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DISEASES OF THE SPINAL CORD
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later by Howell and coworkers, as noted on page 89 The disorder under discussion must be differentiated clinically from the syndrome of continuous muscle ber activity of Isaacs and the stiff man syndrome (see page 1279) and focal tetanus The last of these lacks the myoclonic nature and progressive course of spinal neuronitis and, of course, typically follows clostridial infection The brunt of the pathologic process in fatal cases, falls on the cervical portion of the spinal cord Widespread loss of internuncial neurons with relative sparing of the anterior horn cells, neuronophagia of internuncial neurons, reactive gliosis and microglial proliferation, conspicuous lymphocytic cuf ng of small blood vessels, and scanty meningeal in ammation are the main ndings Involvement of the white matter is less marked The pathophysiology of the rigidity in these cases is not well understood but is presumed to be due to the impaired function (or destruction) of Renshaw cells, with the release of tonic myotatic re exes (Penry et al) The painful spasms and dysesthesias relate in some way to neuronal lesions in the posterior horns of the spinal cord and dorsal root ganglia Whitely and Lhermitte and their coworkers have proposed that these cases probably represent a rare and obscure form of viral myelitis Myoclonic jerking of the trunk and limbs in a focal or segmental distribution is probably due to neuronal damage that is limited to the spinal cord We have seen several such cases, usually with regional abdominal or thoracic myoclonus, in otherwise healthy patients and have been unable to determine its cause The spinal uid has been normal Anticonvulsants and antispasticity drugs in some combination may partially suppress the myoclonus, and local injection of botulinum toxin has improved the symptoms in some A similar syndrome in a few cases has complicated vertebral or spinal artery angiography (see later) A paraneoplastic variety, not of the stiff-man type, has been proposed, as in the case described by Roobol and colleagues, but its nature has not been fully elucidated
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Vertebral A Ascending Cervical A
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VASCULAR DISEASES OF THE SPINAL CORD
In comparison with the brain, the spinal cord is an uncommon site of vascular disease Blackwood, in a review of 3737 necropsies at the National Hospital for Nervous Diseases, London, in the period 1903 to 1958, found only 9 cases of spinal cord infarction, but in general hospitals such as ours, the incidence (on clinical grounds) is somewhat higher The spinal arteries tend not to be susceptible to atherosclerosis, and emboli rarely lodge there Of all the vascular disorders of the spinal cord, infarction, dural stula, bleeding, and arteriovenous malformation are the only ones that are encountered with any regularity, but they are rare in comparison with demyelinating myelitis or compression by tumor In current practice, most cases of infarction have developed in relation to operations on the aorta, usually the thoracic portion, where the aorta must be clamped for some period An understanding of these disorders requires some knowledge of the blood supply of the spinal cord Vascular Anatomy of the Spinal Cord The blood supply of the spinal cord is derived from a series of segmental vessels arising from the aorta and from branches of the subclavians and internal iliac arteries (Fig 44-6) The most important branches of the subclavian are the vertebral arteries, small branches of which give rise to the rostral origin of the anterior spinal artery and to smaller posterolateral spinal arteries and constitute the major blood supply to the cervical
Internal Iliac A Lateral Sacral A
Figure 44-6 Anterior view of spinal cord with its segmental blood supply from the aorta See text for details (From Herrick and Mills, by permission)
cord The thoracic and lumbar cord is nourished by segmental arteries arising from the aorta and internal iliac arteries Segmental branches of the lateral sacral arteries supply the sacral cord A typical segmental artery divides into an anterior and a posterior ramus (Fig 44-7) Each posterior ramus gives rise to a spinal artery, which enters the vertebral foramen, pierces the dura, and supplies the spinal ganglion and roots through its anterior and posterior radicular branches Most anterior radicular arteries are small and some never reach the spinal cord, but a variable number (four to nine), arising at irregular intervals, are much larger and supply most of the blood to the spinal cord Tributaries of the radicular arteries supply blood to the vertebral bodies and surrounding ligaments The venous drainage of the marrow is into the posterior veins forming the spinal plexus Their importance relates to the pathogenesis of brocartilaginous embolism (see further on)
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