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Dr GR

Antonio Emanuele Vona

D027

CLINICAL PRESENTATION OF CONUS LESIONS
Spinal Cord
The spinal cord is the major communication link between the brain and the PNS
inferior to the head
...
, 2008)
...
The spinal cord is composed of cervical, thoracic, lumbar and sacral
segments, named according to the portion of the vertebral column from which their
nerves enter and exit
...
The nerves
from the lower segments descend some distance in the vertebral canal before they
exit because the spinal cord is shorter than the vertebral column
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Two enlargements occur where nerves supplying the upper and the lower limbs
enter and leave the spinal cord
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The lumbosacral enlargement in the inferior
thoracic, lumbar, and superior sacral regions is the site where the nerve fibres
supplying the lower limbs enter or leave the spinal cord
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It’s tip is the inferior end of the spinal
cord; it extends to the level of the second lumbar vertebra
...
, 2008)
...

Neurologic deficit related to a spinal cord pathologic abnormality is termed as
“myelopathy
...
Clinical history and physical examination are critically important
diagnostic tools in the initial assessment of myelopathy
...
Neuroimaging of the spinal cord and brain is
indispensable for assessment of structural causes of myelopathy
...
, 2015):

Dr GR

Antonio Emanuele Vona

D027

(1) Nontraumatic: (a) Neoplastic: benign or malignant
 (b) Nonneoplastic:
degenerative, congenital, inflammatory, infection, vascular, etc
(2) Traumatic
Both clinical and imaging parameters are important to arrive at a diagnosis
...
As an example, upper cervical involvement
leads to quadriplegia with impaired sensation, whereas lower cervical lesion leads
to hand and leg weakness with preservation of proximal arm strength
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Sensory examination helps to localize
a dermatome of a particular segment of cord
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Spinothalamic tract involvement leads to loss
of pain and temperature sensation (Baruah et al
...
The following imaging
findings are important:
(1) Site (cervical, thoracic, or lumbosacral)
(2) Location in the cord

(3) Associated brain involvement

(4) Cord expansion or atrophy
(5) Enhancement pattern
(6) Presence of calcification or hemorrhage
(7) Secondary syrinx formation
Various inflammatory conditions involve the cord and may have imaging
appearance indistinguishable from other etiologies
...
For example, CSF analysis
showing elevated IgG index (multiple sclerosis [MS]) or pleocytosis (infection)
...
, 2015)
...
Intramedullary spinal cord tumors
account for 1% of all central nervous system tumors and some infectious diseases in
the CM were reported as case reports
...
,
2014)
...
Summary of the intramedullary Spinal Lesions in the Conus
Medullaris (Eun et al
...
The VT has been described as
 a normal developmental
phenomenon in newborns and pediatrics, but is a rare pathology in adults, with only
21 cases reported to date (De Moura et al
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Cystic dilatation of the VT in
children may be associated with congenital anomalies, such as tethered cord
syndrome, Chiari type I malformation, lipomyelomeningoceles, and lumbosacral
lipoma (Erkan et al
...

Infrequently, the isolated dilatation of the VT is detected in the elderly, combined
with clinical symptoms
...
(1968) remarked that intramedullary cystic
lesion of the conus medullaris may be produced by trauma, hemorrhage,
compressive pathology, or vascular impairment
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Of note, one patient was associated with kyphotic deformity, and
cord edema was noted
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Dr GR

Antonio Emanuele Vona

D027

Table 2
...
, 2012)

Syringohydromyelia
Syringohydromyelia is not an infrequent intramedullary lesion
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Ependymal cells in such
cases line the cavity (Baruah et al
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Syringomyelia refers to accumulation of
CSF in a paracentral cavity in the white matter adjacent to the central canal
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In many cases, both
hydromyelia and syringomyelia exist and the condition is referred to as
syringohydromyelia
...
, 2015)
...
Early symptoms include headache,
altered pain and temperature sensation, and paraesthesia (Wollman, 2004)
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Subjective complaints may include symptoms
associated with upper motor neuron lesions such as changes in bowel or bladder
control, progressive extremity weakness, difficulty walking, and clumsiness (Patel et
al
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Myelopathy is most common in the cervical spine (Cook et al
...
History of trauma, tumor, or
degenerative diseases such as rheumatoid arthritis or cervical spondylosis may also
raise concern of myelopathy (Hudson et al
...

Radiculopathy, a pattern of symptoms due to nerve root irritation (Cook, 2007), and
myelopathy have some similar clinical features; therefore, care must be taken to

Dr GR

Antonio Emanuele Vona

D027

distinguish between the two (Hudson et al
...
An evaluation process that
incorporates an upper or lower quarter screen can assist with this distinction (Cook,
2007)
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Physical exam findings indicative of myelopathy may
include numbness, weakness, spasticity, and abnormal gait (Sizer et al, 2007)
...
, 2008)
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Usually, surgical treatment is recommended if the syrinx
is enlarging or is symptomatic (Singhal et al
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Table 2
...
, 2008)
...
Like ADEM, this may also
be associated with viral infection, vaccination, etc
...
, 2015)
...
A lesion typically
involves more than half of the cross-sectional area of cord and usually extends over
3- 4 vertebral segments in length (Jacob, 2008)
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Other differentials to consider include cord infarct and neoplastic
conditions of cord
...
, 2015)
...
Owing to posterior column
involvement, the predominant clinical picture is loss of vibration and
proprioception
...
, 2015)
...
Lesions on MRI are
usually bilaterally symmetric (Srikanth, 2002)
...
, 2015)
...
The etiology may involve hematogenous or contiguous spread from
nearby infection
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It may also be
associated with prior surgery, immunocompromised state, meningitis, etc
...
, 2015)
...
MRI shows T2 hyperintensity, irregular
ring enhancement, cord expansion, and restricted diffusion (Crema, 2007)
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Usually, the cause is an osteophyte or
disc causing severe stenosis of the spinal canal
...
,
2015)
...
Imaging appearance may be difficult to differentiate from other
entities such as ATM and MS (Bae et al
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In doubtful cases, concomitant brain
imaging may help in the diagnosis of ATM or MS
...

