Approach to a Patient With Paraplegia

WHAT IS PARAPLEGIA?WHAT IS PARAPLEGIA?

PARALYSIS OF LOWER PART OF PARALYSIS OF LOWER PART OF BODY,COMMONLY AFFECTING BODY,COMMONLY AFFECTING BOTH LEGS AND OFTEN INTERNAL BOTH LEGS AND OFTEN INTERNAL ORGANS BELOW WAIST.ORGANS BELOW WAIST.

ETIOLOGYETIOLOGY

DIVIDED INTO 2 TYPESDIVIDED INTO 2 TYPES

DUE TO UPPER MOTOR NEURON DUE TO UPPER MOTOR NEURON LESIONLESION

DUE TO LOWER MOTOR NEURON DUE TO LOWER MOTOR NEURON

LESIONLESION

UMN LESIONSUMN LESIONS

SPINAL LESIONS (common)SPINAL LESIONS (common) Spinal cord compression( Pott’s disease,disc Spinal cord compression( Pott’s disease,disc

prolapse or fracture, tumors,epidural prolapse or fracture, tumors,epidural abscess,cervical spondylosis etc)abscess,cervical spondylosis etc)

VASCULARVASCULAR Hemorrhage, InfarctionHemorrhage, Infarction SYSTEMIC DEGENERATION OF TRACTSSYSTEMIC DEGENERATION OF TRACTS Multiple sclerosis, MND, Sub acute combined Multiple sclerosis, MND, Sub acute combined

degeneration of cord. degeneration of cord. INFECTION INFECTION Transverse myelitis, NeurosyphilisTransverse myelitis, Neurosyphilis

UMN LESIONSUMN LESIONS

CEREBRAL LESIONS CEREBRAL LESIONS (uncommon)(uncommon)

Thrombosis of superior sagital Thrombosis of superior sagital sinussinus

Tumor of falx-cerebriTumor of falx-cerebri

HydrocephalusHydrocephalus

LMN LESIONSLMN LESIONS

Anterior horn cellsAnterior horn cells

Poliomyelitis, Motor neuron diseasePoliomyelitis, Motor neuron disease Peripheral nervePeripheral nerve

Peripheral neuropathyPeripheral neuropathy Neuromuscular junctionNeuromuscular junction

Myasthenia gravisMyasthenia gravis MusclesMuscles

Muscular dystrophiesMuscular dystrophies

SPINAL CORD SPINAL CORD COMPRESSIONCOMPRESSION

It may be acute with It may be acute with trauma,metastasistrauma,metastasis or or

Arterial occlusionArterial occlusion or it may be slow or it may be slow developing over weeks as in developing over weeks as in Pott’s Pott’s disease,cervical spondylosisdisease,cervical spondylosis etc. etc.

POTT’S DISEASEPOTT’S DISEASE

TB of spine often involves two or TB of spine often involves two or more adjacent vertebral bodies. more adjacent vertebral bodies. Lower thoracic and upper lumber Lower thoracic and upper lumber vertebrae are commonly vertebrae are commonly involved.Intervertebral disc is also involved.Intervertebral disc is also destroyed. With advanced disease destroyed. With advanced disease paravertebral cold abscessparavertebral cold abscess , , gibbusgibbus formationformation and and PARAPLEGIAPARAPLEGIA occur. occur.

TRANSVERSE MYELITISTRANSVERSE MYELITIS It is an acute or subacute It is an acute or subacute

inflammation of spinal cord inflammation of spinal cord occuring after infection or recent occuring after infection or recent vaccination. Many agents like vaccination. Many agents like influenza,measles,CMV,EBV and influenza,measles,CMV,EBV and mycoplasma have been mycoplasma have been implicated.implicated.

Guillain Barre SyndromeGuillain Barre Syndrome

Acute inflammatory or post-Acute inflammatory or post-infective demyelinating infective demyelinating polyneuropathy. polyneuropathy.

Develops 1-3 weeks after Develops 1-3 weeks after respiratoryinfection or diarrhea in respiratoryinfection or diarrhea in >70% cases.>70% cases.

Ascending polyneuropathy.Ascending polyneuropathy.

MOTOR NEURON DISEASEMOTOR NEURON DISEASE

Progressive degenerative disorder of Progressive degenerative disorder of upper and lower motor neurons in spinal upper and lower motor neurons in spinal cord,cranial motor neurons and cord,cranial motor neurons and pyramidal neurons in motor cortex.pyramidal neurons in motor cortex.

Cause- unknown.Cause- unknown. PatternsPatterns

Progressive bulbar palsyProgressive bulbar palsy

Progressive muscular atrophyProgressive muscular atrophy

Amytrophic lateral sclerosis.Amytrophic lateral sclerosis.

