PARAPLEGIA note for medical students.pptx

Detailed summary on management and diagnosis of paraplegia

1. PARAPLEGIA & PARAPARESIS ETIOLOGY AND MANAGMENT Prof. OR Obiako

2. Table of content Definition of terms Classification Causes Clinical features Complications Approach to patient with paraplegia History Physical examination Investigations Treatment

3. Definition of terms Paraparesis  is weakness affecting both lower limbs. Sometimes refers to as partial paralysis Paraplegia is from a Greek word which means half stricken. It’s defined as impairment in motor function of the lower of limbs with or without involvement of the sensory system (complete paralysis). It’s usually cause by involvement of the cerebral cortex, spinal cord, the nerves supplying the muscles of the lower limbs, or due to involvement of the muscle directly.

4. Types of paraplegia Base on part of NS involved Spastic paraplegia extension/flexion Flaccid paraplegia

5. Spastic paraplegia Weakness of muscles along with increase tone It occurs in UMN diseases due to loss of inhibition of contraction Increased muscles tone, exaggerated deep tendon reflexes, planter extension with or without clonus Further divided into two types paraplegia in extension and paraplegia in flexion

6. Differences between paraplegia in extension & flexion Type of paraplegia Extension Flexion Cause of lesion Pyramidal tract damage Pyramidal + Extrapyramidal Position of legs Extension Flexion Hypertonia Extensors Flexors Clonus Present Absent Deep reflexes Exaggerated Not exaggerated Superficial reflexes Dorsi flexion May be absent Bladder control Precipitant Automatic Mass reflexes Absent May be present

7. Flaccid paraplegia Decreased tone and contractility of muscles along with weakness It occurs in lower motor neuron diseases due to loss of stimulatory innervation to muscles. Decreased muscle tone, atrophied muscles, absent deep tendon reflexes, flexor or equivocal planters with or without fasciculation

8. Clinical features Loss of movement Loss or change in sensation( heat, cold and touch) Loss of bowel or bladder control Exaggerated reflex activities or spasms Changes in sexual behaviour Chronic pain eg back pain Trouble breathing, coughing or clearing secretions from the lungs Weakness, incoordination or loss of control in any part of the body

9. Contd., Numbness, tingling or loss of in the hands, fingers, feet or toes. Trouble with balance and walking A twisted neck or back (scoliosis) Cerebral paraplegia Weakness of upper limbs Mental retardation Delayed milestones Seizures Altered sensorium

10. Spinal paraplegia Spasticity Exaggerated Deep tendon reflexes Redicular pain Depending upon the level of spine Dermatomal sensory involvement+ Specific motor weakness present If peripheral nerve involvement occur: Distal weakness Sensory loss Muscles atrophy Absent tendon reflexes

11. Complications Pressure sores Respiratory problems Loss of bladder or bowel control Hypotension Osteoporosis Chronic pain Sexual challenges Deep vein thrombosis Contractures Depression

12. Approach to patient with paraplegia/ paraparesis Onset Sudden - trauma: fracture dislocation of vertebra -infection: epidural abscess, - vascular: Thrombosis of ASA endarteritis/ hematomyelia -transverse myelitis Gradual neoplastic-meningioma/ glioma / ependymoma /astrocytoma

13. Duration of symptoms short duration: trauma/ infection long duration: -neoplastic/hereditary/congenital/ dymyelinating causes sensory: -pattern of sensory loss -sacral sparing or sacral area involved -radicular (root) pain indicates an extradural lesion

14. Motor limb involvement: symmetrical/asymmetrical weakness: proximal/distal weakness: progressive/static Associated symptoms -fever/seizure/delayed milestone -specific systemic symptoms eg vitamin deficiency Any preceding illness/specific trauma/prior vaccination/ involuntary movements

15. In young children antenatal/natal/postnatal history maternal infection perinatal asphyxia hyperbilirubinemia hospitalization Ask about bladder and bowel control Significant past medical history and family history

16. complete systemic examination including proper neurological examination is a must. Neurological examination Higher mental function status affected in cerebral and degenerative diseases Tone increased in upper motor neuron(UMN) disease decreased in lower motor neuron(LMN) disease Deep tendon reflexes exaggerated in UMN lesions absent in LMN lesions and spinal shock

17. Sensory examination To assess particular sensory level To find the extent of sensory loss Proper examination of the skull and spine look for any localized tenderness depressed fracture deformity

18. Investigations Routine blood tests (FBC, PS, CRP, C/S) Blood chemistry (urea, creatinine, serum electrolytes) Routine urine tests (urinalysis, MCS) Plain x-ray spine (lateral & oblique view) Spinal MRI (thoraco-lumbar) CSF analysis CSF electrophoresis to show oligoclonal bands of multiple Sclerosis & multiple myeloma Brain MRI/MRA for medial frontal lobules lesions

19. MRI brain is more informative than CT scan it helps in diagnosing degenerative/neoplastic/vascular/infection Spinal MRI Sagittal view differentiate Syringomyelia from intramedullar tumors/transverse myelitis It also shows cord compress either internal/external Myelogram Electromyography (EMG) Nerve conduction velocity test (NCV)

20. MANAGEMENT OF PARAPLEGIA/Paraparesis This usual involved multidisciplinary team approach of neurologist, neurosurgeon, physiotherapist, occupational therapist, and many others. Early treatment is essential Treatment range from case to case depending on the disability Aim is to help patient regain function and independence as possible Recovery may be long time

21. 1. General Frequent change of posture Skin care Care of bladder , if there is retention use parasympathomimetic drugs, if fails use urinary catheter Incase urinary retention, frequent change of bed sheet 2. Physiotherapy Restore function Improvement muscle strength Transfer skills Prevent secondary complication eg chest physiotherapy help improve vital capacity and reduces risk for pneumonia

22. 4. Specific treatment ATT + supportive measures in Pott’s disease Drainage of para spinal abscess Traumatic spine stabilization Surgical management of some tumors 3. Symptomatic treatment analgesics and sedatives for pain Muscle relaxants for the spasticity Vitamins and mineral supplementation

23. 5. Rehabilitation Management of complications Occupational therapy Gait retaining Community re-integration Psychological counseling

24. References Harrison’s principle of internal medicine 17 th edition Adam and Victor text book of neurology Nelson’s text book of pediatrics first South Asia edition Scot pedia - Tricks textbook Nelson’s text book of pediatrics 19 th edition

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