Flaccid paraplegia divya sai.pptx neurology

A case of flaccid paralysis

1. CNS CASE PRESENTATION Presenter – Dr. G Divya Sai Post graduate, General Medicine

2. Patient Details Name: XYZ Age: 35 years Gender: Male Address: Puthupet , Pondicherry Occupation: Hospital attender Informant : Patient himself

3. Chief Complaints Weakness of both lower limbs since 8 years Loss of sensations in both lower limbs since 8 years Difficulty in passing urine and stools since 8 years

4. History of Presenting Illness Patient was apparently normal until August 2015 , when he suffered a road traffic accident while riding a two wheeler. He was hit from behind by a car after which he fell on his back on the bonnet of the car, following which he fell on the ground and had loss of consciousness for approximately 5 minutes. He was woken up by people near by and he complained sudden severe back pain, which was localized, non radiating and aggravated when he tried to move. When he tried getting up, he was unable to do so on his own and was unable to move both his lower limbs.

5. People nearby lifted him up. He was unable to stand even with support and fell down immediately. He noticed his limbs were loose and flail after that trauma. He was also not able to feel the sensation of his clothes below the knee. He was able to respond to the people around him appropriately. He was immediately taken to nearby hospital(PIMS) in a car in sitting position. After reaching the hospital, he was not able to feel the sensation of his clothes from below hip. He underwent a spinal surgery the very next day.

6. Post surgery - The weakness of both lower limbs has remained the same, without worsening or improving . Both limbs effected simultaneously and symmetrically with both proximal and distal weakness. Since that incident he is unable to use his both limbs. The lower limbs were loose and there was no stiffness or heaviness of lower limbs at any time. There is no h/o weakness in upper limbs, able to do all daily activities with upper limbs like buttoning shirt, mixing food, combing hair. Able to lift his neck from pillow. Able to roll over the bed and get up from the bed. No h/o difficulty in breathing. For the subsequent years, he noticed thinning in both lower limbs, it was not associated with twitching of muscles.

7. He noticed that he was unable to feel the clothes and bedsheet from below umbilicus post surgery.. Not able to perceive touch, pain, hot and cold sensations below umbilicus. He gave history of a constricting broad band like sensation below umbilicus. The lower back pain was continued post surgery but intensity reduced. The pain was more in lying down posture, non radiating and, the pain was reduced in sitting posture when compared to lying down posture, which was relieved only after heavy medications. He is able to feel clothes , hot and cold sensation above umbilicus. There is no unsteadiness on closing his eyes or washing his face in sitting position. No h/o tingling, burning sensations. No electric shock like sensation down the spine while flexing or extending his neck.

8. Patient was catheterized during spinal surgery. 4 days later, when urinary catheter was clamped for removal, he was not able to appreciate bladder fullness. When the catheter was removed, he was unable to appreciate bladder sensation, unable to initiate micturition. After a few hours of removing catheter, he noticed urine dribbling constantly in small amounts, and suprapubic fullness was present. He was catheterized again; almost 2 liters of urine was drained. Presently patient himself catheterizing on his own 3 times a day in a periodical manner or whenever he see the dribbling from urethra.

9. Patient didn’t pass stool for 4 days post surgery, initially suppositories were given but they were not helpful. He was unable to initiate defecation. Manual evacuation of stool was done At present performing manual evacuation of stool daily. History of erectile dysfunction is present since the traumatic event. He noticed there was decreased sweating present in both lower limbs and limbs were dry always.

10. No h/o decreased sense of smell, visual disturbances, double vision, drooping of eye lids, difficulty in appreciating hot and cold water while washing his face, asymmetry of face, inability to close eyes, diminution of taste sensation, loss of hearing, tinnitus, vertigo, difficulty in swallowing, nasal regurgitation, nasal twang of voice, difficulty in lifting arms above his head and turning his head. No spillage of food while eating nor clumsiness of hand. No h/o giddiness or palpitation. No history of neck stiffness, fever, headache, seizure or photophobia prior to the episode. No history of loss of weight, recent vaccination, exposure to pesticides, chemicals or heavy metals.