SUBACUTE COMBINED SUBACUTE COMBINED DEGENERATIONDEGENERATIONOF SPINAL CORDOF SPINAL CORD

Syndrome of combined spinal cord Syndrome of combined spinal cord and peripheral nerve damageand peripheral nerve damage

cause: Vit.B12 deficinencycause: Vit.B12 deficinency Changes start in posterior columnn Changes start in posterior columnn

(affecting vibration and position (affecting vibration and position sense) then involve lateral sense) then involve lateral column(pyramidal tracts)column(pyramidal tracts)

MYASTHENIA GRAVISMYASTHENIA GRAVIS

Acquired autoimmune disorder of Acquired autoimmune disorder of NMJ.NMJ.

Causes skeletal muscle fatigubility Causes skeletal muscle fatigubility and weakness, esp of proximal and weakness, esp of proximal limb muscles,ocular anb bulbar limb muscles,ocular anb bulbar muscles.muscles.

DUCHENNE’S MUSCULAR DUCHENNE’S MUSCULAR DYSTROPHYDYSTROPHY

X-linked recessive disorderX-linked recessive disorder Deficiency of protein dystrophin in Deficiency of protein dystrophin in

muscles. muscles. Symptoms start in Symptoms start in

childhood,become severe in childhood,become severe in adolescence and death occurs by adolescence and death occurs by age 20 years.age 20 years.

MANAGEMENT OFMANAGEMENT OF PARAPLEGIAPARAPLEGIA

HISTORYHISTORY EXAMINATIONEXAMINATION INVESTIGATIONS INVESTIGATIONS TREATMENTTREATMENT

HISTORYHISTORY

AGE AND SEXAGE AND SEX Young age: Inherited disorders,muscle Young age: Inherited disorders,muscle

dis.,infectionsdis.,infections Old age: malignancies r common.Old age: malignancies r common. DURATIONDURATION ACUTE:GBS,transverse myelitis, cord compression.ACUTE:GBS,transverse myelitis, cord compression. CHRONIC:MND,polyneuropathies,muscle dis.CHRONIC:MND,polyneuropathies,muscle dis. SPHINCTER DISTURBANCESSPHINCTER DISTURBANCES (INITIALLY (INITIALLY

URGENCY OR HESITENCY OF MICTURATION,THEN URGENCY OR HESITENCY OF MICTURATION,THEN URINARY RETENTION)URINARY RETENTION)

Seen in UMN lesions.Seen in UMN lesions.

HISTORYHISTORY

SENSORY SYMPTOMSSENSORY SYMPTOMS Numbness,tingling and hyperesthesias in Numbness,tingling and hyperesthesias in

neuropathy.neuropathy. ROOT PAINROOT PAIN In cord compression.In cord compression. BACKACHEBACKACHE In cord compression,transverse myelitis.In cord compression,transverse myelitis. HEADACHE,VOMITINGHEADACHE,VOMITING Intracranial lesionsIntracranial lesions PRECEDING FEVER,URTIPRECEDING FEVER,URTI In GBSIn GBS

EXAMINATIONEXAMINATION MOTOR SYSTEMMOTOR SYSTEM

FEATURESFEATURES UMNLUMNL LMNLLMNL

Muscle Muscle waistingwaisting

absenabsentt

presenpresentt

Muscle toneMuscle tone

PowerPower

Deep reflexesDeep reflexes ++++++ __

Superficial Superficial reflexreflex

absenabsentt

presenpresentt

PlantersPlanters

FasciculationsFasciculations absenabsentt

presenpresentt

SENSORY SYSTEMSENSORY SYSTEM

Sharp sensory level in transverse Sharp sensory level in transverse myelitis differentiates it from GBS. myelitis differentiates it from GBS. Neuropathy:glove and stocking Neuropathy:glove and stocking distribution.distribution.

Romberg sign +ve if posterior Romberg sign +ve if posterior column is involved.column is involved.

SIGNS OF SPINAL CORD SIGNS OF SPINAL CORD COMPRESSIONCOMPRESSION

CERVICAL,ABOVE C5CERVICAL,ABOVE C5 UMN signs and sensory loss in all 4 limbsUMN signs and sensory loss in all 4 limbs CERVICAL,C5 TO T1CERVICAL,C5 TO T1 LMNsigns and segmental sensory loss in LMNsigns and segmental sensory loss in

arms,and UMN signs in legsarms,and UMN signs in legs THORACIC CORDTHORACIC CORD Spastic paraplegia with a sensory level on trunk.Spastic paraplegia with a sensory level on trunk. CONUS MEDULLARISCONUS MEDULLARIS Sensory loss in sacral area and extensor plantar Sensory loss in sacral area and extensor plantar

responseresponse CAUDA EQUINACAUDA EQUINA LMN signs in lower limbs.LMN signs in lower limbs.

EXAMINATION EXAMINATION

EXAMINATION OF SPINEEXAMINATION OF SPINE

For deformity and tenderness.For deformity and tenderness. SPHINCTERSSPHINCTERS:Look for incontinence or :Look for incontinence or

retention of urine or faecesretention of urine or faeces.. OTHER FEATURES:OTHER FEATURES:

Anemia-B12 deficiencyAnemia-B12 deficiency

Stiff neck in cervical spondylosisStiff neck in cervical spondylosis

Site of malignancy.Site of malignancy.

