinal cord grows more slowly than the spinal column, so that the spinal cord ends behind the body of the first lumbar vertebra, and its roots take a more vertical downward direction to reach the structures of the limbs or innervated by them. internal organs. Rule of thumb is that. that the cervical roots (with the exception of CVIII) leave the spinal canal through the foramina above their corresponding vertebral bodies, while the thoracic and lumbar roots leave under the vertebrae of the same name. The upper cervical segments lie behind the vertebral bodies with the same numbers, the lower cervical segments are one segment higher than the corresponding vertebra, the upper thoracic ones are two segments higher, and the lower thoracic ones are three. The lumbar and sacral segments of the spinal cord [(the latter form the conus medullaris)] are localized behind the vertebrae ThIX - LI. To clarify the distribution of various extramedullary processes, especially in spondylosis, it is important to carefully measure the sagittal diameters spinal canal. Normally, at the cervical and thoracic levels, these figures are 16-22 mm; at the level of vertebrae LI-LIII - about 15-23 mm and below - 16-27 mm.

Clinical syndromes of spinal cord diseases

The main clinical symptoms of spinal cord damage are loss of sensation below the border running along the horizontal circle on the trunk, i.e., the “level of sensitivity disorders,” and weakness in the extremities innervated by descending corticospinal fibers. Sensory disturbances, especially paresthesias, may begin in the feet (or one foot) and spread upward, initially giving the impression of polyneuropathy, before a permanent border of sensory disturbances is established. Pathological lesions leading to interruption of the corticospinal and bulbospinal tracts at the same level of the spinal cord cause paraplegia or tetraplegia, accompanied by increased muscle tone and deep tendon reflexes, as well as Babinski's sign. A detailed examination usually reveals segmental abnormalities, for example a band of changes in sensitivity near top level conduction sensory disorders (hyperalgesia or hyperpathy), as well as hypotonia, atrophy and isolated loss of deep tendon reflexes. The level of conduction sensitivity disorders and segmental symptoms approximately indicate the localization of the transverse lesion. An accurate localizing sign is pain felt in the midline of the back, especially at the thoracic level; pain in the interscapular region may be the first symptom of spinal cord compression. Radicular pain indicates the primary localization of a spinal lesion located more laterally. When the lower part of the spinal cord, the conus medullaris, is involved, pain is often noted in the lower back.

In the early stage of acute transverse injury, the limbs may exhibit hypotonia rather than spasticity due to so-called spinal shock. This condition may persist for up to several weeks, and is sometimes mistaken for an extensive segmental lesion, but later the reflexes become high. In acute transverse lesions, especially those caused by infarction, paralysis is often preceded by short clonic or myoclonic movements in the limbs. Another important symptom of transverse spinal cord lesions that requires close attention, especially when combined with spasticity and the presence of a level of sensory disorders, is autonomic dysfunction, primarily urinary retention.

Considerable efforts are made to clinically distinguish between intramedullary (within the spinal cord) and extramedullary compression lesions, but most rules are approximate and do not reliably differentiate one from the other. Signs indicative of extramedullary pathological processes include radicular pain; Brown-Sequard spinal lesion syndrome (see below); symptoms of damage to peripheral motor neurons within one or two segments, often asymmetrical; early signs of corticospinal tract involvement; significant decrease in sensitivity in the sacral segments; early and pronounced changes CSF. On the other hand, hard-to-localize burning pains, dissociated loss pain sensitivity with preservation of muscular-articular sensitivity, preservation of sensitivity in the perineal area, sacral segments, late-onset and less pronounced pyramidal symptoms, normal or slightly altered composition of the CSF are usually characteristic of intramedullary lesions. “Intact sacral segments” means intact perception of pain and temperature stimuli in the sacral dermatomes, usually from SIII to SV. with rostral zones above the level of sensitivity disorders. As a rule, this is a reliable sign of an intramedullary lesion, accompanied by the involvement of the innermost fibers of the spinothalamic tract, but not affecting the outermost fibers that provide sensory innervation to the sacral dermatomes.

Brown-Séquard syndrome refers to a symptom complex of a half transverse lesion of the spinal cord, manifested by homolateral monoclial hemiplegia with loss of muscle-articular and vibration (deep) sensitivity in combination with contralateral loss of pain and temperature (superficial) sensitivity. The upper limit of pain and temperature sensitivity disorders is often determined 1-2 segments below the site of spinal cord injury, since the fibers of the spinothalamic tract, after forming a synapse in the dorsal horn, pass into the opposite lateral cord, rising upward. If there are segmental disorders in the form of radicular pain, muscle atrophy, extinction of tendon reflexes, then they are usually one-sided.

Pathological lesions limited to the central part of the spinal cord or affecting mainly it primarily affect the neurons of the gray matter and segmental conductors that intersect at this level. The most common processes of this kind are contusion due to spinal cord injury, syringomyelia, tumors and vascular lesions in the anterior spinal artery. When the cervical spinal cord is involved, central spinal lesion syndrome is accompanied by arm weakness, much more pronounced compared to leg weakness, and dissociated sensory disorders (analgesia, i.e. loss of pain sensitivity with a cape-like distribution on the shoulders and lower neck, without anesthesia, i.e. loss of tactile sensations, and with preservation of vibration sensitivity).

Lesions localized in the area of the body C or below compress the spinal nerves that make up the cauda equina and cause flaccid asymmetric paraparesis with areflexia, which is usually accompanied by dysfunction of the bladder and intestines. The distribution of sensory disorders resembles the outline of the saddle, reaches the L level and corresponds to the zones of innervation of the roots included in the cauda equina. Achilles and knee reflexes are reduced or absent. Pain radiating to the perineum or thighs is often noted. In pathological processes in the area of the conus of the spinal cord, the pain is less pronounced than with lesions of the cauda equina, and disorders of the bowel and bladder functions occur earlier; Only the Achilles reflexes fade away. Compressive processes can simultaneously involve both the cauda equina and the conus and cause a combined peripheral motor neuron syndrome with some hyperreflexia and Babinski's sign.

Classic foramen magnum syndrome is characterized by weakness of the shoulder girdle and arm muscles, followed by weakness of the homolateral leg and finally the contralateral arm. Volumetric processes of this localization sometimes give suboccipital pain, spreading to the neck and shoulders. Another evidence of a high cervical level of the lesion is Horner's syndrome, which is not observed in the presence of changes below the TII segment. Some diseases can cause sudden “stroke-like” myelopathy without previous symptoms. These include epidural hemorrhage, hematomyelia, spinal cord infarction, prolapse of the nucleus pulposus, and vertebral subluxation.

Spinal cord compression

Spinal cord tumors. Tumors of the spinal canal are divided into primary and metastatic and classified into extradural (“epidural”) and intradural, and the latter into intra- and extramedullary (see Chapter 345). The most common are epidural tumors that originate from metastases to the adjacent spinal column. Metastases from the prostate and mammary glands and lungs, as well as lymphomas and plasmacytic dyscrasias, are especially common, although the development of metastatic epidural compression of the spinal cord has been described in almost all forms of malignant tumors. The first symptom of epidural compression is usually localized back pain, often worsening when lying down and causing the patient to wake up at night. They are often accompanied by radiating radicular pain, which increases with coughing, sneezing and straining. Often pain and local tenderness on palpation precede other symptoms by many weeks. Neurological symptoms usually develop over several days or weeks. The first manifestation of spinal cord lesion syndrome is progressive weakness in the limbs, eventually acquiring all the signs of transverse myelopathy with paraparesis and a level of sensitivity disorders. Conventional radiography may reveal destructive or blastomatous changes or a compression fracture at a level consistent with spinal cord lesion syndrome; radionuclide scans of bone tissue are even more informative. The best methods for visualizing spinal cord compression remain CT, MRI and myelography. An area of horizontal symmetrical expansion and compression of the spinal cord, compressed by an extramedullary pathological formation, is noticeable along the boundaries of the blockade of the subarachnoid space; usually, changes in the adjacent vertebrae are also noted (Fig. 353-1).

