Myelitis - Causes, symptoms and treatment. MF.

Myelitis is an infection of the spinal cord.

Causes of myelitis

Myelitis is divided into primary and secondary. Primary include diseases caused by various neurotropic viruses( Coxsackie, ECHO, rabies, etc.).Secondary myelitis occurs with a number of common infections - typhus, brucellosis, measles, syphilis. An infectious agent, entering the spinal cord with a hematogenous or contact route, causes a local inflammatory process, accompanied by a violation of the circulation and the development of perifocal edema.

In cases of signs of myelitis in traumatic, vascular and toxic spinal cord injuries, it is more correct to talk about myelitic syndrome.

Symptoms of myelitis

The disease can be preceded by a short-lived prodrome with general malaise, weakness, musculo-articular pain. Usually, before the spinal cord injury, there is a rise in body temperature, the appearance of radiculoneuritic pain syndrome, short-term urination difficulties. Paresthesias in the extremities are also quite typical. Syndrome of spinal lesion can occur acutely, stroke or gradually increase within 1 to 3 days. Acute lateral lesion of the spinal cord is accompanied by the development of spinal shock( diashiz) with inhibition of reflex activity below the lesion. In this regard, for several days, and sometimes even weeks, muscle hypotension, tendon areflexia, the absence of pathological reflexes and spinal automatisms are noted. Only later on, in the paralyzed limbs, a true spasticity appears. With a higher localization of the focus, the signs of a spinal shock are more pronounced and a longer time is observed.

The clinical picture of myelitis depends on the severity of the development of the process, as well as on the localization of the focus and the prevalence of lesions both across the length and the length of the spinal cord. And in the first 2-3 weeks of the disease with edema and compression of the spinal cord, a complete transverse lesion appears and only later the true dimensions of the process are revealed. The most frequent myelitis with the localization of the focus in the thoracic segments of the spinal cord.

Symptoms of myelitis consist of segmental and conduction disorders. Paresis and paralysis are peripheral or central genesis( with spastic muscle type hypertension, high tendon reflexes, expansion of reflex zones, clonus of feet).Extensory pathological reflexes on the legs( reflexes of Babinsky, Oppenheim, Scheffer, etc.) appear in the first days of the disease, and flexion( reflex Rossolimo) - after 10-14 days. Usually, especially with foci located in the cervical and thoracic segments of the spinal cord, protective reflexes are clearly expressed, on the basis of which contractures are subsequently formed. Sensitivity disorders in transverse myelitis have a conductive character, with all kinds of sensitivity falling out. The upper limit of sensitivity disorders is located 1-2 segments below the upper border of the spinal focus. Skin reflexes disappear in the zone of sensitivity disorders. In the early days of the disease, there is usually a delay in urination and defecation. Only with the lumbosacral location of the myelitic focus, there is a peripheral paresis of sphincters with true incontinence of urine and feces. In cases of maintaining the elasticity of the neck of the bladder, paradoxical urination occurs. In the future, with central disorders, urination and defecation are performed automatically. Accumulation of residual urine in the bladder creates a constant threat of uroseptic complications. With transverse myelitis, trophic disorders in the form of pressure sores are more or less pronounced, which can become infected again and cause sepsis and intoxication.

If the inflammatory focus does not capture the entire diameter of the spinal cord, then the spinal symptoms are much less pronounced. When half of the spinal cord is affected, Braun-Secar syndrome develops with paresis and a violation of deep and partly tactile sensitivity on the side of the focus and loss of pain and temperature sensitivity on the opposite side. In the presence of several foci, disseminated myelitis is diagnosed, with the combination of spinal pathology with cerebral - encephalomyelitis, with simultaneous damage to the spinal cord and spinal roots and nerves - myelopolyradiculoneuritis. In the latter case, the symptoms of spinal lesion are revealed only as the polyradiculoneuritis component decreases.

