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Spinal Arachnoiditis, Toxic Myelopathies, Radiation Myelopathy, and Electrical Injury
Entries from the Neuromuscular Disease Center's "Spinal Cord Disorders" section
Alan Pestronk M.D.Original URL: http://www.neuro.wustl.edu/neuromuscular/spinal/arachnoid.htm
SPINAL ARACHNOIDITIS
Clinical syndrome
- Pain: Low back & radiating down both legs
- Weakness: One or multiple lumbar or sacral root distribution
- Sensory loss: One or multiple lumbar or sacral root distribution
Causes
- Spinal surgery: Especially multiple
- Chemical
- Oil based radiographic contrast agents
- Spinal drugs: Anesthetics; Steroids; Amphotericin B; Methotrexate
- Infections: Tuberculosis; Cryptococcosis; Syphilis; Viral
- Trauma: Vertebral injuries; Disc herniation
- Spinal subarachnoid hemorrhage
TOXIC MYELOPATHIES
Systemic
- Organophosphates: TOCP
- Source: Contaminants in cooking oil or flour; Alcohol substitute
- Myelopathy & polyneuropathy
- Pathology: Distal axonal degeneration: CNS & PNS
- Iodochlorhydroxyquinoline (Clioquinol)
- Source: Used as anti-diarrheal drug
- Epidemiology: Predominantly in Japan
- Clinical features
- Myelopathy
- Dose: Oral intake of 2 g/day for >3 weeks
- Onset: Numbness & pain in legs
- Signs: Decreased Sensation, especially vibration; Hyperesthesia; Leg weakness & stiffness (50%)
- ± Optic neuropathy: Especially children
- Course: Rapid onset; Slow recovery
- Nitrous oxide
- Source: Gas used in general anesthesia & Dental analgesia
- Some patients with associated cobalamin deficiency
- Myelopathy or polyneuropathy
- Onset: Delayed; 3 months to 5 years after exposure
- Prognosis: Slow, often incomplete recovery
- Substance abuse
- Heroin; ? Cocaine
- Anterior spinal artery syndrome
- Hexacarbons: Occasional delayed myelopathy
- Muzolimine
- Use: Diuretic
- Toxicity especially with renal insufficiency
- Myelopathy
- Polyneuropathy: Demyelination
Direct
- Angiographic contrast agents
- Myelographic contrast agents
- Acute onset spinal cord irritability: Often transient
- Arachnoiditis
- Chymopapain: Used to treat herniated discs
- Spinal anesthesia: ? direct toxic vs. vascular
- Chemotherapeutic agents: Methotrexate; Cytosine arabinoside
- Often in patients treated with both systemic & intrathecal drugs
- Onset: Acute (Hours) to Subacute
- Increased Risk
- More frequent treatments;
- High cumulative dose
- Concurrent methotrexate & cytarabine
- Spinal radiotherapy
- Pathology: 2 types
- Spinal white matter: Peripheral cord; Lateral & posterior funiculi
- Grey matter lesions
- Amphoterecin B
- Focal myelopathy
- Diffuse radiculopathy
RADIATION MYELOPATHY
Clinical: 4 syndromes; Dose related (> 4,000 rads)
- Transient sensory symptoms
- Onset: 2 to 37 weeks after treatment
- Lhermitte sign: Shock-like sensation after neck flexion
- Course: resolution after 2 to 36 weeks
- Chronic progressive myelopathy
- Onset: Mean 17 months after Rx; Range 3 months to 5 years
- Asymmetric; Brown-Séquard syndrome
- Course: Progression over months
- Treatment: ? Anticoagulation
- Pathology: Vasculopathy; White matter > Grey
- Acute transverse myelopathy
- Local amyotrophy: ? spinal lesion vs. radiculopathy
ELECTRICAL INJURY
Clinical
- Most often cervical
- < 1,000 volts: Predominantly anterior horn cell damage
- > 1,000 volts, or with burns near spinal cord: Lateral & posterior column damage
- Acutely: Associated encephalopathy
- Course: Progressive for few months or static
Pathology
- Perivascular & petechial hemorrhages