In the past, emergency laminectomies were considered necessary to treat patients with extramedullary spinal cord compression. However modern technique treatment with high doses of corticosteroids and rapid fractionated radiation therapy was no less effective. The outcome often depends on the type of tumor and its radiosensitivity. The severity of paraparesis often improves within 48 hours of corticosteroid administration. For some incomplete early syndromes of transverse spinal cord lesions, surgical treatment is more appropriate, but in each case an individual analysis of treatment tactics is required, taking into account the radiosensitivity of the tumor, the location of other metastases and the general condition of the patient. But whatever treatment is chosen, it is advisable to proceed quickly and administer corticosteroids as soon as spinal compression is suspected.

Intradural extramedullary tumors are less likely to cause spinal cord compression and develop more slowly than extradural pathological processes. Meningiomas and neurofibromas are more common; hemangiopericytomas and other meningeal tumors are quite rare. Initially, radicular sensitivity disorders and asymmetrical syndrome usually occur. neurological disorders. CT and myelography show a characteristic pattern of dislocation of the spinal cord away from the outlines of the tumor located in the subarachnoid space. Primary intramedullary tumors of the spinal cord are discussed in Chapter 345.

Neoplastic compression myelopathies of all types initially lead to a slight increase in protein content in the CSF, but with the onset of complete blockade of the subarachnoid space, the protein concentration in the CSF increases to 1000-10,000 mg/l due to a delay in the circulation of CSF from the caudal sac to the intracranial subarachnoid space. Cytosis is usually low or absent, cytological examination does not reveal malignant cells, glucose levels are within normal limits, unless the process is accompanied by widespread carcinomatous meningitis (see Chapter 345).

Epidural abscess. Patients with epidural abscess can be treated, but it is often misdiagnosed in its early stages (see Chapter 346). Furunculosis predisposes to the formation of an abscess occipital region, bacteremia, as well as minor back injuries. An epidural abscess can develop as a complication of surgery or lumbar puncture. The cause of abscess formation is

Rice. 353-1. Sagittal MRI view demonstrating compressive deformation of the TXII vertebral body by metastatic adenocarcinoma (under arrows), as well as compression and displacement of the spinal cord. (Courtesy Shoukimas G., M.D., Department of Radiology, Massachusetts General Hospital.)

Which, as it increases in size, compresses the spinal cord, causing spinal osteomyelitis. The lesion of osteomyelitis is usually small and often not detected on plain radiographs. For a period of several days to 2 weeks, the patient may experience only unexplained fever and mild back pain with local tenderness on palpation; later radicular pain appears. As the abscess grows, it quickly compresses the spinal cord, and transverse lesion syndrome appears, usually with a complete interruption of the spinal cord. In this case, rapid decompression through laminectomy and drainage, followed by antibiotic therapy prescribed based on the results of culture of purulent material, is advisable. Inadequate drainage often leads to the development of chronic granulomatous and fibrotic processes, which can be sterilized with antibiotics, but which continue to act as a compressive volumetric process. Tuberculosis purulent abscesses, more common in the past, are still found in developing countries.

Spinal epidural hemorrhage and hematomyelia. Acute transverse myelopathy, which develops over minutes or hours and is accompanied by severe pain, can be caused by bleeding in the spinal cord (hematomyelia), subarachnoid and epidural space. The source of the latter is arteriovenous malformation or bleeding into the tumor during anticoagulant therapy with warfarin, but much more often hemorrhages are spontaneous. Epidural hemorrhages can develop as a result of minor trauma, lumbar puncture, anticoagulant therapy with warfarin, and secondary to hematological diseases. Back pain and radicular pain often precede the onset of weakness by several minutes or hours and are so severe that patients are forced to take strange positions when moving. A lumbar epidural hematoma is accompanied by loss of the knee and Achilles reflexes, while with retroperitoneal hematomas only the knee reflexes are usually lost. With myelography, a volumetric process is determined; CT scans sometimes show no changes because the blood clot cannot be distinguished from the adjacent bone tissue. Blood clots can form as a result of spontaneous bleeding or be caused by the same factors as epidural hemorrhages, and in the subdural and subarachnoid spaces they cause particularly severe pain. In epidural hemorrhage, the CSF is usually clear or contains few red blood cells; With subarachnoid hemorrhage, the CSF is initially bloody, and later acquires a pronounced yellow-brown tint due to the presence of blood pigments in it. In addition, pleocytosis and a decrease in glucose concentration may be detected, which gives the impression of bacterial meningitis.

Acute disc protrusion. Herniated discs in the lumbar spine are a fairly common pathology (see Chapter 7). Protrusion of the discs of the thoracic or cervical vertebrae is less likely to cause spinal cord compression and usually develops after spinal trauma. Degeneration of the cervical intervertebral discs with associated osteoarthritic hypertrophy causes subacute spondylytic-compressive cervical myelopathy, discussed below.

Arthritic diseases of the spine manifest themselves in two clinical forms: compression of the lumbar spinal cord or cauda equina as a result of ankylosing spondylitis, compression of the cervical segments during destruction of the cervical apophyseal or atlantoaxial joints in rheumatoid arthritis. Complications to the spinal cord that occur as part of generalized joint damage in rheumatoid arthritis are often missed. Anterior subluxation of the cervical vertebral bodies or atlas relative to the second cervical vertebra(CII) can lead to devastating and even fatal acute compression of the spinal cord after a minor injury, such as whiplash, or to chronic compressive myelopathy, similar to that of cervical spondylosis. Separation of the odontoid process from CII can cause narrowing of the upper part of the spinal canal with compression of the cervicomedullary junction, especially during flexion movements.

Non-compression neoplastic myelopathies

Intramedullary metastases, paracarcinomatous myelopathy and radiation myelopathy. Myelopathies in malignant diseases are mostly compression. However, if radiological studies fail to detect a block, it is often difficult to distinguish between intramedullary metastases, paracarcinomatous myelopathy and radiation myelopathy. A patient diagnosed with metastatic cancer and progressive myelopathy, the non-compressive nature of which was confirmed by myelography. CT or NMR, most likely intramedullary metastasis; Less common in this situation is paraneoplastic myelopathy (see Chapter 304). Back pain most often serves as the first, although not obligatory, symptom of intramedullary metastasis, followed by increasing spastic paraparesis and, somewhat less frequently, paresthesia. Dissociated loss of sensitivity or its intactness in the sacral segments, more characteristic of internal than external compression, are rarely observed, while asymmetric paraparesis and partial loss of sensitivity are the rule. Myelography, CT and NMR show a swollen spinal cord without signs of external compression: in almost 50% of patients, CT and myelography give a normal picture; NMR is more effective in differentiating a metastatic lesion from a primary intramedullary tumor (Fig. 353-2). Intramedullary metastases usually arise from bronchogenic carcinoma, less commonly from breast cancer and other solid tumors (see Chapter 304). Metastatic melanoma rarely causes extrinsic compression of the spinal cord and usually occurs as an intramedullary space-occupying process. Pathologically, metastasis is a single eccentrically located node, formed as a result of hematogenous dissemination. Radiation therapy is effective in appropriate circumstances.

Carcinomatous meningitis, a common form of central nervous system involvement in cancer, does not cause myelopathy unless there is widespread subpial infiltration from adjacent roots, resulting in nodule formation and secondary compression or infiltration of the spinal cord.

Rice. 353-2. Sagittal NMR image of a fusiform extension of the cervical spinal cord in an intramedullary tumor.

The tumor appears as low-density signals (shown by arrows). (Courtesy Shoukimas G., M.D., Department of Radiology, Massachusetts General Hospital.)

