Paraplegia

paraplegia

1. APPROACH TO PARAPLEGIA IN CHILDREN Dr. C. Kannan Post graduate Pediatrics MGMCRI

2. DISCUSSION Definition Etiology Classification A natomy Approach to patient Clinical features Examination Investigations Conditions A/W paraplegia Management Complications

3. PARAPLEGIA Originates from Greek language Para + plēssein means ‘strike at side’ Impairment in motor function of the lower extremities With or without involvement of sensory system Paraplegia - Complete paralysis Paraparesis - Partial paralysis

4. CAUSES OF PARAPLEGIA Cerebral Spinal Infection Immuno-allergic Inflammatory Demyelinating Heredofamilial Toxic myelopathy Vascular Metabolic/nutritional Tropical Para neoplastic syndromes Physical agents

5. CEREBRAL 1. Causes in the Parasagittal Region Traumatic Depressed fracture of the vault of the skull Subdural hematoma Vascular Superior sagittal sinus thrombosis Inflammatory Encephalitis Meningo -encephalitis Neoplastic Parasagittal meningioma Degenerative Cerebral palsy

6. Contd., 2. Causes in the Brain Stem Syringobulbia and midline tumours. These lesions arise in the midline Involves the innermost fibers Which supplies lower limbs

7. SPINAL 1. Intramedullary Syringomyelia Hematomyelia Ependymoma Glioma Astrocytoma 2. Extramedullary Intradural Meningioma Neurofibroma Arachnoiditis Extradural

8. Contd., Extradural Vertebral Fracture or fracture-dislocation of the vertebra Disc prolapse and spondylosis Deformity of the vertebral (e.g. kyphoscoliosis) Infective - Pott's disease Congenital - S pina bifida Neoplastic diseases - Primary(myeloma)/metastatic( leukemia ) Paravertebral – Abscess/hematoma/aortic aneurysm

9. INFECTIVE CAUSES Bacterial Acute - Staphylococcal (extradural or intradural) Chronic - Tuberculosis/Syphilis Parasitic Hydatid Cysticercosis Schistosomiasis Viral Polio/Rabies/Herpes zoster/HIV

10. OTHERS Inflammatory Transverse myelitis Myelomeningitis/ Myeloradiculitis Immuno Allergic causes Post vaccinal – Rabies/tetanus/polio Post exanthematous - Chicken pox/Herpes zoster Demyelinating Multiple sclerosis/ Neuromyelitis optica /SACD

11. CLASSIFICATION Based upon nervous system involved and tone Paraplegia is classified into Spastic paraplegia Flaccid paraplegia .

12. SPASTIC PARAPLEGIA Weakness of muscles + increased tone Occurs in UMN diseases Loss of inhibition of contraction Increased muscle tone Exaggerated deep tendon reflexes Plantar extension with or without clonus Classified into Paraplegia in extension Paraplegia in flexion

13. Contd., Paraplegia in extension Occurs i n initial stages of lesion Partial transection of spinal cord with Involvement of pyramidal tract Hypertonia is more in extensor group of muscles

14. Contd., Paraplegia in flexion Occurs as the disease or lesion progresses further or With complete transection of spinal cord Extra pyramidal tracts get involved More hypertonia in flexor group of muscles Resulting in flexed posture of limbs

15. FLACCID PARAPLEGIA Decreased tone and contractility of muscles + weakness . It occurs in lower motor neuron diseases Occurs due to Loss of stimulatory innervation to muscle Decreased muscle tone Atrophied muscle Absent deep tendon reflexes Flexor or equivocal plantar with or without fasciculations

16. SEGMENTS/FUNCTION C1-C6 - Neck flexors C1-T1 - Neck extensors C3-C5 - Supply diaphragm (mostly C4 ) C5-C6 Raise arm(deltoid) Flexion of elbows(biceps) C6 - Externally rotates the arm(supinator) C6-C7 Extends elbow and wrist Triceps and wrist extensor Pronates arm C7-T1 - Flexes wrist C7-T1 - Supply small muscles of hand