Sarcoidosis
Sarcoidosis is an idiopathic granulomatous disease with systemic involvement
...

Pathologically, sarcoidosis is characterized by the presence of noncaseating
granulomas
...
Central nervous system
(CNS) involvement is known as neurosarcoidosis
...
, 2012)
...
Presentations described in the liter- ature include paraparesis,
quadriparesis, autonomic symptoms, sensory changes, and Guillain-Barré–type

Dr GR

Antonio Emanuele Vona

D027

presentation (Shah & Lewis, 2003) Involvement of the cervical cord is more
common than that of the lower spinal cord
...
Lesions in the cord are hyperintense on T2W images with enhancement on
postcontrast
...
Extension of
enhancing lesion from the meninges to the cord parenchyma is postulated in the
literature (Baruah et al
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Cord Infarction
Acute infarction of the cord clinically presents with hyperacute or acute paralysis
and loss of pain and temperature sensation, although vibration and proprioception
may be preserved (Baruah et al
...

Clinical history is very important to differentiate from entities with similar imaging
appearance, such as ATM
...
, 2012)
...

Cord Hematoma (Hematomyelia)
Cord hematomas are usually posttraumatic when other find- ings such as fracture,
ligament tear, and soft tissue hematoma may point toward diagnosis
...
It responds quite well to conservative treatment with steroids
...
Blood products show expected
evolution with time with variable appearance on T1W and T2W images (Bozzo et al
...
Rarely, hematomyelia may result from vascular malformation or
hemorrhagic tumor when serial MRI with contrast may help
...
These tumors constitute
20% of all intraspinal tumors in the adult population and 35% of such tumors in
children
...
However, common symptoms described with intramedullary
tumors include pain, sensory and motor involvement, scoliosis, paraplegia, and
bladder and bowel disturbances
...
, 2015)
...

Most of these (80%-90%) are low-grade neoplasms whereas the rest are high grade
...
The low-grade
tumors are classified as papillary, pilocytic, or pilomyxoid tumors, whereas the highgrade tumors can be anaplastic or glioblastoma multiforme (GBM)
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Fibrillary astrocytomas tend to occur
in older children and adults
...
, 2015)
...
Hemorrhage is
uncommon, but they may have intratumoral and juxtatumoral cysts
...
Malignant astrocytomas are more vascular and without
distinguishable planes (Baruah et al
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Dermoid/Epidermoid
Dermoid and epidermoid tumors are usually seen in childhood or early adolescence
...

Lesions can be congenital or can be acquired due to trauma or lumbar puncture
(Van Aalst et al
...

These tumors can be intramedullary (40%), extramedullary (60%), or extradural
(rare)
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An associated dermal sinus can be seen in 20% cases
...
Epidermoid tumors
can be hyperintense on diffusion weighted imaging and slightly hyperintense on
fluid attenuated inversion recovery (Baruah et al
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Dr GR

Antonio Emanuele Vona

D027

REFERENCES:
Alblas Cornelis L, Bouvy Willem H, A Geert J, et al
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J Clin Neurol 2012;8(3):218–23
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Compressive myelopathy: Magnetic resonance imaging
findings simulating idiopathic acute transverse myelopathy
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Baruah D, Chandra T, Bajaj M, Sonowal P, Klein A, Maheshwari M, Guleria S; A
simplified algorithm for the diagnosis of spinal cord lesions
...
44(2015) 256-266
Bozzo A, Marcoux J, Radhakrishna M, et al
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J Neurotrauma 2011;28 (8):1401–
11
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A pragmatic neurological screen for
patients with suspected cord compressive myelopathy
...

Cook C
...
Upper Saddle
River, NJ: Prentice Hall, 2007
...
Intramedullary spinal cord abscess
complicating thoracic spondylodiscitis caused by Bacteroides fragilis
...


De Moura Batista L, Acioly MA, Carvalho CH, Ebner FH, Tatagiba M
...
J Neurosurg
Spine 2008;8:163-168 

Duhon BS, Shah L, Schmidt MH
...
Eur Spine J 2012;21(Suppl
4): S390–S395
...
Terminal syringomyelia in association with the tethered
cord syndrome
...

JKSMRM 18(2):144-150, 2014
Hudson RB, Cook CC, Goode A, Identifying myelopathy caused by thoracic
syringomyelia: a case report
...
2008
(16)2
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An approach to the diagnosis of acute transverse myelitis
...


Nassar SI, Correll JW, Housepian EM
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J Neurol Neurosurg Psychiatry 1968;31:106-109 

Patel S, Kettner N, Obourne C
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J Manipulative
Physiol ther 2005;28:539–546
...
2008
...

McGraw-Hill international edition
...

Shah JR, Lewis RA
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J Neurol Sci 2003;208(1):13–117
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Natural history of untreated
syringomyelia in pediatric patients
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Sizer Jr P, Brismee J, Cook C
...
Pain Pract 2007;7:53–71
...
MRI in subacute combined
degeneration of spinal cord: A case report and review of literature
...


Suh SH, Chung T, Lee S, Cho Y, Kim KS, Ventriculus terminalis in adults: unusual
magnetic resonance imaging features and review of the literature
...
Intraspinal dermoid and epidermoid tumors:
Report of 18 cases and reappraisal of the literature
...


Wollman D
...
J Am Geriatr Soc 2004;52:1033–1034

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