Approach to Paraperesis

Approach to Paraperesis

1. Approach to Paraperesis Dr. Navin Adhikari

2. Spinal reflex p athway

3. Potential workup for transverse myelities from uptodate

4. APPROACH TO THE PATIENT Compressive and Noncompressive Myelopathy differentiation first.

5. Inflammatory and Immune Myelopathies ( Myelitis ) the demyelinating conditions MS, NMO, and postinfectious myelitis , as well as sarcoidosis and systemic autoimmune disease one-quarter of cases of myelitis , no underlying cause can be identified. . Recurrent episodes of myelitis are usually due to one of the immune-mediated diseases or to infection with herpes simplex virus (HSV) type 2

6. inflammation of TM is generally restricted to one or two segments, usually in the thoracic cord develop rapidly over several hours; approximately 37 percent of patients worsen maximally within 24 hours inflammation is bilateral, producing weakness and multimodality sensory disturbance below the level of the lesion In addition to diminished sensation, pain and tingling are common and frequently include a tight banding or girdle-like sensation around the trunk, which may be very sensitive to touch. Back and radicular pain are also common. Bowel and bladder dysfunction, reflective of autonomic involvement, also occur.

7. Magnetic resonance imaging (MRI) of the involved section of the spinal cord shows gadolinium-enhancing signal abnormality, usually extending over one or more cord segments. Cerebrospinal fluid (CSF) is abnormal in half of patients, with elevated protein level (usually 100 to 120 mg/100 mL ) and moderate lymphocytosis (usually <100/mm 3 )

8. Transverse myelitis can occur as part of the spectrum of MS. In some cases, transverse myelitis is the initial demyelinating event. Transverse myelitis manifesting as a longitudinally extensive spinal cord lesion spanning three or more vertebral segments is one of the characteristic manifestations, along with bilateral optic neuritis, of NMOSD. Transverse myelitis may be seen in patients with acute disseminated encephalomyelitis.

9. spastic paraplegia Causes (7 T’s): • Trauma. • Tuberculosis ( Pott’s disease). • Tumour ( meningioma , neurofibroma , lymphoma, leukaemia , myeloma, glioma , secondary deposit). • Transverse myelitis . • Tabes dorsalis . • Twelve (B12 deficiency). • Thrombosis of anterior spinal artery

10. Cerebral causes of spastic paraplegia As follows: • Parasagittal meningioma (usually involving falx meningioma ). • Thrombosis of superior longitudinal sinus. • Thrombosis of unimpaired anterior cerebral artery. • Multiple cerebral infarctions. • Hydrocephalus. • Trauma. • In children, cerebral palsy (cerebral diplegia , usual lesion is bilateral parasagittal cortical lesion)

11. Localisation of the level of compressive myeloathy Distribution of root pain Upper border of sensory loss— Girdle-like sensation or sense of constriction at the level of lesion (usually due to involvement of posterior column Zone of hyperaesthesia or hyperalgesia —This will localise the level of lesion one segment below i.e., zone of hyperaesthesia is present just above the level of girdle-like sensation, and is due to compression of posterior nerve roots Analysis of abdominal reflex— f upper abdominal reflex is intact with loss of middle and lower one, the site of lesion is probably at T10 spinal segment

12. Analysis of Beevor's sign (do the ‘rising test’. In paralysis of lower part of rectus abdominis , umbilicus moves upwards and in paralysis of upper part of rectus, umbilicus goes downwards)— Beevor’s sign detects the weakness of abdominal muscles. Deformity or any swelling in the vertebra. Tenderness in the vertebra.

13. Spastic paralysis GRADUAL ONSET : I. Cerebral causes—Cerebral diplegia , parasagittal meningioma , hydrocephalus. II. Spinal causes— a) Compressive or transverse lesion in the spinal cord—Cord compression (see below). b) Non-•compressive or longitudinal lesion or systemic diseases of the spinal cord ( i ) Motor neurone disease (MND) e.g., amyotrophic lateral sclerosis. (ii) Multiple sclerosis, Devic’s disease. (iii) Friedreich’s ataxia. (iv) Subacute combined degeneration (i.e., from vitamin B(2 deficiency). (v) Lathyrism . (vi) Syringomyelia . (vii) Hereditary spastic paraplegia. (viii) Syphilitic meningomyelitis (rare). (ix) Tropical spastic paraplegia. (x) Paraneoplastic myelitis . (xi) Antiphospholipid antibody syndrome. (xii) Radiation myelopathy

14. SUDDEN ONSET: I. Cerebral causes—Thrombosis of unpaired anterior cerebral artery, superior sagittal sinus thrombosis, bullet injury at paracentral lobule. II. Spinal causes— a) Acute transverse myelitis . b) Injury to the spinal cord (fracture-dislocation or collapse of the vertebra). c) Thrombosis of anterior spinal artery ( myelomalacia ). d) Haematomyelia (from arteriovenous malformations, angiomas , or endarteritis). e) Post- vaccinal . f) Prolapsed intervertebral disc (PID). g) Spinal epidural abscess or haematoma . h) Radiation myelopathy .

15. . Intramedullary (5%) : a) Glioma . b) Ependymoma . c) Chordoma . d) Syringomyelia , haematomyelia . n. Extramedullary : a) Intradural (15%)— ( i ) Meningioma . (ii) Neurofibroma . (iii) Patchy arachnoiditis (tuberculosis, syphilis, sarcoidosis ). (iv) Arteriovenous malformations. b) Extradural (80%)— ( i ) Caries spine ( Pott’s paraplegia). (ii) Myeloma, lymphomatous or metastatic deposits in the vertebra; osteomyelitis . (iii) Patchy meningitis. (iv) Prolapsed intervertebral disc (PID).

16. A) UMN LESION IN SHOCK STAGE—i.e., sudden onset spastic paraplegia in 'neural shock’ stage e.g., acute transverse myelitis , spinal injury. (B) LESION INVOLVING ANTERIOR HORN CELLS — a) Acute anterior poliomyelitis. b) Progressive musclular atrophy (variety of MND). c) Trauma. (C) DISEASES AFFECTING NERVE ROOTS— Tabes dorsalis , radiculitis , G.B. syndrome. (D) DISEASES AFFECTING PERIPHERAL NERVES— a) Acute infective polyneuropathy (G.B. syndrome). b) High cauda equina syndrome. c) Disease of peripheral nerves involving both the lower limbs. d) Lumbar plexus injury (e.g., posas abscess or haematoma ). (E) DISEASES AFFECTING MYONEURAL JUNCTION— a) Myasthenia gravis, Lambert-Eaton syndrome. b) Periodic paralysis due to hypo- or hyperkalaemia . (E) DISEASES AFFECTING MUSCLES— Myopathy . (F) HYSTERICAL PARALYSIS.

17. History

18. Examination

19. Terminology ‘ Plegia ’ means complete or near complete paralysis, and ‘paresis’ means weakness or partial paralysis Paraplegia : Paralysis of both the lower limbs (mostly due to spinal cord lesion) Paraparesis : Weakness of both the lower limbs. Quadriplegia or tetraplegia : Paralysis of all the four limbs, and also the trunk (a feature of cervical cord disease). Monoplegia : Paralysis of one limb Bi-brachial paralysis : Paralysis of both upper extremities.

20. Management

21. CAUSES OF PARAPARESIS Trauma to spinal cord – most common cause other non traumatic etiologies of myelopathy include autoimmune, infectious, neoplastic , vascular, and hereditary-degenerative diseases