SPINAL DISORDERS: Points in differential diagnosis

MNEMONIC Vascular Infectious B12 Deficiency Radiation ALS Tumor, Trauma & Toxic Epidural Abscess & Electricity Developmental & Hereditary Spondylosis & Spine Paraneoplastic & Parasagittal Arachnoiditis Syringomyelia Multiple Sclerosis & Myelitis Systemic Disorders SPINAL LEVELS Motor Sensory C3 Post neck & ear C4 Upper neck C5 Deltoid Shoulder C6 Pronator Thumb C7 Ticeps Middle finger C8 Intrinsic hand 5th finger L1 Hip flex Groin L2 Hip flex Ant-Med thigh L3 Knee ext Cent thigh L4 Knee ext Med leg L5 Ankle dorsiflex Large toe S1 Toe plantarflex Lateral foot FOCAL LESIONS AVM Fluctuating signs Slow progression Radiation Partial Brown-Squard Epidural abscess: Pain Parasagittal lesion: Leg Spine: Disk; Stenosis Spondyolsis Mass: Neoplasm; Hematoma; Cyst spinal root or vessel Arachnoiditis: Sarcoid; Mpl surgery; Infection Trauma Toxic: Contrast agents; Chymopapain; Methotrexate; Cytosine arabinoside 1 CNS DISEASE Multiple sclerosis ALS: Pure motor Syringomyelia Transverse myelitis: Parainfectious; Vaccine; Immune SYSTEMIC CAUSES OF MYELOPATHY Spinal Cord lesions Connective Tissue Disease Lupus Erythematosis Sjgren's Mixed Connective Tissue Systemic Sclerosis (PSS) Behet's Embolism Decompression Sickness Ischemic Atherosclerosis Liver disease: Portosystemic shunt Aortic Aneurysm Anemia Hyperviscosity: Waldenstrm's Paraneoplastic Infectious HIV: Posterior columns HTLV 1: Spastic Syphilis Vitamin : E; B12 Toxic: Organophosphate N2O; Heroin Electricity Skeletal lesions Atlanto (C1)-Axial (C2) Arthritis: RA; Psoriasis Trisomy 21 Morquio A & B Skeletal dysplasias Klippel-Feil: Cervical vertebral fusion Ochronosis von Recklinghausen Ankylosing spondylitis Spinal canal stenosis Achondroplasia Coffin Lowry Stickler dysplasia Acrodysostosis (lumbar) Familial Lumbar Stenosis Hypophosphatemia, Vit D resistant rickets Spondyloarthropathy & chronic renal failure Other Epidural Masses: Gout; Xanthoma; Large nerves; Amyloid; Hematopoesis; Lipomatosis (Steroids) Acromegaly Myelomeningocoele Metastasis

ANATOMICAL SYNDROMES Cord Region Clinical features Sensory loss: Pain & temperature Sacral sparing Weakness: Arms > legs Related lesion Trauma Syringomyelia Cervical arthritis Spondylosis Neoplasm: Glial; Metastatic Lymphoma Ant spinal artery Disk; Osteophyte Post spinal artery collateral perfusion: Atherosclerosis Vitamin : B12; E Lipoma; Lig flavum Trauma: Penetrating Radiation Decompression Tumor: Dumbbell Facet; Luschka joint Tumor Compression Ischemia Spastic Paraplegias

FAMILIAL MYELOPATHIES Other syndromes Syringomyelia + Arnold-Chiari & Scoliosis Cleidocranial dysplasia Acromesomelic dysplasia Spine Disorders & Myelopathy Coffin-Lowry Syndrome: Ribosomal Protein S6 kinase Morquio's Syndromes: A: Galactosamine sulfatase B: -galactosidase Achondroplasia: FGF Receptor-3 Type II Collagenopathies Spine dysplasias; Spina bifida Trisomy 21 Ankylosing spondylitis Lumbar Stenosis Hypophosphatemia: Vitamin D resistant rickets Other familial syndromes Arnold-Chiari Malformation Spastic Ataxias: DRPLA Charlevoix-Saguenay Paroxysmal Choreoathetosis/Spasticity Hereditary Motor Syndromes Spastic dystonia syndromes: DOPA-responsive dystonias: GTP cyclohydrolase I; Tyrosine hydroxylase; Mitochondrial & Leber's optic atrophy Infections: HTLV-1 Mass lesion: Meningioma

Central

Anterior

Sensory loss: Pain & temperature Weakness: Legs arms Sensory loss: Position sense Relative preservation: Motor Pain & temperature Ipsilateral loss: Position sense; Motor Contralateral loss: Pain & temperature Onset: Rapid; Symmetric Pain: Perineum & thighs Sensory: Saddle; Pain, Temp Weakness: Sacral Reflex : Ankle > Knee Bladder ; Impotence Onset: Progressive; Asymmet Pain: Severe; Radicular Fatigue; Fasciculations Sensory: All modalities; Lumbar > sacral

Dominant (Strumpell) SPG3 (FSP1): Atlastin; 14q SPG4 (FSP2): Spastin; 2p22 SPG6 (FSP3): 15q11.1 SPG8: 8q23 SPG9: 10q23 SPG10: KIF5A; 12q13 SPG12: 19q13 SPG13: HSPD1; 2q24 SPG17: 11q12 SPG19: 9q33 Multiple exostoses Recessive SPG5A: 8q SPG5B: ? SPG7 (5C): Paraplegin; 16q24 SPG11: 15q13 SPG14: 3q27-q28 SPG15: 14q22-q24 SPG20 (Troyer): Spartin; 13q12.3 Sjgren-Larsson: FALDH; 17p11 DRPLA: 12p13 Homozygotes Intermediate # repeats Spastic paraplegia +: Dementia & Extrapyramidal Retinal degeneration Evans syndrome Leukodystrophies: Late-onset MLD & Krabb X-linked SPG1: L1CAM; Xq28

Posterior

Hemicord (BrownSquard)

Inferior (Conus)

Cauda equina

Compression Tumor Arachnoiditis

Weakness: Lumbar > Sacral Reflex loss: Knee > Ankle Bladder involvement

SPG2: Proteolipid protein; Xq21 SPG16: Xq11 AMN: ALDP protein; Xq28 Adult onset: 5q31 Retardation, psychosis, macroorchidism Woods-Black-Norbury

von Hippel-Lindau Hemangioblastoma Neurofibroma

Alan Pestronk 1/30/2003: More information at Neuromuscular Website: http://www.neuro.wustl.edu/neuromuscular/