During myelitis, several periods are isolated. The acute period of myelitis is characterized by an increase in symptoms and lasts from several days to 2-3 weeks. The early recovery period begins with the stabilization of the symptoms. Its duration is usually 5-6 months. At this time there is a regression of neurological pathology, sometimes quite intense. Favorable prognostic signs in this period are the closure of pressure sores and the restoration of pelvic organs. Then follows the late recovery period and the period of residual phenomena.

Infectious myelitis should be distinguished from recurrent encephalomyelitis and multiple sclerosis. The latter are characterized not only by symptoms of spinal involvement, but also by symptoms of brain damage, and often by optic nerves, rapid recovery and recurrent course.

Differential diagnosis of myelitis and spinal tumors is based on a slow increase in symptoms in tumors, the sequence of the appearance of syndromes, the presence of pain syndrome and a complete or partial block of the spinal subarachnoid space revealed during the liquorodynamic tests.

Pathologic anatomical picture of myelitis: the affected parts of the spinal cord are macroscopically flabby and have a grayish color;the characteristic transverse pattern of the spinal cord is blurred;the inflammatory focus can occupy the whole of its diameter;Multiple foci located at different levels usually have small dimensions. Microscopically observed vascular disorders, inflammatory infiltration, degenerative changes in neurons, fragmented decomposition of nerve fibers and their membranes below the lesion, which can spread to several segments. In the future, cysts and scars form on the site of the dead nervous tissue.

Treatment of myelitis

Acute development of transverse myelitis with severe compression syndrome and the presence of a spinal block require resolution of the question of surgical intervention for the purpose of decompression. Surgical treatment is also indicated for purulent epiduritis and other purulent-septic foci in the immediate vicinity of the spinal cord.

From the methods of conservative treatment in the acute period, antibacterial therapy is used. It is especially indicated for suspected bacterial etiology or septic complications. The duration of treatment on average 12-14 days. Showing glucocorticoids - prednisolone( dexazon, dexamethasone).The dose reduction begins on the 10th-12th day, the total duration of the course of treatment is 4-6 weeks. In some patients, according to the indications, a maintenance dose( about 5 mg) should be left for 2-3 months or more. Hormones are given in combination with potassium preparations. It should be preferred to the appointment of potassium orotate, which has an anabolic effect. Of dehydrating drugs used glycerol. It is advisable to use cinnarizine, trental, xanthinol nicotinate, large doses of ascorbic acid, vitamins of group B.

In the absence of independent urination, twice a day, catheterization of the bladder is performed. At the same time, antiseptic agents are used - derivatives of nitrofuran: furagin, furadonin, furazolidone. Recommended drugs alternate with each other, as well as with 5-NOC( nitroxoline).Each of the drugs is given within 7-10 days.

Of great importance are proper nutrition, proper care( comfortable position, use of an underlay, use of suspensions, daily washing of the skin with warm water and soap and wiping it with camphor or simple alcohol, cologne).It is necessary to remove necrotic masses with decubituses, rinse them with a weak solution of potassium permanganate or hydrogen peroxide. To eliminate necrotic tissue, use sterile wipes with a solution of chemopsin or trypsin, which are applied to pressure sores for several hours. With abundant purulent discharge apply tampons with hypertonic( 5-10%) solution of sodium chloride, on the treated surfaces apply bandages with Vishnevsky ointment, sea buckthorn oil, balms. To improve granulation and epithelialization of pressure sores, you can water the fresh tomato juice, insulin and other stimulants. Excess granulation is cauterized with a solution of silver nitrate.

When the process is stabilized, they switch to rehabilitative treatment. It should be prescribed massage, exercise therapy, thermal procedures, electrophoresis of nicotinic acid on the area of ​​the spinal focus;carry out orthopedic activities. During this period anticholinesterase preparations( galantamine, oxazil, etc.), stimulants( dibazol), vitamins of group B, nootropic agents, amino acids( methionine, cerebrolysin) are shown. With a pronounced spasticity of the muscles, the midocals are used. Sanatorium treatment( mud resorts) can be prescribed after 5-6 months after the onset of the disease.

Doctor neurologist Novikova Т.V.