Table Of ContentClinical Medicine and the Nervous System
Series Consulting Editor: Michael Swash
Syndromes that have an underlying neurological basis are common
problems in many different specialties. Clinical Medicine and the
Nervous System is a series of monographs concerned with the diagnosis
and management of clinical problems due primarily to neurological
disease, or to a neurological complication of another disorder. Thus the
series is particularly concerned with those neurological syndromes that
may present in different contexts, often to specialists without special
expertise in neurology. Since the range of clinical practice embraced
by neurologists is wide, the books in this series will appeal to many
different specialists in addition to neurologists and neurosurgeons.
It is the aim of the series to produce individual volumes that are suc-
cinct, informative and complete in themselves, and that provide suf-
ficient practical discussion of the issues to prove useful in the diagnosis,
investigation and management of patients. Important advances in
basic mechanisms of disease are emphasized as they are relevant to
clinical practice. In particular, individual volumes in the series will be
useful especially to neurologists, neurosurgeons, physicians in internal
medicine, oncologists, paediatricians, neuro-radiologists, rehabilitation-
ists, otorhinolaryngologists and ophthalmologists, and to those in training
in these specialties.
Titles in the series already published: Forthcoming titles in the series:
Headache Malignant Brain Tumours
Richard Peatfield Edited by David G.T. Thomas and D.1.
Graham
Epilepsy: Electroclinical Syndromes
Edited by Hans Liiders and Ronald Motor Neuron Disease
P. Lesser Edited by Nigel Leigh and Michael
Swash
The Heart and Stroke
Edited by Anthony J. Furlan Electrophysiological Diagnosis
E.M. Sedgwick
Hierarchies in Neurology
Christopher Kennard and Michael Hydrocephalus and the Cerebrospinal
Swash Fluid
Edited by J.D. Pickard
Imaging of the Nervous System
Edited by Paul Butler
Guillain-Barre Syndrome
Richard A.c. Hughes
Vertigo: Its Multisensory Syndromes
Thomas Brandt
Treatment of Multiple Sclerosis
Edited by Richard A. Rudick
and Donald E. Goodkin
Diseases of the
Spinal Cord
Edmund Critchley and Andrew Eisen (Eds.)
With 88 Figures
Springer-Verlag
London Berlin Heidelberg New York
Paris Tokyo Hong Kong
Barcelona Budapest
Edmund Critchley, DM, FRCP
Consultant Neurologist, Department of Neurology, Royal
Preston Hospital, Sharoe Green Lane, Preston, Lancashire
PR24HT, UK
Andrew Eisen, MD, FRCP(C)
Professor of Medicine (Neurology), University of British
Columbia, and Head of the Neuromuscular Disease Unit,
Vancouver General Hospital, Vancouver, British Columbia, V5Z
4E3, Canada
Consulting Editor
Michael Swash, MD, FRCP, MRCPath
Consultant Neurologist, Neurology Department, The London
Hospital, Whitechapel, London EI1BB
Cover illustration: Ch. 23, Fig. 5. Intradural tumour:
neurofibroma with cord and root compression - conus medullaris
ISBN-13: 978-1-4471-3355-1 ISBN-13: 978-1-4471-3353-7
DOl: 10.1 007/978-1-4471-3353-7
British Library Cataloguing in Publication Data
Disease of the spinal cord. - (Clinical medicine and the nervous system)
I. Critchley, Edmund II. Eisen, Andrew III. Series 616.73
Library of Congress Cataloging-in-Publication Data
Diseases of the spinal cord/edited by Edmund Critchley and Andrew
Eisen.
p. cm.-(Clinical medicine and the nervous system)
Includes index.
1. Spinal cord - Diseases. I. Critchley, E.M.R. (Edmund Michael R.)
II. Eisen, Andrew, 1936- . III. Series.
[DNLM: 1. Spinal Cord Diseases. WL 400 D611j
RC400.D52 1992
616.8'3-dc20
DNLM/DLC 91-5079
for Library of Congress CIP
Apart from any fair dealing for the purposes of research or private study, or
criticism or review, as permitted under the Copyright, Designs and Patents Act
1988, this publication may only be reproduced, stored or transmitted, in any form
or by any means, with the prior permission in writing of the publishers, or in the
case of reprographic reproduction in accordance with the terms of licences issued
by the Copyright Licensing Agency. Enquiries concerning reproduction outside
those terms should be sent to the publishers.
© Springer-Verlag London Limited 1992
Softcover reprint of the hardcover 1st edition 1992
The use of registered names, trademarks etc. in this publication does not imply,
even in the absence of a specific statement, that such names are exempt from the
relevant laws and regulations and therefore free for gene~al use.