INVESTIGATIONSINVESTIGATIONS X-RAY SPINE:X-RAY SPINE: May show collapse or erosion of May show collapse or erosion of

vertebrae,herniated interverteberal disc,mets.,# or vertebrae,herniated interverteberal disc,mets.,# or dislocation of vertebra etc.dislocation of vertebra etc.

MRI:MRI: Investigation of choiceInvestigation of choice CT SCANCT SCAN BLOOD CP:BLOOD CP: Megaloblastic anemia in subacute combined Megaloblastic anemia in subacute combined

degeneration of spinal cord.degeneration of spinal cord.

ESR is raised in inflammatory cases.ESR is raised in inflammatory cases.

CSF CSF

INVESTIGATIONSINVESTIGATIONS

CSF examination:CSF examination:

Inflammatory lesionsInflammatory lesions, both cells and proteins , both cells and proteins are increased.are increased.

InIn malignancy malignancy,malignant cells may be ,malignant cells may be present.present.

In In transverse myelitistransverse myelitis ,proteins are increased ,proteins are increased and upto 50 lymphocytes/cmm are present.and upto 50 lymphocytes/cmm are present.

In In MSMS,monoclonal IgG is increased.,monoclonal IgG is increased.InIn GBS GBS,protein cell dissociation is seen.,protein cell dissociation is seen.

INVESTIGATIONSINVESTIGATIONS MYELOGRAPHY:MYELOGRAPHY: Site of cord compression is Site of cord compression is

demonstrated.demonstrated. NERVE CONDUCTION STUDIESNERVE CONDUCTION STUDIES:: Helpful in diagnosis of neuropathies.Helpful in diagnosis of neuropathies. FUNDOSCOPY:FUNDOSCOPY: For papilloedema due to intracranial For papilloedema due to intracranial

tumor or MS.tumor or MS. BONE SCAN:BONE SCAN: Mets and inflammatory vertebral Mets and inflammatory vertebral

lesions r detected. lesions r detected.

TREATMENTTREATMENT

GENERAL MEASURESGENERAL MEASURESSKIN CARE:SKIN CARE:Change posture every 2-4 hrly to avoid bed Change posture every 2-4 hrly to avoid bed

sores.sores.Keep skin dry and clean.Keep skin dry and clean.BLADDER CARE:BLADDER CARE:CATHETERIZATION for urinary retention.CATHETERIZATION for urinary retention.BOWEL CARE:BOWEL CARE:Avoid constipation by suitable diet and Avoid constipation by suitable diet and

laxatives.laxatives.

TREATMENTTREATMENT

PREVENTION OF PREVENTION OF CONTRACTURESCONTRACTURES

By regular passive movements.By regular passive movements. REHABILITATIONREHABILITATION

By using wheel chair,standing By using wheel chair,standing frames,vocational training etc.frames,vocational training etc.

SPECIFIC TREATMENTSPECIFIC TREATMENT

POTT’S DISEASEPOTT’S DISEASE

ImmobilizationImmobilization

ATT ATT

Surgery:Anterior transthoracic Surgery:Anterior transthoracic decompression.decompression.

TRANSVERSE MYELITISTRANSVERSE MYELITIS

Glucocorticiods are given.Initially I/V Glucocorticiods are given.Initially I/V methylprednisolone,then oral methylprednisolone,then oral prednisolone.prednisolone.

TREATMENTTREATMENT

MNDMND Symptomatic T/M like Symptomatic T/M like

physiotherapy,walking aids,splints and physiotherapy,walking aids,splints and speech therapy.speech therapy.

Glutamate antagonist,RILUZOLE ?Glutamate antagonist,RILUZOLE ? SUBACUTE COMBINED SPINALCORDSUBACUTE COMBINED SPINALCORD

DEGENERATIONDEGENERATION Injection vit.B12 1000 ug I/M daily for 7-Injection vit.B12 1000 ug I/M daily for 7-

10 days,then weekly for a month and 10 days,then weekly for a month and then monthly for whole life.then monthly for whole life.

TREATMENTTREATMENT

GBSGBS Plasma pharesis(effective only in first 2 Plasma pharesis(effective only in first 2

weeks)weeks) i/v immunoglobulins(2g/kg in 5 days)i/v immunoglobulins(2g/kg in 5 days) No role of steriods.No role of steriods.

SPINAL CORD TUMORSSPINAL CORD TUMORS RadiotherapyRadiotherapy Surgical decompression.Surgical decompression.

COMPLICATIONSCOMPLICATIONS

BEDSORESBEDSORES BOWEL AND BLADDER INCONTINENCEBOWEL AND BLADDER INCONTINENCE DVTDVT PULMONARY EMBOLISMPULMONARY EMBOLISM PSYCHIATRIC LAYOUTPSYCHIATRIC LAYOUT HYPOSTATIC PNEUMONIAHYPOSTATIC PNEUMONIA DISEASE RELATED COMLICATIONSDISEASE RELATED COMLICATIONS

THANK YOUTHANK YOU