Meningomyelitis is a complex lesion of the substance of the spinal cord, its membranes and spinal roots. It is a complication of infectious diseases such as syphilis, tuberculosis, brucellosis. It is characterized by a combination of symptoms: paresthesia, radicular pain, impaired motor functions and skin sensitivity. The diagnosis is made based on the analysis of cerebrospinal fluid, serological examination of blood, MRI or CT results. Treatment depends on the root cause that caused the development of meningomyelitis, as a rule, it is antibiotic therapy, physiotherapy, balneological treatment, physical therapy.
General information
Meningomyelitis is an inflammatory process that simultaneously covers the membranes of the spinal cord (from the ancient Greek “meningos” – the meninges) and its substance (from the ancient Greek. “myelos” – spinal cord). In neurology, meningomyelitis is not considered as a separate disease, since it is a complication of other pathological processes, the result of their spread to the central nervous system. The process of inflammation usually begins with the membranes of the spinal cord, then passes to the spinal roots and its substance. Therefore, during meningomyelitis, 3 distinct stages can be traced: meningeal manifestations, radicular syndromes and signs of damage to the substance of the spinal cord.
The danger of meningomyelitis lies in the fact that the result of the completion of the inflammatory process are adhesions that occur between the membranes and the substance of the spinal cord and lead to chronic compression of the latter with the development of compression myelopathy. In most cases, foci of meningomyelitis are localized in the thoracic region.
Causes
Meningomyelitis is almost never primary; it occurs as a complication in diseases such as various infections (measles, syphilis, scarlet fever, brucellosis, tuberculosis), rheumatic diseases.
- Syphilis. Damage to the nervous system, or neurosyphilis, is characteristic of the secondary or tertiary period of the disease. One of its forms is meningovascular syphilis, which is based on damage to the membranes of the spinal cord, passing to its substance, as well as thrombosis of blood vessels. The process is chronic. As a result of a prolonged inflammatory process, a slow compaction of the spinal membranes occurs due to the proliferation of connective tissue, the formation of coarse adhesions, leading to compression of the spinal cord substance.
- Tuberculosis. The defeat of the nervous system in tuberculosis is secondary, mycobacteria enter the meninges with blood flow, while the primary tuberculous focus is located in the lungs or bronchial lymph nodes. Miliary tubercles form on the soft meninges, leading to a local allergic reaction and the formation of non-inflammatory (serous) fluid. In the absence of treatment, the fluid is replaced by coarse connective tissue fibers with the formation of adhesions. In addition, with a prolonged course, the substance of the spinal cord itself is affected: calcification foci (petrifications) are formed in it.
In diseases such as measles, scarlet fever, brucellosis, damage to the nervous system with the development of meningomyelitis is associated with the direct penetration of the pathogen with blood flow into the meninges.
Symptoms
Although the causes of meningomyelitis are various diseases, each of which has its own clinical picture of spinal cord damage, there are a number of common symptoms. Meningomyelitis, as a rule, develops gradually, in the clinical picture it is possible to distinguish alternating periods of involvement in the inflammatory process of the meninges, roots and spinal cord matter. Meningomyelitis is not characterized by an acute onset. This is an important sign that underlies the differential diagnosis with other diseases of the nervous system.
The onset of meningomyelitis is usually characterized by the appearance of paresthesia (changes in sensitivity) in the chest, abdomen, arms and legs (depending on the level of spinal cord damage). The patient complains of tingling, crawling, burning, numbness. In the future, root symptoms are added: when the thoracic region is affected, these are shingling pains around the chest, which can sometimes simulate angina and myocardial infarction.
After the transition of inflammation to the substance of the brain, weakness develops in the extremities, up to complete paralysis; pathological reflexes appear; the work of the rectum and bladder is disrupted by the type of delay; all types of skin sensitivity disappear to the level of localization of the lesion. Meningomyelitis is characterized by the presence of short-term remissions, when the symptoms of the disease either disappear or become less pronounced.
Syphilitic meningomyelitis is characterized by the gradual development of weakness of the lower extremities, turning into paralysis of both legs with impaired pelvic organ function. Tuberculous meningomyelitis, as a rule, develops very slowly, so its main manifestations are symptoms of compression of the spinal cord by spikes with the development of sensitivity disorders and voluntary movements below the compression site. However, in some cases, the disease may debut in the form of radicular pains of the type of sciatica. Such a diverse clinical picture often causes diagnostic errors.