Product liability: The publisher can give no guarantee for information about drug
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Typeset by Best-set Typesetter Ltd., Hong Kong
2128/3830-5432lO Printed on acid-free paper
Consulting Editor's Foreword
The spinal cord is a long structure, conslstmg of white and
grey matter, that not only serves to provide a neural connection
between the brain and the body, but also contains neural circuits
that are organized segmentally and that are responsive to central
and peripheral sensory input. Thus the spinal cord is capable of
some behavioural activity that is of clinical significance, and
that is more evident when higher modulation is disturbed. The
released activity of spasticity, and the disturbances of bladder and
bowel control that occur in patients with spinal cord lesions are
examples. The spinal cord is well protected within its bony canal
but is, nonetheless, susceptible to compression by degenerative
joint or bone disease, or by neoplasm. Spinal cord compression is
a common clinical problem that is not always easy to recognize.
However, it is particularly important because of the good re-
sults of appropriate treatment and the unfortunate consequences
should the diagnosis be missed. Many other medical and surgical
disorders affect the spinal cord, including vascular disease, decom-
pression sickness, degenerative disorders and multiple sclerosis.
In this book Dr. Critchley and Dr. Eisen, and their col-
laborators, chosen for their expertise and experience in spinal
cord disorders, have gathered together descriptions of the symp-
toms and signs of spinal cord disease. They have planned the
book in relation to the underlying causes of spinal cord syn-
dromes, and have carefully considered the methods of clinical
assessment and diagnosis in current use, including the well-
established and newer clinical neurophysiological and imaging
techniques. Accurate diagnosis is an essential prerequisite to
adequate clinical management. Diseases of the spinal cord and
their clinical manifestations deserve to be better understood
and better managed in clinical practice. This book will serve to
address this aim.
The Royal London Hospital Michael Swash
May 1991
Preface
Publication of a textbook of diseases of the spinal cord is born of
necessity: to correct the low standards of diagnosis and manage-
ment of spinal cord problems in the past and the neglect of the
subject in the teaching of neurology and neurosurgery. In fact,
many of the older neurologists felt it beneath their dignity to
teach on such a mundane subject as the spinal cord.
The purpose of the present volume is to provide a clinical
guide appealing to all those involved in spinal cord problems
whatever their experience or designation. Exciting advances, es-
pecially in the application of neuroradiological and neurophysio-
logical techniques, justify a fresh enthusiasm for this aspect of
neurological endeavour. With the support of these new diagnostic
facilities many neurologists and neurosurgeons have developed a
research interest in disorders of the spinal cord and nerve roots
and this is reflected in the chapters in which contributors elaborate
on features they feel important for the optimum management of
patients. Controversies are not ignored and among the special
topics discussed are diving injuries, disorders of the conus, para-
plegia and rehabilitation.
Nonetheless, the primary aim is to provide a sound and com-
prehensive manual for the clinician, valuable for learning, review
and reference. Early chapters include the application of basic
sciences, knowledge of neuropathology and diagnostic techniques
at the bedside, but where necessary more specific details of the
underlying anatomy and physiology are re-emphasized in the
clinical chapters, as for example in that concerned with spinal
and neural compression, in order to give a holistic view of the
clinician's approach to the problem posed.,
Preston, Lancashire Edmund Critchley
Vancouver, British Columbia Andrew Eisen
Contents
List of Contributors xi
1 Introduction
E.M.R. Critchley and A.A. Eisen. . . ... . .. . . .. . . .. . . . .. 1
2 Anatomy as a Key to Function of the Spinal Cord
M. T. Isaac ......................................... 9
3 Spinal Modulation of Noxious Stimuli
E.M.R. Critchley and M. T. Isaac. . . . . . . . .. . .. . . . . . . . . . 15
4 Spasticity
M. T. Isaac. . . . . . . . . . . . . . . . . . . .. . . . . . . . . .. . .. . .. . . . . 31
5 Hazards of Lumbar Puncture
l.P.R. Dick ........................................ 35
6 Neuropathology
D.l. Graham ..................................... . . 41
7 Embryonic Development of the Spinal Cord and
Associated Disorders
M.J. Noronha ...................................... 79
8 Imaging of the Spine and Spinal Cord
1.S. Lapointe. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
