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Spinal Cord - Spinal Cord Lesion

 

LMN signs at level of a spinal cord lesion, and UMN below.

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Note that if the patient has spastic paraparesis (bilateral weakness with upper motor neuron signs), if you work along the neuroaxis, a spinal cord lesion is not the sole site/explanation (see differentials below). Hence, whilst this script is practising for someone who may have a spinal cord lesion with a spinal sensory level, if the presentation is solely spastic paraparesis, then you need to discuss the potential differentials.

 

Thank you for asking to me to examine Harry who presented with difficulty walking.

 

The salient findings on examination was symmetrical weakness affecting both/proximal/distal distribution with upper motor neuron signs with a sensory level at ___, most consistent with spastic paraparesis due to a spinal cord lesion at ___.

 

In further detail...

 

The patient was comfortable with nil apparent gait aids.

 

There was a surgical scar over the thoracic/lumbar spine. There was/was not obvious deformity.

 

There was a scissor-gait, suggestive of paraparesis. The patient could/could not walk heel to toe, suggesting the presence/absence of a cerebellar pathology. The patient could/could not walk on their toes (S1), and the heels (foot drop, L4 or L5). Romberg’s sign was negative/positive. (eyes closed - posterior columns, eyes open - cerebellar).

 

On inspection of the legs, there were/were not scars. There was muscle wasting with contractures. There were no fasciculations. 

 

There was/was not muscle tenderness. Tone was increased in the knee and ankle, and there was clonus.

 

Power was reduced symmetrical with __/5 power on the left leg, and __/5 power on the right.

 

There was hyperreflexia in the knee and ankle. Plantar response was upgoing/inadequately assessed due to withdrawal.

 

Coordination was normal.  

 

Sensation was reduced symmetrically with a sensory level at ____. Pinprick, vibration and proprioception were all impaired, suggesting involvement of both the dorsal and spinothalamic columns.

 

On examination of the upper limbs...

 

In summary, my findings are consistent with spastic paraparesis secondary to a spinal cord lesion with evidence of previous surgery. This may represent a previous tumour, abscess, or trauma.

  • Alternatively, "my findings are consistent with spastic paraparesis. Localising this along the neuroaxis..."

 

The findings are suggestive of a spastic paraparesis. Differentials include:

  • Hereditary spastic paraparesis (caused by length dependent degeneration of the corticospinal tract) - usually minimal sensory deficits although there can be

  • Hereditary ataxias with spasticity such as certain spinocerebellar ataxias and Friedreich’s ataxia

  • Spinal cord lesions

    • Extrinsic

      • Degenerative/osteophytes/bulge

      • Compression from tumours or abscess

      • Trauma

    • Intrinsic

      • Vascular malformations or infarcts

      • Subacute combined degeneration (weakness, sensory ataxia, spasticity, paraesthesias, preserved pain/temperature)

    • Specific cord syndrome

      • Anterior (anterior spinal artery)

      • Brown Sequard

      • Central (pain/temperature and UMN weakness arm > legs)

      • Subacute

  • Brain lesions

    • Cerebral palsy

    • Other - tumour, vascular, demyelinating

  • Demyelinating disorders such as:

    • Progressive MS

    • Neuromyelitis optica

  • Motor neuron disease

    • Including motor only form

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For further information about spinal cord lesions, and spinal cord syndromes, check out this Twitter thread - https://mobile.twitter.com/AaronLBerkowitz/status/1270934939534426112

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