Diagnostics
Since meningomyelitis always has another serious disease under it, its diagnosis should be based on a comprehensive assessment of the patient’s condition. All patients are required to have a blood test for syphilis (Wasserman reaction, RPR test), and a lumbar puncture is performed.
Meningomyelitis must be differentiated from the spinal form of multiple sclerosis, spinal cord tumors, acute myelitis. Meningomyelitis is distinguished from multiple sclerosis by the absence of the following symptoms: nystagmus (involuntary frequent movements of the eyeballs), fuzzy boundaries of sensitivity disorders, trembling of hands and feet, changes in speech. These signs are crucial in multiple sclerosis and never occur in meningomyelitis.
Very often, in its course, chronic meningomyelitis resembles the clinical picture of a tumor of the spinal membranes, this is especially pronounced with the formation of multiple adhesions that compress the substance of the brain. An important distinguishing feature is the composition of the cerebrospinal fluid. With tumors of the central nervous system, protein-cellular dissociation will be detected in it (an increase in protein content with unchanged cellular composition). The final diagnosis can be made based on the analysis of CT or MRI images of the spinal cord .
Unlike meningomyelitis, acute myelitis always has an acute onset, develops against the background of infection, proceeds violently, with the rapid development of motor and sensory disorders, urinary and fecal incontinence, the formation of extensive pressure sores. The analysis of cerebrospinal fluid also helps to distinguish one type of meningomyelitis from another. So, with a disease that is a manifestation of neurosyphilis, there will be pleocytosis (an increase in the number of cellular elements) and a positive Wasserman reaction. If rheumatic diseases have become the cause of meningomyelitis, then lymphocytes will predominate in the spinal fluid, and if it is a purulent infection, then the number of leukocytes will increase. To suspect meningomyelitis as a complication of measles, scarlet fever, typhus, data on a previous disease will help. Tuberculous meningomyelitis also has characteristic features: in the cerebrospinal fluid at the first stage of the disease, leukocytes predominate, which are then replaced by lymphocytes after a short time; there is an increase in protein content while reducing glucose levels. The diagnosis is confirmed by a special staining of the cerebrospinal fluid smear with the detection of Mycobacterium tuberculosis. Chest x-ray and a tuberculin test are mandatory.
Treatment
Tuberculosis. “Triple” therapy is used: isoniazid, rifampicin, pyrazinamide. B vitamins (especially B6) are necessarily prescribed to prevent side effects from the effects of anti-tuberculosis drugs.
Syphilis. Penicillin is still the drug of choice for the treatment of syphilis. Therapy will be effective only if the concentration of the drug in the blood is maintained for a long time at a level sufficient to completely destroy the pathogen of the disease. To do this, the drug probenecid is used, which delays the withdrawal of penicillin and cephalosporin preparations from the body by the kidneys. This leads to the fact that the content of these substances in the blood increases so much that their concentration is sufficient for the complete destruction of the microorganism. There are various treatment regimens. If you are allergic to penicillin, you can replace it with drugs from the group of cephalosporins.
Measles. Patients with measles meningomyelitis need mandatory hospitalization. Since an effective anticorrhea drug has not yet been developed, measures are being taken to detoxify, normalize water-salt metabolism; drugs are prescribed that improve blood circulation in the vessels of the spinal cord.
Typhus, brucellosis. Meningomyelitis in these diseases is treated with a combination of antibacterial drugs to which pathogens are sensitive.
Whatever the reason for the development of meningomyelitis, after the etiological treatment (aimed at destroying the pathogen), the neurologist must send the patient to physiotherapy, physical therapy and rehabilitation treatment in the conditions of sanatorium-resort areas.
Prognosis and prevention
The prognosis for meningomyelitis directly depends on the cause that led to its development. In addition, the more acute the process, the faster it is treatable and the faster the nervous system is restored. The most favorable are meningomyelitis, which arose against the background of common infectious and allergic diseases: measles, rheumatism, brucellosis, typhus.
The prognosis for neurosyphilis and tuberculous meningomyelitis depends on the duration of the disease: the more time has passed since infection, the worse the prognosis. This is due to the fact that with a sluggish chronic process, irreversible changes occur in the membranes of the spinal cord and its substance. Therefore, there is a high probability that neurological symptoms, even with the removal of the pathogen, will persist.
Prevention of meningomyelitis primarily consists in the timely detection and treatment of patients with infectious diseases.