Localizaiton of level of lesion in paraplegia

LOCALISATION OF THE LEVEL OF LESION IN A

COMPRESSIVE MYELOPATHY

SPINAL CORD

31 segments

Embryological developmentgrowth of cord lags behind mature spinal cord ends at L1

Upper quadriplegia + weakness of diaphragm

C4-C5 Quadriplegia

C5-C6 Biceps

Cervical cord

C7 extensors

C8 flexion

Nipples T4 Umbilicus T10

SENSORY LEVEL

Disturbance of bladder & bowel habits

Thoracic cord

L2-L4 Paralysis of flexion & adduction of thigh + weakening of leg extension at knee+ patellar reflex lost

L5-S1 Mvmnts of foot & ankle + flexion & knee + extension of thigh + ankle jerk LOST

Lumbar cord

B/L saddle anaesthesia [S3-S5]

Bladder & Bowel dysfunction

Impotence

Bulbocavernosus & anal reflexes absent

Muscle strength preserved

Conus medullaris

Low back& radicular pain

Asymmetrical leg weakness , sensory loss,areflexia in lower extremities

Sparing of bowel & bladder function

Cauda equina

1) Distribution of root pain

ask for specific dermatomes involved

due to the involvement of posterior nerve roots

2) Upper border of sensory loss

examine the patient from below upwards for demonstration of upper border of sensory loss

Due to the affection of spinothalamic tract

3) Girdle like sensation / sense of constriction at the level of lesion

due to the involvement of posterior column

4) Zone of hyperaesthesia/ hyperalgesia

localise the level of lesion one segment below

Due to compression of posterior nerve roots

5) Analysis of abdominal reflex

[ upper abdominal reflex (T7-T9) intact - loss of middle (T9-T11) & lower (T11-T12) ones - site of lesion is probably at T10 spinal segment ]

6) Atrophy of the muscles in a segmental distribution

Due to involvement of anterior horn cells

7) Loss of deep reflexes if the particular segment is innvolved

brisk below the involved segment

8) Analysis of BEEVOR’S SIGN

when the patient attempts to lift his head up from the pillow, against resistance

Rectus abdominis

useful in deciding the level of thoracic spoinal cord lesions

9) Deformity / any swelling in the vertebra

10) Tenderness in the verterbra

11) Area of sweating

Lack of sweating below the level

12) level can also be localised by X-Ray of the spine, Myelography, CT Scan / MRI

DETERMINATION OF SPINAL SEGMENTS IN RELATION TO VERTEBRA…

Cervical vertebra

add 1

T1 - T6

Add 2

T7 – T9

Add 3

T 10

overlies L 1 & L 2 segments

T 11

overlies L 3 & L4 Segments

T 12

Arch overlies L 5 segment

L I arch overlies sacral & coccygeal segments

In the case of non-compressive myelopathy , the question of localisation of the level of lesion does not arise

Synopsis Of Bladder Dysfunction In Neurological Diseases NEUROGENIC BLADDER

UB receives nerve supply from sympathetic- L 1,2,3 [ NERVE OF FILLING ] & Parasympathetic- S 2,3,4 [NERVE OF EVACUATION]

SPINAL BLADDER

A) Incomplete lesion

Precipitancy involvement of inhibitory fibres [multiple sclerosis]

Hesitancy facilitatory fibres involved [incomplete cord compression]

B) Complete lesion

1-Retention of urine wt overflow incontinence

commonly seen in ‘neural shock stage’ of a/c transverse myelitis

evacuation of bladder is usually

incomplete

2-Automatic Bladder

evacuation complete

commonly seen when the neuronal shock stage is over& evacuation occurs by local reflex arc

frequency, urgency &urge incontinence

C) Lesion in the local reflex arc

1- sensory paralytic bladder

loss of awareness of fullness of bladder large volume of urine collects in the

bladder wt huge residual volume

2- motor paralytic bladder

inability to initiate & continue micturition

seen in trauma, pelvic neoplasm

3- Autonomous bladder-

common in cauda equina lesions, pelvic malignancy, spina bifida

no sensation of bladder fullness, bt

having continuous dribbling

THANK YOU…..