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Clinical Approach to Paraplegia

"Internal Medicine", Neurology, “Clinical approach, Paraplegia, Aswini

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Clinical Approach to Paraplegia

  1. 1. CLINICAL EVALUATION OF PARAPLEGIA DR.S.ASWINI KUMAR.MD Professor of Medicine Medical College Hospital Thiruvananthapuram
  2. 2. Introduction: Paraplegia is uncommon but important Thorough and systematic approach is neededfor making an accurate localization and arriving at an etiological diagnosis At the end of a neurological examination ask oneself the following questions 2
  3. 3. What is the onset of paraplegia? Is it acute – Is it subacute – Is it chronic – within, minutes within days or within months or or hours? weeks? years? Was there a history of trauma? Fall from a Road traffic Direct injury to height? accident? the spine? 3
  4. 4. Was there a history of backache? What is the site Was there a What is the total of maximum history of spinal duration? intensity? surgery? Is there any girdle pain / sensation? Any pain around Does it increase Is it unilateral or the thorax or with coughing bilateral? abdomen? and sneezing? 4
  5. 5. Is there a history of root pains? Is it unilateral or Does it radiate to Does it aggravate bilateral? the limbs? with coughing? Any pyramidal tract involvement? Buckling of knees Slipping of Tripping on small while walking? chappals? objects? 5
  6. 6. Symmetry of symptoms? Is the motor Is the sensory Or they are weakness symptoms asymmetrical? symmetrical? symmetrical? Any wasting or fasciculations? Any where in the Small muscles of Thigh and gluteal body? the hand? muscles? 6
  7. 7. Any swaying while walking? To the front or To both sides or Swaying while back even while to right or left? eyes closed? sitting? Any bladder involvement? Retention of Overflow Bladder urine? incontinence? sensation? 7
  8. 8. Any bowel involvement? Bowel sensation Bowel Constipation? present or incontinence? absent? History of impotence? Morning Erection Is there impaired Normal Sexual present in male? ejaculation? activity or not? 8
  9. 9. History of sexual promiscuity? Premarital Post marital Promiscuous exposure? exposure? contact History of infections? Pulmonary Viral infections? Chicken pox? Tuberculosis? 9
  10. 10. History of vaccination? Anti Rabies Polio Others? vaccination? vaccination? History of increased ICT? Fever and Projectile Seizures or loss Headache? vomiting? of consciousness? 10
  11. 11. Dietary history? Dietary habits – Deficiencies of Alcohol intake in veg / non veg? vitamins? excess or not? History suggestive of spasticity? Stiffness of Flexor spasms? Mass reflex? limbs? 11
  12. 12. History suggestive of conus/cauda? Peri-anal sensory Bowel bladder Impotence? loss? involvement? History of Malignancy? Swellings or bone Surgery for Chemotherapy or tenderness? tumors? radiation? 12
  13. 13. Now ask oneself the following questions The first 3 are general questions: They are based on common problems we face in the day today practice 13
  14. 14. 1.Is this patient having a neurological disease? Is he having a For example fracture Consider hysterical medical condition dislocation of the paraplegia but arrive simulating pelvis or polyarthritis at a conclusion only paraplegia? of lower limbs at the end 14
  15. 15. 2.What is the nature of the neurological deficit? Is it a? Paraplegia Quadriplegia Brainstem lesion Cerebral diplegia? Consider and exclude Gullain Barre Syndrome 15
  16. 16. 3.What was the mode of onset of Paraplegia? Acute • Transverse myelitis • Traumatic paraplegia • Anterior spinal artery syndrome Sub acute: • Pott’s paraplegia • Spinal epidural abscess • Spinal cord tumors Chronic • Familial spastic paraplegia • Amyotrophic lateral sclerosis • Cranio-vertebral junctional anomalies 16