Incomplete cauda equina syndrome, not accompanied by pain, can be caused by carcinomatous infiltration of the roots (see Chapter 345). Patients often complain of headaches, and repeated CSF tests eventually reveal malignant cells, elevated protein levels, and in some cases, decreased glucose concentrations.

Progressive necrotizing myelopathy associated with low-grade inflammation occurs as a late effect of cancer, usually in solid tumors. The myelographic pattern and CSF are usually normal; the protein content in the cerebrospinal fluid may be only slightly increased. Subacute progressive spastic paraparesis develops over several days or weeks and is usually characterized by asymmetry; it is accompanied by paresthesia in the distal extremities, spreading upward to the formation of sensory disorders, and later by bladder dysfunction. Several adjacent segments of the spinal cord are also affected.

Radiation therapy causes late subacute progressive myelopathy due to microvascular hyalinization and vascular occlusion (see Chapter 345). It often presents a serious differential diagnostic problem when the spinal cord is within the area being irradiated for the purpose of therapeutic effects to other structures, for example to The lymph nodes mediastinum. The distinction between paracarcinomatous myelopathy and intramedullary metastasis is difficult unless there is a clear history of previous radiation therapy.

Inflammatory myelopathies

Acute myelitis, transverse myelitis and necrotizing myelopathy. This is a group of related diseases that are characterized by internal inflammation of the spinal cord and a clinical syndrome that develops over a period of several days to 2-3 weeks. It is possible to develop a syndrome of complete transverse spinal lesions (transverse myelitis), as well as partial variants, including posterior columnar myelopathy with ascending paresthesia and loss of vibration sensitivity; ascending, predominantly spinothalamic disorders; Brown-Séquard syndrome with leg paresis and contralateral sensory disorders of the spinothalamic type. In many cases the reason is viral infection. More often, transverse myelitis is manifested by back pain, progressive paraparesis and asymmetrical ascending paresthesia in the legs; later, the hands are also involved in the process, and therefore the disease can be mistaken for Guillain-Barre syndrome. To exclude the compressive nature of the lesion, it is necessary to conduct radiological studies. In most patients, the CSF contains 5-50 lymphocytes per 1 mm; sometimes more than 200 cells per 1 mm are found, occasionally polymorphonuclear cells predominate. The inflammatory process is most often localized in the middle and lower thoracic segments, but the spinal cord can be affected at almost any level. Chronic progressive cervical myelitis has been described, mainly in elderly women; this condition is considered a form of multiple sclerosis (see Chapter 348).

In some cases, necrosis is deep, can grow intermittently over several months and involve adjacent areas of the spinal cord; the latter decreases in size to a thin glial cord. This condition is referred to as “progressive necrotizing myelopathy.” Sometimes the entire spinal cord is involved in the pathological process (necrotizing panmyelopathy). If a transverse necrotic lesion occurs before or shortly after optic neuritis, then this condition is referred to as Devic's disease, or neuromyelitis optica. It seems that such processes are associated with multiple sclerosis, and many of them are variants of it. Systemic lupus erythematosus and others autoimmune diseases may also be accompanied by myelitis. Post-infectious demyelinating processes usually have a monophasic course and only rarely recur, but they are often observed various symptoms, indicating damage to the same level of the spinal cord (see Chapter 347).

Toxic myelopathy. Toxic non-inflammatory myelopathy sometimes occurs simultaneously with optic nerve atrophy. It is more common in Japan and is caused by ingestion of iodochlorohydroxyquinoline. Most patients recover, but many of them have persistent paresthesia.

Arachnoiditis. This nonspecific term refers to inflammation accompanied by scarring and fibrous thickening of the arachnoid membrane, which can lead to compression of the nerve roots and sometimes the spinal cord. Arachnoiditis, as a rule, is a postoperative complication or aftereffect from the introduction of radiocontrast agents, antibiotics and harmful chemicals into the subarachnoid space. Soon after the adverse effect, a large number of cells and a high concentration of protein can be found in the CSF, but then the inflammatory process subsides. In the acute period, a slight fever is possible. The most pronounced bilateral asymmetric radicular pain is in the extremities; signs of compression of the roots, such as loss of reflexes, are also detected. Back pain and radicular symptoms appear to be associated with lumbar arachnoiditis more often than should be the case; in addition, arachnoiditis is not a common cause of spinal cord compression (see Chapter 7). Treatment approaches are controversial; Some patients improve after laminectomy. Multiple meningeal arachnoid cysts located along the nerve roots may be a congenital anomaly. As these cysts grow, they cause deformation or stretching of the spinal nerve roots and ganglia, causing severe radicular pain in middle-aged people.

Spinal cord infarction

Since the anterior and posterior spinal arteries usually remain intact in atherosclerosis and are only rarely affected by angiitis or embolism, most spinal cord infarctions are the result of ischemia due to distant arterial occlusions. Aortic thrombosis or dissection causes spinal infarction by occluding the radicular arteries and cutting off direct arterial flow to the anterior and posterior spinal arteries. Infarction usually develops in the area of adjacent blood supply to the thoracic spinal cord between the large spinal branch of the aorta, the Adamkiewicz artery below and the anterior spinal artery above. Anterior spinal artery syndrome usually occurs suddenly, apoplectiformly, or forms in postoperative period as a result of clamping of the proximal aorta. However, in some patients, symptoms increase within 24-72 hours, making diagnosis difficult. There are isolated reports of spinal infarction with systemic arteritis, immune reactions with serum sickness, and after intravascular administration of a contrast agent; in the latter case, the harbinger is severe back pain during the injection.

Cerebral infarction, caused by microscopic fragments of a herniated disc containing the nucleus pulposus, can develop after minor trauma, often sustained during sports. In this case, acute local pain is noted, followed by rapidly onset paraplegia and transverse spinal cord lesion syndrome, developing within a few minutes to an hour. Pulpous tissue is found in small intramedullary vessels and often within the bone marrow of the adjacent vertebral body. The route of its penetration from the disc material into the bone marrow and from there into the spinal cord remains unclear. This condition should be suspected in young people with transverse spinal cord injury syndromes resulting from an accident.

Vascular malformation of the spinal cord

Arteriovenous malformation (AVM) of the spinal cord is the most difficult pathological process to diagnose, due to its inherent clinical variability. In its manifestations, it can resemble multiple sclerosis, transverse myelitis, spinal stroke, and neoplastic compression. AVMs are most often localized in the lower thoracic and lumbar spinal cord and occur in middle-aged men. In most cases, the disease begins to manifest itself as a syndrome of incomplete progressive spinal cord lesions, which can occur episodically and proceed subacutely, resembling multiple sclerosis and accompanied by symptoms of bilateral involvement of the corticospinal, spinothalamic tracts and dorsal columns in various combinations. Almost all patients suffer from paraparesis and are unable to walk for several years. Approximately 30% of patients may suddenly develop solitary acute transverse myelopathy syndrome as a result of hemorrhage that resembles acute myelitis; others experience several severe exacerbations. Approximately 50% of patients complain of back pain or radicular pain, which causes intermittent claudication, similar to that of lumbar canal stenosis; sometimes patients describe an acute onset with sharp, localized pain in the back. Changes in the intensity of pain and the severity of neurological symptoms during exercise, in certain body positions and during menstruation help in diagnosis. Murmurs under the AVM area are rarely heard, but an attempt should be made to detect them at rest and after exercise. Most patients have slightly elevated CSF protein levels, and some have pleocytosis. Hemorrhages in the spinal cord and CSF are possible. With myelography and CT, lesions are detected in 75-90% of cases if the dorsal subarachnoid space is examined with the patient lying on his back. The anatomical details of most AVMs can be detected using selective spinal angiography, a procedure that requires considerable experience.