11. Past history : Not a known diabetic/hypertensive/asthmatic/epilepsy/TB Personal history : Mixed diet Smokes 1 cigarette /day for 5 years before trauma. Used to drink 180 ml of Brandy everyday for 5 years before trauma. Married and have 2 children ( the elder is 12 years and the younger is 10 years)

12. Family history: Born out of a non consanguinous marriage. Birth history not known. Developmental history not known .

13. History Summary 35 years old male with no previous comorbidities presented with acute onset bilateral symmetrical flaccid weakness of both lower limbs since the day of trauma,8 years ago, which is static and associated with wasting. There is pan sensory loss of touch, pain , temperature and vibration(mobile phone) sensations from below umbilicus associated with band like sensation below umbilicus with significant autonomic involvement of bowel and bladder (autonomous type) dysfunction, without involvement of cranial nerves, higher mental functions and cerebellum. Probably Lesion is in lower spinal cord with definite sensory level also there are features suggesting conus , cauda equina syndrome probably secondary to trauma. DD: Traumatic myeloradiculopathy with cauda equina syndrome Ischemic myeloradiculopathy due to Injury of artery of Adamkiewicz due to trauma Vertebral fracture dislocation at multiple levels / herniation of disc

14. General Examination Conscious, oriented, cooperative, stable at rest. Normally built and nourished. Right handed individual. Afebrile No pallor, icterus, clubbing, cyanosis, lymphadenopathy, pedal edema.

15. No neurocutaneous markers. No peripheral nerve thickening. Tattoos over both arms present Ulcer present over right gluteal region. Surgical scar present over T12 vertebra.

16. VITAL DATA - PR- 95/Minute, regular in rate, rhythm, normal volume, no specific character, no vessel wall thickening, no radio radial or radio femoral delay. BP – 120/80mmHg, measured in the right upper limb in supine position and 100/60 mmHg in sitting position. RR – 14/Minute , regular , abdominothoracic Temp = 98 F

17. NERVOUS SYSTEM EXAMINATION Higher Mental Function Conscious and well oriented to time, place and person Memory- Immediate, Recent and Remote intact Speech and language – normal No emotional lability No delusions, hallucinations. MMSE: 28/30

18. Cranial nerve Right Left I- perceives smell of coffee N N II- visual acuity (Snellen’s) Visual field (confrontation) Color vision Fundus 6/6 N N N 6/6 N N N III, IV, VI- Ptosis Squint Extraocular movements Pupil size Light reflex(direct, indirect) Accommodation Smooth pursuit Saccades No No Full 3mm + + Normal Normal No No Full 3mm + + Normal Normal V- Sensory: over opthalmic , maxillary and mandibular divisions Motor- temporalis, masseter and pterygoids Reflex- corneal, conjunctival, jaw jerk Intact Normal + Intact Normal +

19. Cranial nerve Right Left VII- Motor: wrinkling of forehead Closing of eyes Nasolabial fold Puffing of cheeks Angle of mouth Sensory: Taste over ant 2/3 rd of tongue Sensation over tragus Secretomotor: Moistness of eyes and tongue N N N N N N N N N N N N N N N N VIII- Rinne’s Test Webers test AC>BC No lateralization AC>BC IX, X- Uvula Gag reflex Palatal movements Midline Normal Normal and equal on both sides Normal XI- Trapezius and Sternocleidomastoid N N XII- Tongue- Bulk,Tone Fibrillation Power and tongue protrusion N - N N - N

20. Motor System Attitude: Patient in supine position B/L ULs on the side of the body B/L LLs – extended, externally rotated , plantar flexed. Wasting noted over both the lower limbs which is symmetrical and with both proximal and distal. Fasiculations (-)

21. Bulk Right (in cm) L1eft (in cm) 10cm above olecranon 31 31 10 cm below olecranon 19 18 18 cm above tibial tuberosity 35 35 10 cm below tibial tuberosity 25 24 Tone Right Left Upper limb Normal Normal Lower limb hypotonia hypotonia BULK TONE

22. POWER:  Upper limbs   Right Left Shoulder         Abduction 5/5 5/5   Adduction 5/5 5/5   Flexion 5/5 5/5   Extension 5/5 5/5 Int. Rotation 5/5 5/5 Ext. Rotation 5/5 5/5 Elbow     Flexion 5/5 5/5 Extension 5/5 5/5 Wrist     Flexion 5/5 5/5   Extension 5/5 5/5 Hand grip Small muscles of hand   GOOD GOOD

