Lecture Notes on Myelopathy

Introduction

• Speaker: Dr. Rybinnik
• Objective: Understanding spinal disorders, with a focus on myelopathy.
• Outcome: Condensed treatment algorithm at the end.
• No relevant disclosures.

Objectives of the Talk

1. Review 6 common chief complaints suspicious for myelopathy.
2. Review spinal cord anatomy (6 common patterns of cord lesions).
3. Differentiate between extramedullary and intramedullary lesions.
4. Differentiate 7 major pathological categories.
5. Discuss 5 neurodiagnostic tools.
6. Overview of available treatments.

Case Presentation

• Patient: 40-year-old woman, previously healthy.
• Symptoms:
  • Progressive weakness in all extremities (started in the right arm).
  • Back pain (described as "electricity shooting" down her spine, improved with flexion).
  • Paresthesias in upper extremities.
  • Denied bowel/bladder issues, weight loss, drug use, etc.
• Initial Evaluation:
  • Normal vital signs and mental status.
  • Significant flaccid weakness in all four extremities (better in legs).
  • Significant sensory loss below clavicle.
  • Reflexes preserved.
  • Needs assistance to walk.
• Diagnosis: Myelopathy.

Chief Complaints in Myelopathy

• **Common Symptoms: **
  • Back pain (may worsen with extension, improve with flexion).
  • Weakness depends on the level of the cord lesion.
  • Unsteady gait (due to weakness or disturbed position sense).
  • Neurogenic claudication (pain/cramping in calves after walking).
  • Bowel/bladder dysfunction (damage to descending pathways).
  • Sensory level (specific complaint).

Spinal Cord Anatomy

• Key Pathways:
  • Dorsal columns (vibration, proprioception, fine touch).
  • Spinothalamic tract (pain, temperature, crude touch).
  • Lateral corticospinal tract (voluntary motor control).
• Lesion Types:
  • Transverse Cord Lesion: Bilateral weakness, sensory level 1-2 segments below lesion.
  • Brown-Sequard Syndrome: Hemicord injury causes ipsilateral weakness and sensory loss (vibration/proprioception), contralateral pain/temp loss.
  • Dorsal Lesions: Sensory ataxia (stomping gait).
  • Anterior Cord Lesion: Loss of motor function and pain/temperature sensation, sparing of proprioception.
  • Central Cord Syndrome: Sensory dissociation; arms affected earlier than legs.

Extramedullary vs. Intramedullary Lesions

• Extramedullary: Painful early, often compressive.
• Intramedullary: Can also be painful, involves sensory pathways.

Vascular Causes of Myelopathy

• Ischemia: Common causes include aortic branch issues, clots, and trauma.
• Hemorrhage: Epidural hematoma is a possible cause.

Infectious Causes of Myelopathy

• Common Pathogens:
  • Bacterial: Staph aureus, TB, Lyme disease.
  • Viral: Herpes, West Nile, HIV.
  • Fungal: Coccidioides, Cryptococcus.
  • Parasitic: Schistosoma.

Immune-Mediated Myelopathies

• Examples: Multiple sclerosis, neuromyelitis optica (NMO), ADEM, paraneoplastic syndromes.
• Clinical Clues: Early presentation, Lhermitte phenomenon.

Treatment Overview

• Acute Management:
  • Steroids (e.g., Methylprednisolone).
  • Plasma exchange.
• Infectious Causes: Antibiotics, antivirals, antifungals.
• Vascular Causes: Supportive care, surgical evacuation for hematomas.
• Structural Causes: Conservative (collars, NSAIDs) or surgical management (decompression).
• Toxic Causes: Remove toxins, replace deficiencies.
• Hereditary Causes: Supportive care, possible gene therapy.

Conclusion

• Case Diagnosis: Neuromyelitis Optica.
• Treatment: Steroids and plasmapheresis, transitioned to Rituximab.
• Key Takeaway: Myelopathy presents with diverse symptoms and requires a thorough workup for accurate diagnosis and treatment.

Final Thoughts

• Encourage to ask questions for clarification on the discussed topics.