  17. 17. Next 6 questions are for localization  Neurological localization is a tiring job, now almost replaced by investigations like CT and MRI 17
  18. 18. What are the sensory deficits? Subjective sensory symptoms Objective sensory deficits 18
  19. 19. Subjective sensory symptoms: Unilateral or bilateral Sharp shooting pain Radicular (root) pain or Girdle pain Dermatomal in distribution Very useful in localization of the level of lesion Exacerbated by coughing, sneezing or valsalva 19
  20. 20. Subjective sensory symptoms: An aching pain Confined to a point of spine Vertebral pain: Accompanied by point tenderness It localizes the vertebral level of lesion Neoplastic or inflammatory dural lesion likely 20
  21. 21. Subjective sensory symptoms: Deep seated Ill defined dull ache Funicular pain Distant from the affected cord level Of poor localizing value Common with intra-medullary lesion 21
  22. 22. Objective sensory deficits: These may be in the form of • Segmental hyper-aesthesia • Hypesthesia (decreased touch sensation) • Hypoalgesia (decreased pain sensation) • Loss of all modalities below a level • Loss of position sand vibration sense 22
  23. 23. Objective sensory deficits: Dissociated sensory loss • Suspended segmental loss of pain and temperature as in syringomyelia • Loss of pain and temperature below a particular level as in brown Sequard’s syndrome 23
  24. 24. What is the motor deficit? Is there any Is there any Is there any gross motor segmental gross motor weakness along paralysis along weakness with with minimal with wasting? an upper level wasting due to disuse atrophy 24
  25. 25. What is the tone of muscles? Reduced muscle tone of a Is the patient in a state of segmental distribution and spinal shock? This is increased tone below that indicated by level • Indicates the level of lesion • Hypotonia, areflexia indefinite or absent plantar 25
  26. 26. What are the changes in the superficial reflexes? Abdominal reflexes of all 4 quadrantsare absent. Cremasteric reflexes absent bilaterally. Plantars are extensor bilaterally D7 lesion Abdominal reflexes of upper quadrants are presentLower quadrants are absent. Beever’s sign is positive. Plantar reflexes are extensor bilaterally D10 lesion Abdominal reflexes of all four quadrants are present. Both cremasteric reflexes are absent. Plantar reflexes are extensor bilaterally. L1 lesion 26
  27. 27. What are the changes in the DTR? Loss of Deep tendon reflexes at segmental level with exaggerated DTR below the level indicate the level of lesion Biceps reflex absent – C5 Supinator reflex absent – C5 Inversion of Supinator – C5 C6 Triceps reflex absent – C7 Knee reflex absent – L2 L3 Ankle reflex absent – L5 S1 27
  28. 28. Is there evidence of LMN or UMN lesion? LMN signs alone would indicate the possibility of • Anterior horn cell lesion • Nerve root disease ( radiculopathy) • Peripheral nerve lesion ( Peripheral neuritis) • Myoneural junction abnormality – (Myasthenia) • Primary Muscle disease (Myopathies) 28
  29. 29. Is there evidence of both LMN and UMN lesion LMN signs of a segmental distribution indicates an appropriate level of lesion Bilateral UMN findings below that level indicates a transection of corticospinal tracts on either sides Combination of LMN and UMN signs other wise is suggestive of a Motor Neuron Disease 29
  30. 30. What is the segmental level of lesion? From the above findings, the segmental level is arrived at, by considering the following data: • Sensory segmental level by root pain or segmental hyperaesthesia confirmed by examination • Motor segmental level • Superficial reflex • Deep tendon reflex level 30
  31. 31. Does the patient have other features? Now one has to see whether the patient has physical signs which are specific for the particular level as obtained by your clinical localization 31