17. Contd., T1-T6 - Intercostal muscles T7-L1 - Abdominal muscles L1-L4 - Thigh flexion L2-L4 - Thigh adduction L4-S1 - Thigh abduction L5-S2 - Extension of leg at hip (gluteus m aximus) L2-L4 - Extension of legs at knee(quad. femoris) L4-S2 - Flexion of leg at knee (hamstrings) L4-S1 - Dorsiflexion of foot/ Extension of toes L5-S2 - Plantar flexion of foot/Flexion of toes

18. APPROACH TO PATIENT History Onset Sudden Trauma - Fracture dislocation of vertebrae Infection - Epidural Abscess, Vascular - Thrombosis of ASA Endarteritis/Hematomyelia Transverse Myelitis Gradual Neoplastic- meningioma/ ependymoma / glioma /astrocytoma

19. Contd., Duration of symptom Short duration - Traumatic/infective causes Long duration Neoplastic/hereditary/ congenital/demyelinating causes Sensory Ask about pattern of sensory loss Sacral sparing or sacral area involved Radicular (root) pain indicates an extradural lesion

20. Contd., Motor Limb involvement – Symmetrical/Asymmetrical Weakness - Proximal /distal muscles Weakness - Progressive/Static Associated symptoms Fever/Seizures/Delayed milestones Specific systemic symptoms e.g. vitamin deficiency Any preceding illness/Specific trauma/Prior vaccination/Involuntary movements

21. Contd., In younger children Antenatal/Natal /Post natal history Maternal infection Perinatal asphyxia Hyperbilirubinemia Hospitalization Ask about bladder and bowel involvement Significant past history and family history

22. CLINICAL FEATURES In cerebral paraplegia W eakness of upper limbs and along with that M ental retardation D elayed milestones Seizures A ltered sensorium

23. Contd., In Spinal paraplegia Spasticity Exaggerated DTR Radicular pain Depending upon level of spine Dermatomal sensory involvement + Specific motor weakness present If peripheral nerve involvement occurs Distal weakness Sensory loss Muscle atrophy Absent tendon reflexes

24. EXAMINATION N eurological examination Higher mental function status Affected in cerebral and degenerative diseases Cranial nerve examination Affected in brain stem leisons Tone Increased in UMN disease Decreased in LMN disease DTR Exaggerated in UMN leisons Absent in LMN leisons and spinal shock

25. Contd., Sensory examination To asses particular sensory level To find the extent of sensory loss Proper examination of skull and spine To look for any localized tenderness Depressed fracture Deformity

26. SUPERFICIAL REFLEXES D7 lesion Abdominal reflexes lost in all four quadrants Cremastric reflexes B/L lost Plantar B/L extensor D10 lesion Abdominal reflexes lost in lower 2 quadrants Cremastric reflexes B/L lost Plantar B/L extensor L1 lesion Abdominal reflexes present in all four quadrants Cremastric reflexes B/L lost Plantar B/L extensor

27. SEGMENTS/SIGNS/SYMPTOMS Foramen magnum & Upper cervical region Severe pain in the occiput & neck In hands Loss of post. column sensation Severe tingling/Numbness Pain/weakness in the limbs/wasting may occur in the upper limb Decreased diaphragm m ovements Compression of phrenic nerve Lower cranial nerve involvement/medullary involvement can occur Descending tract of trigeminal can be involved

28. Contd., C5C6 segment lesion Inverted supinator reflex Wasting of muscles supplied by C5C6 Deltoid/biceps/ brachioradialis /rhomboids C8T1 Level Wasting of small muscle of hands Wasting of flexors of wrist & fingers Horner’s syndrome DTR of upper limbs preserved Spastic paralysis of trunk & lower limbs Cervical spondylosis never involves C8&T1 So small muscle wasting rules out cervical spondylosis

29. Contd., Mid Thoracic region of spinal cord Upper limb normal Wasting of intercostal muscles (supplied by involved segments) Movements of diaphragm normal Spastic paralysis of abdominal muscles &lower limbs 9th &10th thoracic segments Lower abdominal muscles are weaker U pper abdominal muscles are intact BEEVER’S SIGN positive when patient raises the head against resistance umbilicus is drawn upwards