The pathogenesis of myelopathy caused by AVMs (that did not bleed) is not well understood. Apparently, it is based on a necrotic non-inflammatory process accompanied by ischemia. Necrotizing myelopathy has been described in dorsal AVMs with a pronounced progressive intramedullary lesion syndrome. Since any necrotic process in the spinal cord can be accompanied by neovascularization and thickening of the vessel walls, there are conflicting opinions regarding the pathological basis of this vascular malformation.

Chronic myelopathies

Spondylosis. This term refers to some similar degenerative changes in the spine that lead to compression of the cervical spinal cord and adjacent roots. The cervical form occurs mainly in older people, more often in men. It is characterized by: 1) narrowing of the intervertebral disc spaces with the formation of herniation of the nucleus pulposus or protrusion of the fibrous ring; 2) the formation of osteophytes on the dorsal side of the vertebral bodies;

3) partial subluxation of the vertebrae and 4) hypertrophy of the dorsal spinal ligament and dorsolateral facet joints(see l. 7). Bone changes are reactive in nature, but there are no signs of true arthritis. The most significant factor symptomatic lesions of the spinal cord, is a “spondylytic bar” formed by osteophytes growing from the dorsal surfaces of the adjacent vertebral bodies; these osteophytes give horizontal compression to the ventral surface of the spinal cord (Fig. 353-3, a and b). The growth of the “bar” in the lateral direction, accompanied by hypertrophic changes in the joints and its invasion of the neural foramina, often leads to the appearance of radicular symptoms. The sagittal diameter of the spinal canal also decreases as a result of disc protrusion, hypertrophy, or flexion of the dorsal spinal ligament, especially during neck extension. Although radiographic signs of spondylosis are common in older adults, few develop myelopathy or radiculopathy, which is often associated with congenital narrowing of the spinal canal. The first symptoms are usually pain in the neck and shoulder, combined with limited movement; compression of the nerve roots is accompanied by radicular pain in the arm, often spreading to the CV-CVI segments. Compression of the cervical spinal cord causes slowly progressive spastic paraparesis, sometimes asymmetrical, and often paresthesia in the feet and hands. In most patients, vibration sensitivity in the lower extremities is significantly reduced; sometimes the limit of violation of vibration sensitivity is determined in the upper part of the chest. Coughing and tension often provoke weakness in the legs and radiating pain in the arms or shoulder girdle. Loss of sensitivity in segmental areas of the arms, atrophy of the muscles of the hands, increased deep tendon reflexes in the legs and an asymmetrical Babinski sign are also often found. With an advanced pathological process, an imperative urge to urinate or urinary incontinence appears. Reflexes in the hands often decrease, especially with biceps muscles shoulders, which corresponds to compression of the spinal segments CV-CVI or involvement of the roots of the same name in the pathological process. The clinical picture is dominated by radicular, myelopathic or combined disorders. This diagnosis should be assumed in cases of progressive cervical myelopathy, paresthesia in the feet and hands, and atrophy of the hand muscles. Spondylosis is also one of the most common causes of difficulty walking in older people, as well as an unexplained increase in tendon reflexes of the lower extremities and Babinski reflexes.

Radiographs reveal spondylytic “crossbars”, narrowing of the intervertebral spaces, subluxations, transformation of the normal curvature of the cervical spine and a decrease in the sagittal diameter of the canal to 11 mm or less or to 7 mm with neck extension (see Fig. 353-3, a). The CSF is usually normal or contains several increased amount squirrel. The study of somatosensory evoked potentials is very indicative, revealing normal conduction velocity along large peripheral sensory fibers and a delay in central conduction in the middle and upper cervical segments of the spinal cord.

Cervical spondylosis is diagnosed quite often. Many patients with lesions

Rice. 353-3. X-rays of the cervical spine. a - lateral radiograph of the cervical spine, demonstrating the formation of a spondylitis “crossbar” as a result of the connection of adjacent osteophytes of the CVI - CVII vertebrae (shown by arrows); b - horizontal projection of a CT scan of the same patient at the level of the CVI vertebra after instillation of a water-soluble contrast agent into the subarachnoid space. The osteophytic process compresses and deforms the spinal cord (shown by arrows). (Courtesy of Shoukimas G„ M.D., Department of Radiology, Massachusetts General Hospital.)

Spinal cord patients, especially those with amyotrophic lateral sclerosis, multiple sclerosis and subacute combined degeneration, undergo cervical laminectomy due to the fact that spondylosis is considered the cause of the existing disorders. Often there is a temporary improvement after this procedure, suggesting that spondylolytic compression may be partially responsible, but soon the myelopathy due to the underlying cause begins to progress again. On the other hand, mild, progressive disturbances in gait and sensation may be erroneously attributed to polyneuropathy.

In mild cases of the disease, rest and immobilization of the cervical spine using a soft corset are effective; in other cases, traction is indicated. Surgical intervention is recommended for those patients who have severe walking problems, significant weakness in the hands or bladder function disorders, or in the presence of an almost complete spinal block (according to myelography and CT).

Lumbar stenosis (see also Chapter 7) is an intermittent chronic compression of the cauda equina, usually caused by a congenital narrowing of the spinal canal at the lumbar level, which is aggravated by disc protrusion and spondylytic changes. Physical activity provokes dull pain in the buttocks, thighs and calves, usually spreading along the sciatic nerve; these pains subside with rest, and therefore resemble intermittent claudication of vascular origin. At the height of pain, compared to the resting state, a decrease in deep tendon reflexes and sensitivity is determined, while no changes are detected in the study of blood vessels. Lumbar stenosis and cervical spondylosis often coexist, and the former appears to be responsible for the occasional presence of fasciculations in the lower extremities in cervical spondylosis.

Degenerative and hereditary myelopathies. The prototype of hereditary diseases, causing syndromes spinal cord lesions is Friedreich's ataxia, a progressive autosomal recessive disease characterized by ataxia of the lower extremities and trunk, manifesting itself in late childhood. Intention tremor, clumsiness in the hands and later dysarthria are also observed. Kyphoscoliosis and pes cavus are common. When examining the patient, areflexia, Babinski's symptoms and gross disorders of vibration and muscle-articular sense are revealed. Fragmentary and mild forms of the disease are also observed, occurring along with other syndromes, including spastic paraparesis (Strumpell-Lauren form), cerebellar cortical degeneration with ataxia, and olivopontocerebellar atrophy.

In patients with symmetrical spastic paraparesis without sensory disorders, amyotrophic lateral sclerosis (motor neuron disease) can be assumed. It causes a pure syndrome of motor disorders with simultaneous involvement in the pathological process of the corticospinal, corticobulbar tracts and anterior horn cells. Clinical and electromyographic signs of fasciculations and muscle denervation, indicating motor neuron degeneration, support the diagnosis (see Chapters 350 and 354).

Subacute combined degeneration with vitamin B12 deficiency. This treatable myelopathy causes progressive spastic and atactic paraparesis with polyneuropathy and usually severe distal paresthesias in the feet and hands. It is necessary to remember about its possible occurrence in cases resembling cervical spondylosis, degenerative myelopathies with late start and late-onset symmetrical spinal multiple sclerosis. The pathological process also involves peripheral and optic nerves, as well as the brain. The diagnosis is confirmed by low levels of vitamin B and serum and a positive Schilling test. This condition and related nutritional degenerations are discussed in Chapter. 349. There are conflicting opinions as to whether folate or vitamin E deficiency can lead to the development of a similar syndrome. In rare cases, multiple sclerosis and B12-deficiency myelopathy are found in the same patient.