23. Lower limb Right Left Hip Flexion 0/5 0/5 Extension 0/5 0/5 Adduction 0/5 0/5 Abduction 2/5 2/5 Int. Rotation 0/5 0/5 Ext. Rotation 0/5 0/5 Knee Flexion 0/5 0/5 Extension 0/5 0/5 Ankle Dorsi flexion 0/5 0/5 Plantar flexion 0/5 0/5

24. DTR  Right Left Biceps (++) (++) Triceps (++) (++) Brachio radialis (++) (++) Knee ( with reinforcement) Absent Absent Ankle ( with reinforcement Absent Absent Beevor’s sign _  Superficial reflexes Right Left Corneal + + Conjunctival + + Jaw jerk + + Abdominal Upper, middle + Lower reflex - Cremasteric - Bulbocavernous Absent ( lax anal sphincter) Anal absent Plantar No response No response

25. Left and right ( dermatomes) Crude Touch Normal till T10 Decreased from from T11 to T12 Below T12 completely absent Pain Temperature Normal till T10 Decreased from from T11 to T12 Below T12 completely absent Fine touch Normal till T10 Absent below T10 Vibration Able to perceive vibration sense till L5 spinal process and absent below L5 spinal process. Joint position joint position sense lost at and below hip joint. Per rectum Saddle anesthesia and perianal sensations lost Cortical: Tactile localisation Two point discrimination Graphaesthesia Stereognosis Not checked as primary modality sensations lost.

26. Cerebellum Titubation - Nystagmus - Rebound phenomenon - Dysdiadokokinesia absent Finger finger test Normal Finger nose test Normal Heel knee test Could not be checked Pendular knee jerk - Tandem walking/ truncal or gait ataxia Could not be checked

27. AUTONOMIC NERVOUS SYSTEM- Postural hypotension - present  Abnormal sweating – + Resting tachycardia – + Bladder ( autonomous type) and bowel dysfunction Erectile dysfunction GAIT : could not be assessed

28. Meningeal signs: Kernig's and Brudzinski negative Spine and Cranium: Normal No gibbus CVS: S1S2 (+). No murmurs. RS: BAE (+), NVBS, No added sounds PA: Soft, non-tender, no organomegaly.

29. Summary Traumatic acute flaccid paraplegia with wasting Band like sensation @ T12 Complete sensory loss below T12 with saddle anesthesia and perianal anesthesia Bowel and bladder involvement. Absent patellar and ankle reflexes. Absent cremastic , bulbocavernous and lower abdominal reflexes.

30. Diagnosis Acute onset symmetrical flaccid paraplegia with pansensory loss below T12 associated with wasting involving autonomic nervous system with bladder ( autonomous type), bowel and erectile dysfunction. No involvement of higher mental functions, cranial nerves and cerebellum. Possible site of lesion is lower thoracic and lumbar spinal cord involving both cauda equina and conus. Motor level – L1 Sensory Level: T12 Superficial Reflex Level: T11 Vertebral level – D9 / D10

31. DIFFERENTIAL DIAGNOSIS Traumatic myeloradiculopathy producing Conus & Cauda Equina Syndromes Injury of artery of Adamkiewicz producing ischemic myeloradiculopathy.

32. SPINAL CORD Cauda Conus conus and cauda with Spinal cord involvement Favouring = Particular sensory level + Band like sensation + Unfavouring = Flaccid paraplegia LMN bladder Favouring = Flaccid paraplegia LMN bladder Unfavouring = Symmetrical No root pain Early bladder Favouring = No root pain Bulbocavournous , anal reflex – absent Saddle anesthesia Early LMN bladder Unfavouring = Motor level at L1 knee reflex absent

33. Plain MRI spine Pedicles screw fixation @ T11,T12 and L1 levels. The vertebral alignment is maintained, there are MRI artefacts associated with the implant due to which the neural elements are not well visualised at these levels. The spinal canal at these levels appears adequate and the spinal cord above and cauda equina below appears normal. No syringomyelia.

34. Thank you 