30. Contd., T12L1 segments Abdominal reflexes preserved Cremastric reflex lost Wasting of internal oblique & transverse abdominal muscle L3 L4 segmental lesion Flexion of hip is preserved Cremastric reflex preserved Quadriceps & adductors of hip are wasted knee jerk is lost or diminished But ankle jerk is present Plantar - Foot drop

31. Contd., S1S2 segments Wasting & paralysis of intrinsic muscles of feet Wasting & paralysis of calf muscles, Plantarflexion impaired But dorsiflexion of foot is preserved In the hip all muscles of hip are preserved Except flexors & adductors In the knee flexors of knee are wasted Knee jerk is preserved, ankle jerk is lost Plantar reflex is lost. No foot drop Anal & Bulbocavernous reflexes are preserved

32. Contd., S3S4 segments Large bowel & bladder are paralysed. There is retention of urine and feces due to Unopposed action of internal sphincters The external sphincters are paralyzed Anal and bulbo cavernous reflex are lost Saddle shaped anaesthesia occurs No paraplegia

33. INVESTIGATIONS Routine blood tests (CBC, PS, CRP & C/S) Blood chemistry (blood urea, creatinine, electrolytes etc.) Routine urine exam , urine for culture and sensitivity Plain X-ray Spine (Lateral and oblique view ) CSF Analysis To R/O infection-bacterial/tubercular/viral meningitis CSF culture and sensitivity testing C.S.F .-Electrophoresis to show oligoclonal bands of multiple sclerosis CT Cranium/Brain

34. Contd., MRI brain is more informative than CT It helps in diagnosing Degenerative/neoplastic/vascular/infective lesions Spinal MRI Sagittal views - differentiates Syringomyelia from intramedullary tumours/transverse myelitis It also shows cord compression whether internal or external Myelogram

35. CONDITIONS A/W PARAPLEGIA Compressive myelopathy Dorsal nerve root U/L or B/L pain aggravated by sudden rapid body movement Ventral nerve root LMN type of paraparesis Corticospinal tract Produce weakness(asymmetrical) Stiffness of lower limbs Posterior column Produce loss of position/vibration

36. Contd., Syringomyleia Cystic dilatation of the spinal cord Obliteration of the flow of CSF From within spinal canal to its point of absorption Hematomyelia Haemorrhage into the substance into spinal cord occurs due to Trauma/vascular malformations/bleeding disorders/neoplasms/

37. Contd., Epidural abscess Form anywhere along spinal canal Two third from haematogenous spread of infection One third from direct extension of local infections P ott’s disease Also known as spinal TB/tubercular spondylitis Haematogenous spread in most cases Small no. of cases from adjacent paravertebral lymph nodes

38. Contd., Anterior spinal artery infarction It supplies the ant. two thirds of the spinal cord Its infarction causes anterior cord syndrome Paraplegia or quadriplegia Dissociated sensory loss Affecting pain and temp sensation But sparing vibration and position sense Loss of sphincter control

39. Contd., Subacute combined degeneration AV malformation of spinal cord Hereditary spastic paraplegia Hydrocephalus Parasagittal meningioma Guillain barre syndrome Transverse myelitis

40. MANAGEMENT OF PARAPLEGIA 1. General Frequent change of posture to guard against bedsores Care of skin Frequent washing with alcohol and Applying talc powder Care of the bladder If there is retention, Use parasympathomimetic drugs If this fails, use a catheter to evacuate the bladder

41. Contd., In case of urinary incontinence Frequent change of bed-sheets 2. Physiotherapy 3. Symptomatic Treatment Analgesics and sedatives for pain Muscle relaxants for the spasticity Vitamins and mineral supplementation

42. Contd., 4. Specific Treatment (treatment of the cause) ATT + supportive measures in Pott's disease Drainage of paraspinal abscess Traumatic spine stabilisation Surgical management of some tumors 5. Rehabilitation Management of complications Occupational therapy Gait retaining Community re- integration

43. COMPLICATIONS OF PARAPLEGIA Bed sores Contractures Urinary tract infection Pneumonia Deep venous thrombosis

44. REFERENCES Nelson’s text book of pediatrics first south Asia edition Ghai essential pediatrics 8th edition Scott pedia – Tricks textbook  

45. THANK YOU!!