  32. 32. Foramen magnum syndrome? Foramen Lesion of Upper Lesion of C5-C6 Magnum Cervical Cord segments Sub occipital pain in Compressive lesion LMN paresis of the arm the distribution of usually muscles great occipital nerve. Sensory loss of Spastic weakness of affected segments remaining arm &legs Syringomyelic type of Lower cranial nerve Biceps and Supinator – sensory dissociation. palsies. diminished or absent Diaphragmatic Triceps & Finger flexion paralysis. – exaggerated Neck stiffness. Down beat nystagmus Knee and ankle reflex - Spastic quadri-paresis exaggerated 32
  33. 33. Foramen magnum syndrome? Lesions of mid Lesion of C7 Lesion of C8-T1 thoracic segment segments region? Paresis of flexors & extensors Weakness of small muscles of Root pain or paresthesias of little fingers the hand mimick intercostal neuralgia Sensory loss at & below 3rd & Associated spastic Para Sensory loss below a thoracic 4th digits paresis level Biceps and Supinator reflex Sensory loss of 5th digit and Segmental LMN lesion is (C5-C6) preserved medial forearm difficult to detect Finger flexion (C8 T1) Unilateral or bilateral Spastic paraplegia exaggerated Horner’s Syndrome Paradoxical Triceps may be Triceps and finger flexion - Disturbances of bladder and present reduced or absent bowel 33
  34. 34. Foramen magnum syndrome? 9th and 10th T12 & L1 L3 – L4 thoracic segments segments segments Root pain and parasthesia along Abdominal recti are normal Flexion of the hip is preserved upper abdomen Abdominal reflexes are Weakness and wasting of Beever’s sign is positive preserved quadriceps adductors of the hip Upper abdominal reflexes are Cremasteric reflexes diminished Spastic paralysis of of the preserved or absent remaining LL Lower abdominal reflexes are Spastic paralysis of lower limbs Diminution or loss of knee jerk absent Sensory along the inguinal Ankle reflex exaggerated, Spastic paralysis of lower limbs region Plantar extensor 34
  35. 35. Foramen magnum syndrome? S1 – S2 S3 – S4 L3 – L4 segments: segments: segments Flexion of hip and adduction of Large bowel and bladder Flexion of the hip is preserved thigh preserved paralysed Extension of knees, dorsi-flexion Weakness and wasting of of feet preserved quadriceps adductors of the hip Retention of urine and faeces Atrophic paralysis of muscles of Spastic paralysis of of the foot and calf remaining LL The bulbocavernosus (S2-S4) and anal(S4-S5) reflexes are Weakness of knee flexion foot absent Diminution or loss of knee jerk adduction Knee jerks normal, Ankle jerk Muscle strength is largely Ankle reflex exaggerated, and plantar absent preserved Plantar extensor 35
  36. 36. What is the corresponding vertebral level? From cervical segments- subtract 1 From upper thoracic segments- subtract 2 From lower thoracic segments- subtract 3 Lumbar 1-2 segments- T10 vertebra Lumbar 3-4 segments- T11 vertebra Lumbar 5 segments- T12 vertebra Sacral and coccygeal segments 36
  37. 37. What does the corresponding vertebral examination show? Inspection: • Deformity, • narrowing of disc space, • gibbus, • meningocoele Palpation: Tenderness Percussion: Tenderness Auscultation: Bruit 37
  38. 38. What are the long tracts involved? 1. Complete transection 7. Combined anterior horn 2. Hemi-section cell + pyramidal 6. Anterior horn 3. Central lesion cell disease 4. Posterior and 5. Posterior lateral column column disease lesions 38
  39. 39. What are the roots and nuclei involved? Do they What are the represent a roots and definite nuclei pattern of involved? involvement? 39
  40. 40. Is it a complete transection of the cord? • Initial spinal shock syndrome • All ascending and descending tracts are interrupted • All motor and sensory functions are disturbed Features: • Sphincter and bowel disturbances • Trauma, • Transverse myelitis Causes: 40