Syringomyelia. Syringomyelia is a progressive myelopathy, pathologically characterized by the formation of cavities in the central part of the spinal cord. The disease is often idiopathic or a developmental anomaly (see Chapter 351), but may also be due to trauma, primary intramedullary tumors, extrinsic compression with central necrosis of the spinal cord, arachnoiditis, hematomyelia, or necrotizing myelitis. In the developmental anomaly variant, the process begins from the middle cervical segments and then spreads upward to the medulla oblongata and down to the level of the lumbar spinal cord. Often the cavities are located eccentrically, which determines one-sided conduction symptoms or asymmetry of reflexes. In many cases, a combination with craniovertebral anomalies is observed, most often with Arnold-Chiari anomaly, as well as with myelomeningocele, basilar impression (platybasia), atresia of the foramen of Magendie and Dandy-Walker cysts (see Chapter 351).

Basic clinical symptoms syringomyelia resembles a syndrome central lesion upper cervical spinal cord and are determined by the extent of the pathological cavity and associated anomalies, for example Arnold-Chiari. Classic manifestations include: 1) loss of dissociated type of sensitivity (loss of pain and temperature while maintaining tactile and vibration) in the back of the neck, shoulders and upper extremities (distribution according to the “cape” or “cape” type) with possible involvement of the hands; 2) atrophy of the muscles of the lower neck, shoulder girdle, upper limbs, hands with asymmetrical loss of reflexes and 3) high thoracic kyphoscoliosis. More often, symptoms occur asymmetrically in the form of a unilateral decrease in sensitivity. In some patients, pain sensitivity in the facial area decreases. which is caused by damage to the nucleus of the spinal tract of the trigeminal nerve at the level of the upper cervical segments. Cough-induced headaches and neck pain are often observed in association with Arnold-Chiari malformation.

In idiopathic cases, symptoms of the disease begin in adolescents or young adults and progress unevenly, often stopping in their development for several years. Only a small number of patients do not become disabled, and more than half remain wheelchair-bound. Analgesia contributes to the appearance of injuries, burns and trophic ulcers on the fingertips. At advanced stages of the disease, neurogenic arthropathy (Charcot's joint) of the shoulder, elbow and knee joints. Severe weakness in the lower extremities or hyperreflexia indicates a concomitant abnormality of the craniovertebral joint. Syringobulbia is the result of extension of the cavity to the level of the medulla oblongata and sometimes the pons; usually the cavity occupies the lateral

Rice. 353-4. A. Horizontal view 1 hour after injection of water-soluble contrast agent into the subarachnoid space shows the cervical spinal cord surrounded by contrast agent. This substance also fills a large intramedullary cystic cavity (shown by an arrow). B. On the NMR image in the sagittal projection of the same patient, a cystic cavity and expansion of the cervical spinal cord are visible (shown by arrows). (Courtesy of Shoukimas G., M.D., Department of Radiology, Massachusetes General Hospital.)

Sections of the tectum of the brain. Paralysis can also be observed soft palate and vocal cord, dysarthria, nystagmus, dizziness, tongue atrophy and Horner's syndrome.

Slow enlargement of the cavity leads to narrowing or complete blockage of the subarachnoid space. The cavities may be separate from the central channel, but are usually connected to it. The diagnosis is made on the basis of clinical signs and is confirmed by detecting an enlarged cervical spinal cord during myelography, as well as according to the results of a CT scan performed several hours after the injection of metrizamide or other water-soluble contrast agent into the subarachnoid space (Fig. 353-4, a). Cystic cavities are best seen with nuclear magnetic resonance imaging (see Fig. 353-4, b). Due to the possibility of developmental anomalies, it is necessary additional research cervicomedullary junction.

Treatment is aimed at decompressing the cavity to prevent progressive damage and decompressing the spinal canal in the event of spinal cord enlargement. When cervical spinal cord dilation is combined with Arnold-Chiari malformation, laminectomy and suboccipital decompression are indicated.

Tabes. Taste and meningovascular syphilis of the spinal cord are rare these days, but they must be kept in mind in the differential diagnosis of most spinal cord lesion syndromes. The most common symptoms of tabes spinal cord are typical transient and recurring shooting pains, mainly in the legs and somewhat less frequently in the face, back, chest, abdomen and arms. In 50% of patients, severe ataxia of gait and legs appears, caused by loss of sense of position. In 15-30% of patients, paresthesia, bladder dysfunction, acute abdominal pain and vomiting (visceral crises) are noted. The most characteristic symptoms of tabes dorsalis are loss of reflexes from the lower extremities, impaired sense of position and vibration sensitivity, positive test Romberg, bilateral pupillary disorders, Argyll Robertson's symptom (absence of pupil constriction when illuminated with preservation of their reaction to accommodation).

Traumatic lesions of the spinal cord and its compression secondary to orthopedic pathology are discussed in the chapter on traumatic brain and spinal cord injuries (see Chapter 344).

General principles of care for patients with acute paraplegia or tetraplegia

IN acute stages paraplegia is given paramount importance to prevention secondary lesion urinary tract. Areflexia of the bladder occurs with urinary retention, the patient does not feel its filling, and therefore there is a possibility of damage to the m. detrusor due to its overstretching. Urological rehabilitation measures include bladder drainage and prevention of urinary tract infections. This is best achieved by intermittent catheterization performed by trained personnel. Alternative methods are long-term drainage using a closed system, but associated with a fairly high incidence of infectious complications, as well as suprapubital drainage. Patients with acute lesions, especially those causing spinal shock, often require special cardiovascular therapy due to paroxysmal hypertension or hypotension, and the administration of solutions is necessary to correct deviations in circulating blood volume. Potential immediate medical problems in patients with complete transverse spinal lesions include stress ulcers of the intestines and stomach. In such situations, therapy with cimetidine and ranitidine is effective.

High cervical spinal cord lesions cause mechanical respiratory failure varying degrees severity requiring artificial ventilation. In case of incomplete respiratory failure with forced vital capacity of 10-20 ml/kg, it is advisable to prescribe physiotherapy for the chest, and in order to relieve atelectasis and fatigue, especially when a massive lesion is localized below the level of CIV, a negative pressure corset can be used. In severe respiratory failure, tracheal intubation (if spinal instability is performed using an endoscope) followed by tracheostomy ensures the availability of the trachea for ventilation and suction. Electrical stimulation of the phrenic nerve in patients with localization of the pathological process at the Cy level or higher appears to be a promising new method.

As the clinical picture stabilizes, it is necessary to pay attention to the psychological state of the patient and the construction of a rehabilitation plan within the framework of realistic prospects. A vigorous program often produces good results in young and middle-aged patients and makes it possible for them to return home to continue normal image life.

Some procedures can be performed by patients themselves with the help of others. Serious problems associated with immobilization: violation of the integrity of the skin over areas of compression, urological sepsis and autonomic instability create the prerequisites for the occurrence pulmonary embolism. The patient needs to frequently change body position, use skin applications of emollients and soft bedding. Beds of a special design make it easier for the patient to turn the body and more evenly distribute body weight without predominant load on the bony protrusions. If the sacral segments of the spinal cord are preserved, automatic emptying of the bladder can be achieved. At first, patients urinate reflexively in the intervals between catheterizations, and later learn to induce urination using various techniques. If the presence of residual urine can lead to infection, then surgical procedures or placement of an indwelling catheter are necessary. Most patients need to monitor bowel function and have bowel movements at least twice a week to avoid bowel distension and obstruction.

Severe hypertension and bradykinesia occur in response to negative surface stimuli, distension of the bladder or bowel, or surgical manipulation, especially in patients with damage to the cervical or upper thoracic spinal cord. Hypertension may be accompanied by severe redness and profuse sweating in areas above the level of the lesion. The mechanism of these autonomic disorders not clear enough. In this regard, the prescription of antihypertensive drugs is required, especially during surgical operations, but the use of beta blockers is not recommended. In some patients, severe bradycardia occurs as a result of tracheal aspiration; this can be avoided by administering small doses of atropine. A serious complication in early period represents an embolism pulmonary artery against the background of immobilization; it is observed in approximately 30% of patients after acute spinal cord injury.