9 Neurophysiological Investigation of the Spinal Cord
M.S. Schwartz and M. Swash .................. . . . . . . . 123
10 Radiculopathy due to Diseases other than Disc Disease
A.A. Eisen. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
11 Disc and Degenerative Disease: Stenosis, Spondylosis
and Subluxation
CH.G. Davis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . 157
x Contents
12 Craniocervical Anomalies and Non-traumatic
Syringomyelia
R.A. Metcalfe. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
13 Cervical Myelopathy due to Rheumatoid Arthritis
i.P.R. Dick ........................................ 201
14 Meningitic Disorders and Myelopathies
E.M.R. Critchley. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
15 Anterior Horn Cell Diseases
i.D. Mitchell ....................................... 235
16 Three Tropical Spinal Cord Syndromes
C. U. Velmurugendran ............................... 255
17 The Conus Medullaris and Sphincter Control
M. Swash .......................................... 269
18 Spinal Vascular Disease
M.l. Aminoff. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
19 Decompression Illnesses and the Spinal Cord
R.R. Pearson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301
20 Hereditary and Nutritional Disorders of
the Spinal Cord
B. Pentland ........................................ 319
21 Vertebral Body Collapse
i.P.R. Dick.... . . . . . . . . . . . . . . . . . . . . .. . . ... . . . . . . . . . 335
22 Spinal Epidural Abscess
i.P.R. Dick. . . . . . . . .. . . . . . . . . . . . .. . . . . . . . . . . . . . .. . . 345
23 Spinal Cord Compression and Spinal Cord Tumours
N. T. Gurusinghe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351
24 Trauma and Paraplegia
K.A. Tucci, H.J. Landy, B.A. Green and F.i. Eismont . . . 409
25 Rehabilitation, Walking Aids, Functional Electrical
Stimulation and Overcoming Spasticity
R.J. Weber and B. Pentland .......................... 429
Subject Index 445
Contributors
M.J. Aminoff, MD, FRCP
Professor of Neurology, School of Medicine, University of
California, San Francisco, California 94143-0114, USA
E.M.R. Critchley, DM, FRCP
Consultant Neurologist, Royal Preston Hospital, Sharoe Green
Lane, Preston, Lancashire PR2 4HT, UK
C.H.G. Davis, FRCS
Consultant Neurosurgeon, Royal Preston Hospital, Sharoe
Green Lane, Preston, Lancashire PR2 4HT, UK
J.P.R. Dick, PhD, MRCP
Consultant Neurologist, The Royal London Hospital,
Whitechapel, London E11BB, UK
A.A. Eisen, MD, FRCP(C)
Professor of Medicine (Neurology), University of British
Columbia, and Head of the Neuromuscular Disease Unit,
Vancouver General Hospital, Vancouver, British
Columbia, V5Z 4E3, Canada
F.J. Eismont, MD
Professor of Orthopedics and Rehabilitation, Neurological
Surgery and Co-Director of the Acute Spinal Cord Injury
Service, University of Miami School of Medicine/Jackson
Memorial Hospital, 8004 Rosenstiel Medical Science Building,
Miami, Florida 33136, USA
D.l. Graham, FRCPath, FRCP
Professor of Neuropathology, Southern General Hospital, 1345
Govan Road, Glasgow G514TF, UK
xii Contributors
B.A. Green, MD
Professor of Neurological Surgery, Orthopedics and
Rehabilitation, and Co-Director of the Acute Spinal Cord Injury
Service, University of Miami School of Medicine/Jackson
Memorial Hospital, Attending Physician at the Veterans
Administration Hospital, President and Director of Clinical
Research at the Miami Project to Cure Paralysis, 1501 NW 9th
Avenue, Miami, Florida 33136, USA
N.T. Gurusinghe, FRCSE
Consultant Neurosurgeon, Royal Preston Hospital, Sharoe
Green Lane, Preston, Lancashire PR2 4HT, UK
M.T. Isaac, MRCPath, MRCPsych
Senior Registrar in Psychiatry, The Bethlem Royal Hospital and
The Maudsley Hospital, Denmark Hill, London SE5 8AZ, UK
H.J. Landy, MD
Assistant Professor of Neurological Surgery, University of Miami
School of Medicine/Jackson Memorial Hospital, 1501 NW 9th
Avenue, Miami, Florida 33136, USA
J.S. Lapointe, MD, FRCP(C)
Associate Professor of Radiology, University of British
Columbia, Neuroradiologist, Vancouver General Hospital,
Vancouver, British Columbia, V5Z 4E3, Canada
R.A. Metcalfe, MD, MRCP
Consultant Neurologist, Southern General Hospital, 1345 Govan
Road, Glasgow G514TF, UK
J.D. Mitchell, MD, FRCPG
Consultant Neurologist, Royal Preston Hospital, Sharoe Green
Lane, Preston, Lancashire PR2 4HT, UK
M.J. Noronha, FRCP, FRCPE
Consultant Paediatric Neurologist, Royal Manchester Children's
Hospital, Pendlebury, Manchester M27 IHA, UK
R.R. Pearson, MD, MFOM, RN
Surgeon Captain, HMS Saker, BFPO 2. (Home address: 1509
Allview Drive, Potomac, Maryland 20854, USA)
B. Pentland, BSc, MB, FRCPE
Consultant Neurologist, Astley Ainslie Hospital, Grange Loan,
Edinburgh EH9 2HL, UK
M.S. Schwartz, MD
Consultant Neurophysiologist, Atkinson Morley's Hospital,
Copse Hill, Wimbledon, London SW20 ONE, UK
