Examination of the Patient With a Suspected Spinal Cord Problem
GOAL
The goal is to recognize, on the basis of the history and examination, when a patient’s symptoms are likely to be due to spinal cord dysfunction so that the appropriate investigations can be performed.
PATHOPHYSIOLOGY OF SPINAL CORD DYSFUNCTION
Spinal cord dysfunction can occur due to a compressive lesion extrinsic to the spinal cord (e.g., tumor, abscess, or disc) or due to an intrinsic lesion within the spinal cord (e.g., demyelination, inflammation, or infarction). Dysfunction of the spinal cord due to any cause is referred to by the generic term myelopathy. Acute dysfunction of the spinal cord causing severe motor and sensory loss below the level of the lesion is often called a transverse myelopathy. When spinal cord dysfunction is thought to be due to an intrinsic demyelinative or inflammatory process, it is called myelitis.
Spinal cord dysfunction generally causes motor, sensory, or autonomic dysfunction below the level of the spinal cord lesion; however, the symptoms of spinal cord disease vary, not only depending on the level of the lesion (e.g., cervical or thoracic), but also the severity of the process and the part of the cord that is being affected at that level (Table 51-1).
TAKING THE HISTORY OF A PATIENT WITH A SUSPECTED SPINAL CORD PROBLEM
When taking the history, use the combination of motor, sensory, and any autonomic (bowel, bladder, sexual) symptoms to clue you in on the possibility that your patient’s symptoms might be due to spinal cord dysfunction. Be aware that cord lesions can present in several different ways (Table 51-1).
Ask about bowel, bladder, and sexual function (patients may not always volunteer this information); these can be affected by lesions at any level of the spinal cord.
Patients with a lesion at the level of the cervical spinal cord will most likely have symptoms of weakness and sensory loss in the arms and legs; however, mild or moderate cervical spinal cord dysfunction might cause primarily lower extremity symptoms. Patients with lesions at the level of the thoracic cord can have weakness and sensory loss in the legs, trunk, or abdomen below the dermatomal level of the lesion, but they would not have symptoms in the arms.
Patients who have hemi-spinal cord dysfunction (i.e., dysfunction affecting only the left or right side of the spinal cord at a particular level) may specifically complain of weakness on one side of the body with sensory loss to temperature sensation (such as when taking a shower or bath) on
the opposite side of the body, symptoms characteristic of the Brown-Séquard syndrome (Table 51-1).
Some patients with a myelopathy have Lhermitte’s sign, an uncomfortable feeling of electricity, vibration, or tingling radiating down the neck, back, or extremities occurring on neck flexion. Lhermitte’s sign is actually
a symptom, and not a sign tested for during the examination. Although often primarily thought of as a symptom of spinal cord dysfunction due to multiple sclerosis, Lhermitte’s sign can occur due to any process affecting the cervical cord (whether intrinsic or compressive), causing dysfunction of the posterior columns. Lhermitte’s sign can be a helpful clue to a cervical spinal cord localization of pathology; therefore, patients with a suspicion of spinal cord dysfunction should specifically be asked about the presence or absence of this symptom.Related posts:
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