Spinal cord diseases are a large group various pathologies, which differ in some ways. The spinal cord, located in the center of the spinal column, plays a huge role in the nervous system. Therefore, it is important to know the diseases themselves, their symptoms, and start therapy on time.

Spinal cord diseases have many symptoms. This organ is divided into specific segments that communicate with a specific pair of nerve endings. Each such pair is fully responsible for the functioning of certain organs. The fibers of the gray matter are crossed, it is for this reason that the pathology on the left side is a direct violation on the right.

Spinal cord tissue consists of two elements: gray matter ( nerve cells) And white matter(shoots). Its length is approximately 45 cm, it regulates all functions of the body, and its work occurs through the transmission of impulses.

Symptoms may vary in severity. The mildest of these are dizziness and nausea, as well as muscle soreness, which appears periodically. Depending on the intensity of the sensations, the condition may worsen.

Frequent and dangerous signs are considered to be motor disorders, that is, limitations of movement with complete or partial paralysis. This is accompanied by increased tone in muscle tissue. Usually such violations are symmetrical, but in some cases there may be exceptions.

Sensory impairment depends on the location of the disease and its degree. It can be superficial, temperature or painful. Autonomic disorders are accompanied by high fever and severe sweating. At the same time, metabolism is disrupted, the nature of stool and urination changes. When the nerves are pinched, the pain symptoms go to the hands. If the lower back is affected, pain will be felt in the lower extremities.

In addition to the main symptoms that accompany the disease, it can be expressed in:

uncontrolled bowel movements;
muscle soreness;
muscle atrophy.

Compression diseases of the spinal cord

Some pathologies can cause pinching of the spinal cord canal, which is called compression. In this case, the functions of this organ are always impaired. This process can be caused by diseases such as otitis media and sinusitis. When they last for a long time, meningitis and encephalitis appear. There is also a risk of compression from hemorrhages that occur as a result of injuries or problems with the walls of blood vessels. In addition, tumors, osteochondrosis, hernia and arthritis are dangerous.

Brain tumors

Absolutely any neoplasms in the spinal cord are dangerous, so greater importance is paid not to malignancy, but to the location of the tumor. Typically, three groups of such formations are distinguished: extradural, intradural and intramedullary.

Extradural ones are the most dangerous and progress faster than others. They appear in the vertebrae or hard tissue of the brain. Intradural occur under the hard tissue of the spinal cord membrane. Intramedullary are located in the brain itself.

Tumors are treated only with surgery, which is not always successful. Restorative therapy is prescribed only after successful surgery, otherwise it will be ineffective.

Intervertebral hernia

The most common of all back diseases are herniated discs. Initially, a protrusion is formed, and only after a while a hernia occurs due to the rupture of the fibrous ring, which performs the fixing function of the disc core.

After the rupture occurs, all the fluid begins to flow out and, most often, it enters the spinal canal. If the disease affects the spinal cord, myelopathy (destruction of the substance of the spine) begins to develop.

There are cases when the disease does not manifest itself in any way, and the patient feels great, but when the spinal cord is involved in the disease, the following symptoms appear:

pain in the affected area;
change in sensitivity;
loss of limb control;
weakness;
disruption of internal organs;
pain extends from the lower back to the kneecap.

These signs appear when the hernia reaches huge size. For treatment, therapeutic effects are used, using medications and physiotherapy.

Radiation and paracarcinomatous myelopathy are considered diseases that are difficult to distinguish between. MRI shows severe swelling of the spinal cord, which is treated with radiation therapy.

Necrotizing myelopathy at the time of exacerbation simultaneously affects several parts of the spinal canal. The reason for this is severe cancerous growths, which are accompanied by inflammation. Patients may experience partial or complete paralysis, and possible pelvic organ disorders.

Carcinomatous meningitis arises from carcinoma. In some cases, it does not cause myelopathy, provided that there is no discrepancy along the nerve roots, which causes infiltration of the spinal canal and provokes acute compression.

The cause of a heart attack is often a severe disruption of spinal circulatory circulation, which results in a severe malfunction of the spinal cord, since blood flows to it with great difficulty. This can happen in any spinal region. The one that is more severely affected develops a heart attack.

Most often, it is very difficult to determine the true reason why a heart attack occurred. But the most common is the formation of blood clots in small blood vessels. They supply blood to the spinal cord even when damage to the extravertebral arteries occurs.

Most often, people over the age of 50 suffer from this disorder, and in patients under the age of 40, a heart attack occurs due to aortic pathologies and vasculitis.

The development of a heart attack occurs during the formation of thrombosis or at the time of aortic dissection. But it can also appear for other reasons - with arteritis and serum sickness. General ischemic infarction is often caused by impaired spinal circulatory circulation or myeloschaemia. When a heart attack occurs, several parts are affected at once.

The cause of a heart attack can be a minor injury, for example, during sports. In this case, it is caused by a microparticle breaking off from a herniated intervertebral disc.

Symptoms of spinal cord diseases are very diverse. Severe pain occurs in the back area, sensitivity, both pain and temperature, decreases. In some cases, bilateral flaccid paralysis of the limbs occurs. Signs of a spinal infarction are constant pain in the head, nausea and weakness, which are accompanied by fainting.

Inflammatory myelopathies

Spinal cord diseases can activate the inflammatory process. This syndrome usually develops over several days or weeks. The most common cause is an infectious disease.

If myelitis worsens, the patient complains of pain in the back and severe weakness in the muscle corset, which develops very quickly. In addition, paresthesia may occur in the lower extremities.

When the spinal cord is infected by a virus, specific types of myelitis can occur. Herpes zoster is a common cause of the disease.

Another disease is arachnoiditis - an inflammatory process in the spinal cord and brain. It is he who amazes arachnoid membrane. There are many reasons for its appearance. These are diseases of various types and severity, injuries and inflammatory processes in the nasal sinuses. When prescribing treatment, the infectious source is first eliminated; for this purpose, antibiotics and various therapies are prescribed.

Chronic myelopathies

Chronic diseases can be localized in various areas and express yourself in different ways.

One common cause is spondylosis. It is dangerous because it can cause severe changes in the intervertebral discs. These disorders cause compression abnormalities in the spinal cord and nerve roots. It can be localized in the thoracic, cervical and lumbar regions.

Spondylosis causes salt deposition, which significantly narrows the canals of the spinal column and the openings between the vertebrae. Its complication is the formation of hernias between the vertebrae.

The disease itself is the next stage in the development of osteochondrosis and actively progresses with poor nutrition of the spine, injuries and physical activity. This disease spreads among the male population over 40 years of age. The key symptom is pain after exercise, hypothermia and sudden movements. In some cases, the movement of the spinal column may be limited.

Treatment is prescribed depending on the degree and symptoms of the spinal cord disease, but it is always comprehensive and aimed at slowing the course of the disease, relieving pain and symptoms, as well as preventing possible complications. They use massage, physiotherapy and medications.

Another chronic illness- This is lumbar stenosis. The disease causes a narrowing of the central canal in the spinal column, resulting in compression in the spine and nerve endings. Pathology is divided into two types:

Congenital stenosis. Appears due to a narrow passage in the spinal canal and certain features of the vertebrae and their anomalies.
Acquired stenosis. Caused by displacement of the vertebrae or their reduction, which occurred after an injury. The disease can cause tumors, disc protrusions, or hernias.

Diagnosis of the disease is carried out using MRI. For treatment, a conservative method is used, and in some cases, surgical intervention is possible.

Vascular diseases

Spinal cord vascular disease is caused by disorders in the vascular system. They can develop due to compression damage or at the time of changes in the walls, as well as with congenital anomalies.