  41. 41. Is it a hemi-section? • Loss of pain and temperature sensation on one side • Upper level is 1-2 segments below the actual level • Interruption of the crossed spinothalamic tract • Loss of position and vibration on the same side Features: • Spastic paralysis on the same side • Pure examples are rare Causes: 41
  42. 42. Is it a central lesion of spinal cord? • Dissociated sensory loss • Segmental neurogenic atrophic paralysis • Areflexia due to involvement of anterior horn cells • Spastic paraplegia below the level of lesion Features • Ipsilateral Horner’s syndrome • Syringomyelia, • Intramedullary tumor Causes: 42
  43. 43. Is it a postero-lateral column disease • Parasthesia of feet • Loss of position and vibration • Sensory ataxia • Intact pain and temperature sensation Features: • Spasticity, hyper-reflexia, Bilateral extensor plantar • Cervical spondylosis • Sub-acute Combined Degeneration Causes 43
  44. 44. Is it a posterior column disease? • Impaired position and vibration sense • Sensory ataxia • Gait stamping • Double tapping Features: • Lhermitte’s sign • Cervical spondylosis, • Tabes dorsalis Causes: 44
  45. 45. Is it an anterior horn cell syndrome? • Atrophic weakness with fasciculations • Hypotonia Features: • Sluggish reflexes • Infantile SMA – Wernig Hoffman • Juvenile SMA – Krugelberg Welander Causes: 45
  46. 46. Is it a anterior horn cell+ pyramidal tract lesion • Diffuse LMN Signs and Diffuse UMN signs • Sluggish DTR in upper limbs Exaggerated in lower limbs • Abdominal reflexes characteristically preserved Features • Sensory changes absent • Amyotrophic lateral sclerosis Causes: 46
  47. 47. Is it a vascular syndrome of spinal cord? • Abrupt onset girdle pain/radicular pain • Flaccid paraplegia within minutes /hours • Thermo anesthesia & analgesia below the level • Impaired bowel and bladder control Features • Watershed zones C4 T4 segments L1 segment • Arteriosclerosis of spinal arteries Causes: 47
  48. 48. Am I dealing with a spinal cord compression? Diseases of Vertibral column Infiltrations: Other causes: 48
  49. 49. Diseases of the vertibral column? Secondaries Trauma, of spine Tuberculosis, Primary neoplasms: • Sarcoma, • Myeloma, • Hemangioma 49
  50. 50. Infiltrations: Spinal cord Reticulosis tumors Leukemis Cystic deposits lesions 50
  51. 51. Other causes of compression • High Cervical cord compression • Cranio Vertibral Junctional Anomalies • Extra dural abscess, • Metastatic or vertibral osteitis 51
  52. 52. Or is it a non compressive myelopathy • Viral – Poliomyelitis, Herpes zoster, Rabies A. • Bacterial – Tuberculosis, Syphilis Infective: • Parasitic, Falciparum Malaria and Schistosomiasis B. • Post exanthematous – Measles, Rubella Immuno- • Post vaccinial – Rabies, Polio allergic 52
  53. 53. Is it an extra-medullary lesion? Radicular pains are common and early to occur Vertibral pain is common Funicular pain – less common UMN signs are present and may occur early LMN signs are unusual and segmental Parasthesia of ascending progression Sphincter involvement is late Trophic changes are uncommon 53
  54. 54. Is it an intra-medullary lesion? Radicular pain is unusual Vertibral pain is also unusual Funicular pains may occur UMN signs are present but late LMN signs are prominent and diffuse Paraesthesia of descending progression Sphincter involvement is early Trophic changes are common 54
  55. 55. Is it a conus-medullaris lesion? Onset – symmetrical Dissociated sensory loss - present Root pain - rare Fasciculation – rare Decubitus ulcer – common Bladder - early Bowel - early 55
  56. 56. Is it cauda-equina lesion? 56
  57. 57. Is it a paraplegia in flexion? Mode of transection: Flexor • Complete Evolution – withdrawal Mass reflex - • Both Late reflex – Present corticospinal and Present extra-pyramidal 57
  58. 58. Is it a paraplegia in extension? Mode of transection – Flexor • Incomplete Evolution – withdrawal Mass reflex – • only cortico- Early reflex – Not Not present spinal tract is present affected 58
  59. 59. Thank You 59