Diseases of the spinal cord are frequently devastating. They produce quadriplegia, paraplegia, and sensory deficits far beyond the damage they would inflict elsewhere in the nervous system because the spinal cord contains, in a small cross-sectional area, almost the entire motor output and sensory input of the trunk and limbs. Many spinal cord diseases are reversible if recognized and treated at an early stage (Table 456-1); thus, they are among the most critical of neurologic emergencies. The efficient use of diagnostic procedures, guided by knowledge of the anatomy and the clinical features of spinal cord diseases, is required to maximize the likelihood of a successful outcome.
TABLE 456-1Treatable Spinal Cord Disorders |Favorite Table|Download (.pdf) TABLE 456-1 Treatable Spinal Cord Disorders
| Epidural, intradural, or intramedullary neoplasm |
| Epidural abscess |
| Epidural hemorrhage |
| Cervical spondylosis |
| Herniated disk |
| Posttraumatic compression by fractured or displaced vertebra or hemorrhage |
| Arteriovenous malformation and dural fistula |
| Antiphospholipid syndrome and other hypercoagulable states |
| Multiple sclerosis |
| Neuromyelitis optica |
| Transverse myelitis |
| Sarcoidosis |
| Sjögren-related myelopathy |
| Systemic lupus erythematosus-related myelopathy |
| Vasculitis |
| Viral: VZV, HSV-1 and -2, CMV, HIV, HTLV-1, others |
| Bacterial and mycobacterial: Borrelia, Listeria, syphilis, others |
| Mycoplasma pneumoniae |
| Parasitic: schistosomiasis, toxoplasmosis |
| Syringomyelia |
| Meningomyelocele |
| Tethered cord syndrome |
| Vitamin B12 deficiency (subacute combined degeneration) |
| Copper deficiency |
APPROACH TO THE PATIENT: Spinal Cord Disease SPINAL CORD ANATOMY RELEVANT TO CLINICAL SIGNS
The spinal cord is a thin, tubular extension of the central nervous system contained within the bony spinal canal. It originates at the medulla and continues caudally to the conus medullaris at the lumbar level; its fibrous extension, the filum terminale, terminates at the coccyx. The adult spinal cord is ~46 cm (18 in.) long, oval in shape, and enlarged in the cervical and lumbar regions, where neurons that innervate the upper and lower extremities, respectively, are located. The white matter tracts containing ascending sensory and descending motor pathways are located peripherally, whereas nerve cell bodies are clustered in an inner region of gray matter shaped like a four-leaf clover that surrounds the central canal (anatomically an extension of the fourth ventricle). The membranes that cover the spinal cord—the pia, arachnoid, and dura—are continuous with those of the brain, and the cerebrospinal fluid is contained within the subarachnoid space between the pia and arachnoid.
The spinal cord has 31 segments, each defined by an exiting ventral motor root and entering dorsal sensory root. During embryologic development, growth of the cord lags behind that of the vertebral column, and the mature spinal cord ends at approximately the first lumbar vertebral body. The lower spinal nerves take an increasingly downward course to exit via intervertebral foramina. The first seven pairs of cervical spinal nerves exit above the same-numbered ...
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