There are cases when the cause of vascular abnormalities is anomalies in the structure of the capillaries themselves, as well as disturbances in the venous beds. Such deviations may not manifest themselves for many years. They can progress in different ways.

Treatment of these diseases is prescribed with extreme caution, and only after a complete examination with precise positioning diagnosis. Incorrectly selected methods for treating spinal cord disease can cause worsening of the condition. In such cases, the disease begins to actively progress.

In addition to the standard complex treatment in some cases, surgical intervention is required to restore blood circulation in the spinal cord.

If the examination reveals acute or complicated abnormalities in the circulatory and vascular system, then further examination is carried out at the same time, repeated tests and medications are prescribed that will relieve symptoms and improve general state sick.

Abnormalities in the spinal cord if not started timely treatment, may cause serious complications. Study self-treatment in this case it is unacceptable, since the condition can worsen. It is recommended to undergo a full examination, establish the true causes of the disease and begin treatment, which in some cases is prescribed individually.

The spinal cord is an element of the central nervous system. It is located in the spinal canal, which is formed by the vertebral foramina. It originates from the foramen magnum, which is located at the level of the connection of the first cervical vertebra with the occipital bone. And the end is located in the gap where the first and second lumbar vertebrae border. When spinal cord diseases affect the body, the quality of life decreases and there is a risk of death, because they differ in severity.

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At the level of the cervical spine

Pathology of the spinal cord at different levels is called myelopathy. Myelopathy of the cervical spine is a very serious process, because if it is affected, there is a high probability of death. Operations in this department are very dangerous; they are carried out only if the risk is justified by preserving human life:

hernia between the vertebrae;
myelitis;
congenital pathologies;
pinching;
infection;
injury.

There are cases when the symptoms of pathology are complications after punctures. It happens that the disease develops due to an unsuccessful operation.

The spinal cord is responsible for the optimal functioning of the nervous system. Of course, cervical myelopathy makes negative adjustments to it. Often neck myelopathy is accompanied by the following symptoms:

the appearance of severe pain in the neck, in the back of the head, between the shoulder blades;
muscle spasms occur;
arms become weak;
upper limbs twitch involuntarily;
the skin of the hands and neck becomes numb.

Myelopathy therapy requires very serious treatment! If you thinklessly treat this disease, then irreversible changes will begin in the body. Complete atrophy of the spinal cord will occur, paralyzing the limbs. And it will be almost impossible to restore their previous activities.

Acute disc protrusion

Protrusion of the cervical spine occurs when the supply of nutrients to the intervertebral discs is disrupted. If the power needed for normal operation is missing, then serious changes begin:

the structure of the core changes (the jelly-like state becomes very dense);
the fibrous membrane loses its elasticity;
the core cannot remain in its normal position;
the disc begins to shift, extending beyond the vertebrae;
depreciation deteriorates.

If the disc protrudes beyond the vertebrae even by one millimeter, then there may be unpredictable consequences. It is possible that compression of the nerve roots and arteries of the spine will occur, which will lead to inflammation, pain and poor circulation. Protrusion has symptoms that depend on how much the disc has protruded and the degree of compression of the nerve roots:

mobility is limited;
pain in the cervical region;
neck muscle spasms;
tingling feeling;
weakness of muscle tissue in the arms;
numbness;
edema;
my hands hurt, namely their muscles.

The disease can affect any segment of the cervical spine. If you do not go to the doctor in time, the spinal canal will protrude further and a hernia will form. Disc protrusion is treated with conservative methods.

Hydromyelia

This congenital pathology characteristic expansion of the spinal cord canal. It affects its trunk and cervical region. Hydromyelia is often accompanied by hydrocephalus. The main reason for its appearance is congenital anomaly channel. Enlargement of the spinal cord canal occurs and develops secondary to the influence of certain pathological changes in the body. Often secondary hydromyelia develops due to the formation of excess fluid, which occurs when the spinal cord is compressed or a cerebellar tumor.

The spinal canal in this disease is lined with ependyma, the boundaries of the canal are expanded from the outside, and fluid from the inside. The development of hydromyelia is often provoked by thinning of the posterior columns of the spinal cord.

It happens that a congenital defect is accompanied by diseases such as lateral aperture of the 4th ventricle, median atresia and internal hydrocephalus. Hydromyelia usually occurs without symptoms. This disease is treated only after identifying the cause that provoked it. It can be completely eliminated through surgery.

At the thoracic level

Myelopathy at the thoracic level occurs very rarely, because it is usually caused by an intervertebral herniation affecting the thoracic spinal cord disc. In general, only 1% of intervertebral hernias occur in this area of the spine. This is due to the special structure of the thoracic region.

Although its treatment is also hampered by the specific structure. It is most often treated with surgery. It happens that myelopathy of this section is mistaken for tumors or foci of inflammatory processes.

Thoracic myelopathy is common. It progresses in the thoracic spine. Usually its provocateur is a hernia in the lower part of the sternum or an abnormally narrow diameter of the canal in the spine. It is especially dangerous if the narrowing is located at the site of the blood supply.

Spinal cord infarction

Infarction can occur at various levels of the spinal cord. The clinical picture is determined by the level of damage and individual characteristics blood supply, taking into account the localization of areas of adjacent blood supply. If a person has arterial hypotension, then this disease will appear in an area that is poorly supplied with blood.

It is usually caused by lesions of the extravertebral arteries. It is accompanied by the following symptoms: sharp and severe pain in the back, decreased or even loss of sensitivity. Diagnosed using MRI. Treatment is most often symptomatic.

Discogenic radiculopathy

It is also called vertebral myelopathy. It is noteworthy that it occurs as one of the complications that was provoked by the formation of intervertebral hernias. It appears as a result of a long process of degeneration. Hard disc herniations occur, which are actually growing bone bodies of the vertebrae. They strongly compress the spinal arteries and spinal cord.

Sometimes complications arise, and hemorrhage may begin in the spinal cord. Because the nerve roots are connected by tissue to the intra-abdominal organs, when they are compressed, severe pain is felt. They are similar to pain syndrome during stomach spasms, diseases of the pancreas, liver and spleen.

To determine the cause of this discomfort, perform unusual testing. Change your position or sit straight in a chair without feeling any pain and rotate your torso. If the cause is discogenic radiculopathy, you will feel pain when turning.

Arteriovenous malformation

This is a very serious pathology blood vessels. Often such vascular anomalies affect the body of young people. Sometimes they are localized in the chest and cervical regions spine. An important symptom The disease includes severe headaches. Associated symptoms include ringing in the ears, nausea, cramps and vomiting.

The reasons for the formation of vascular malformation of the spinal cord have not yet been clearly elucidated. It is assumed that vascular disorders are a congenital problem that in the future progresses into this type of pathology.

At lumbar level

This type of myelopathy is localized in the lumbar region and affects the spinal cord. Its syndromes and accompanying symptoms:

When compression of the spinal cord occurs between the first lumbar and tenth thoracic vertebrae epiconus syndrome appears. It provokes radicular pain in the lumbar region, near the hips and lower legs. Characterized by slight weakness of the legs. At the same time, reflex abilities, such as Achilles and plantar, are reduced. The sensitivity of the outer hindfoot and lower leg begins to deteriorate.
When compression forms at the level of the 2nd lumbar vertebra, conus syndrome begins to develop. The pain is not severe, but disturbances in the functioning of the rectum and genitourinary system occur. Sensitivity changes in the anogenital area. Bedsores may appear and there is no anal reflex.
When compression of the 2nd disc and lumbar root, located lower than the vertebrae, progresses, cauda equina syndrome occurs. It is characterized by severe painful painful sensations in the lower part of the body, they radiate to the limbs. There is a possibility of developing paralysis.

Vascular malformation

Pathology is the cause of hemorrhagic ischemic diseases. A very common form of vascular malformation is venous hemangioma. Accompanied by cramping pain that intensifies when you lie down. If vascular thrombosis occurs, the symptoms intensify.

With arteriovenous angiomas, the symptoms of a spinal cord disease take the form of slow tissue compression due to a tumor. With thrombosis, acute pain occurs and motor and sensory activity is impaired. Treatment includes endovascular vascular obliteration techniques.

Ischemic processes take precedence over hemorrhagic ones. In most cases, cerebral vessels degrade. The clinical picture is interconnected with the compensatory capabilities of blood flow. Most often the lumbar and cervical regions are affected.

Arthritic diseases

Rheumatoid arthritis of the spine is a chronic inflammatory disease. It is characterized by damage to the connective tissue of the spine and causes damage to the spinal cord. These diseases are characterized by two clinical forms. The first is compression of the lumbar spinal cord or ankylosing spondylitis of the cauda equina. The second is compression of segments during the destruction of joints in rheumatoid arthritis.

Complications on the spinal cord arise as a result of one of the elements of generalized joint damage in rheumatoid arthritis. This complication is often overlooked. Any signs of illness should not be tolerated. If you notice any changes in your body, consult a doctor. It will help you not only relieve symptoms, but also find out what kind of disease you have.

Video “Symptoms of spinal cord damage”

From this video you will learn about the symptoms that indicate spinal cord damage.

Signs and symptoms: The main clinical signs of spinal cord diseases are: loss of sensation below a certain level (“sensitivity disorder level”), accompanied by muscle weakness and spasticity of the limbs.

Sensory disorders: Frequent paresthesia; they may develop in one or both feet and spread upward. The level of pain or vibration sensitivity disorders often coincides with the localization of the level of transverse spinal cord lesions.

Movement disorders: Rupture of the corticospinal tracts causes quadriplegia or paraplegia with increased muscle tone, increased deep tendon reflexes and positive symptom Babinsky.

Segmental signs: There are indicative indicators of the level of damage, for example, a streak of hyperalgesia or hyperpathy, decreased tone and atrophy of individual muscles with loss of tendon reflexes.

Autonomic dysfunctions: First, urinary retention, which should raise suspicion of spinal cord disease when combined with spasticity and (or) sensitivity disorders at a certain level.

Pain: Midline back pain has diagnostic value for localizing the level of the lesion; pain between the shoulder blades may be the first sign of compression of the spinal cord at the level of the middle part of the thoracic spine; radicular pain may indicate a more laterally located lesion; pain that occurs when the lower part of the spinal cord (conus medullary) is damaged can radiate to bottom part backs.

Lesions at or below the level of the L 4 vertebrae: Damage to the cauda equina causes the development of flaccid asymmetrical paraparesis with absence of reflexes, dysfunction of the bladder and rectum, loss of sensitivity from the L level; Usually there is pain radiating to the perineum or thighs. Damage to the conus medullary does not cause pain, but entails an earlier onset of symptoms of bladder and rectal dysfunction. Compression injuries of the conus and cauda equina simultaneously (cauda equina) can cause the combined development of signs of peripheral motor neuron damage and hyperreflexia or a positive Babinski reflex. (This combination of symptoms is usually observed when not only the cauda equina and conus are affected, but also the spinal cord at the level of the lumbar enlargement. Note ed.).

Lesions at the foramen magnum level: In typical cases, muscle weakness of the shoulder and arm is accompanied by ipsilateral and then contralateral involvement of the leg and finally the contralateral arm; The presence of Horner's syndrome suggests involvement of the cervical spine.

Extramedullary lesions: Accompanied by radicular pain, Brown-Séquard syndrome, signs of asymmetric segmental damage to lower motor neurons, early corticospinal signs, sacral sensory loss, early manifestations CSF pathologies.

Intramedullary lesions: Accompanied by burning pain, the localization of which is difficult to determine, loss of pain sensitivity with a preserved sense of joint position, with preservation of perineal and sacral sensations, less pronounced corticospinal signs; CSF is normal or slightly abnormal.

Etiology:

Spinal cord compression:1. Spinal cord tumors: primary or metastatic, extra- or intra-radural; most of them are epidural metastases from adjacent vertebrae; the most common malignant tumors affect the prostate gland, chest, lungs, lymphomas, plasmacytic dyscrasias; The first symptom is usually back pain, which is worse when lying down, with painful points, this symptom precedes other symptoms by many weeks.

2. Epidural abscess: initially, fever of unknown etiology with aching spinal pain and pain points, then radicular pain develops; soon after the development of neurological symptoms, compression of the spinal cord rapidly increases.

3. Spinal epidural hemorrhage and hematomyelia: manifests itself as acute transverse myelopathy, developing within minutes or hours against a background of severe pain. Causes: minor injury, lumbar puncture, anticoagulant therapy, hematological disorders, arteriovenous anomalies, tumor hemorrhage. The etiology of most of these disorders is unclear.

4. Acute protrusion of the intervertebral disc: formation of a herniated disc in the cervical and thoracic regions occurs less frequently than in the lumbar (see Chapter 5).

5. Acute injury with spinal fracture or dislocation: may not manifest as myelopathy until mechanical pressure causes further displacement destabilized spine.

6. Chronic compression myelopathies: a) cervical spondylosis; b) narrowing of the spinal canal at the lumbar level: intermittent and chronic compression of the cauda equina, associated with congenital narrowing of the lumbar canal and provoked by disc protrusion or spondylitis.

Noncompressive neoplastic myelopathies. Intramedullary metastases, paracarcinomatous myelopathy, complications after radiation therapy.

Inflammatory myelopathies

1. Acute myelitis, transverse myelitis, necrotizing myelopathy: the disease develops over several days with the manifestation of sensitive and motor symptoms, often involving the bladder. May be the first sign of multiple sclerosis.

2. Infectious myelopathy: herpes zoster with preceding radicular symptoms and rash, most often viral nature; also occurs during infection with lymphotropic retrovirus, HIV, and poliomyelitis.

Vascular myelopathies. Spinal cord infarction, vascular development abnormalities.

Chronic myelopathies. Spondylosis, degenerative and hereditary myelopathies, subacute combined degeneration (vitamin B 12 deficiency), syringomyelia, tabes dorsalis.

Instrumental studies

Plain radiography, CT scan of the spine to detect fractures and curvatures of the spinal column, as well as to determine possible metastases in the spine. MRI serves as a rapid, high-resolution assessment modality, especially for the diagnosis of intramedullary lesions, and is preferable to conventional myelography. Analysis of CSF for the presence infectious process, multiple sclerosis, carcinoma. Somatosensory evoked responses may be pathological.

Treatment:

Compression caused by tumor: For epidural metastases - large doses of glucocorticoids (to reduce swelling) and local irradiation of metastases, with or without chemotherapy; surgery is used if the tumor is insensitive to radiation therapy or cannot be treated maximum doses irradiation. Surgical removal of the tumor is indicated for neurofibromas, meningiomas or other extramedullary tumors.

Epidural abscess: Usually requires emergency surgery to drain the abscess and bacteriological research followed by a course of intravenous antibiotics.

Epidural hemorrhage, or hematomyelia: If access is available, the clot is immediately removed. The causes of dyscrasia leading to hemorrhage should be established and, if possible, eliminated or corrected. Diagnosis of arteriovenous developmental anomalies can be made using MRI, myelography or arteriography of segmental spinal arteries.

Acute disc protrusion, spinal fracture or displacement: Requires surgery.

Complications: Urinary tract injury associated with urinary retention due to bladder distension and damage to the bladder detrusor muscle; paroxysmal hypertension or hypotension with volume disturbances; ileus and gastritis; with high cervical spinal cord injuries - mechanical respiratory failure; severe hypertension and bradycardia in response to irritation or distension of the bladder and bowel; urinary tract infections; bedsores; TELA.