PARAPLEGIA

ByDr Bashir Ahmed Dar

Associate professor Medicine

Chinkipora sopore kashmir

Causes of flaccid paralysis

• Anterior horn cells-poliomylitis

• Nerve root- radiculitis,polyradiculopathy,tabes dorsalis,cauda equina

• Peripheral nerves-GB syndrome,peripheral neuropathy

• Myoneural junction- myasthenia gravis,lambert eaton syndrome,periodic paralysis

• Muscles - myopathy

• Flaccid paralysis means lower motor neuron paralysis resulting from the disease of anterior horn cells,radicles,peripheral nerves and muscles

• Acute onset of UMN type of paralysis may present flaccid instead of spastic paralysis due to shock.

Causes of spastic paraplegia Compressive

• Extramedullary• Intradural - --

meningioma,neurofibroma,arachnoiditis

• Extradural--- potts disease(caries spine)

• Vertebral neoplasms eg, metastasis,myloma

• Pachymeningitis• Prolapsed IVD• Epidural abcess or

haemorrage• Fracture dislocation of

vertebra ,pagets disease,osteoporosis

Intramedullary

• syringomyelia,

• haematomyelia,

• intramedullary tumor eg,

• ependymoma, glioma

What is Cerebral Paraplegia

• The lower limbs and bladder (micturition centre)are represented in paracentral lobule, leisions in this area produce paraplegia with bladder disturbance-eg retension urine and cortical type of sensory loss.may b associated with headache,vomiting and fits.

• Causes are

• cerebral diplegia

• superior sagital sinus thrombosis

• Parasagital meningioma

• Thrombosis of unpaired anterior cerebral artery

• Gunshot injury of this area

• Internal hydrocephalus

What is spastic paraplegia

• Involvement of spinal cord and cerebrum produce spastic UMN paraplegia.

• Has two types

• Paraplegia in flexion and paraplegia in extension.

Differences

• Etramedullary • Root pain---common• UMN signs –early• Sensory deficit—

contralateral loss of pain and temp with ipsilateral loss of proprioception

• Intramedullary • Rare • Late • Dissociated sensory

loss

• Sacral sparing-absent• Bowel bladder

disturbances– early• Vertebral tenderness

may be present• CSF changes –froins

syndrome common

• Present

• Late • Absent

• Rare

Non compressive causes

• MND –amyotropic lateral sclerosis

• MS• Acute transverse

myelitis• Subacute combined

degeneration of cord vit 12 def.

• Lathyrism• Syringomyelia• Hereditory spastic

paraplegia• Tropical spastic

paraplegia• Radiation myelopathy

Differences between compressive and non compressive paraplegia

• (compressive)• Boney changes• Root pains• Upper level of sensory

loss present • Zone of

hyperaesthesia may be present

• (non compressive)• No boney changes• No root pains• No definite level

• Absent

• Usually gradual onset• Asymetrical

involvement of limbs• Commonest cause is

caries• Bladder bowel

disturbance occurs

• Usually acute onset• Symmetrical

involvement of limbs• Commonest cause

MND• Occours but late

Cord compression at multiple sites

• Arachnoiditis( tubercular there is patchy involvement)

• Neurofibromatosis

• Multiple sclerosis

• Secondary deposits

• Cervical spondylitis

Paraplegia without sensory loss

• Hereditory spastic paraplegia

• Lathyrism

• GB syndrome

• Amyotropic lateral sclerosis

• fluorosis

Paraplegia with loss of deep tendon jerks

• In paraplegia the tendon jerks are brisk.they can only become absent when pt is either in spinal shock or there is involvement of affrent or efferent side of reflex

• eg , in• Neural shock(spinal)• Radiculitis- the jerk whose

root is involved will be absent

• Peripheral neuropathy-bilat ankle jerks will be absent

• Reflex activity may be absent in presence of severe infection due to supression.

Difference between conus medularis and cauda equina syndrome

• The conus medularis is terminal portion at which cord ends and cauda equina is bunch of roots.therefore the main distinction between the two is the plantars extensor and symmetrical LMN

Signs in conus medullaris while planter are flexor or not elicitable with asymmetrical LMN paralysis in cauda equina syndrome.

• Conus leison• Bilateral symmetrical

of both lower limbs

• No root pains

• Bilateral saddle anaesthesia

• Cauda equina leion• Asymmetrical

involvement of both lower limbs

• Severe root pains

• Asymetrical sensory loss

• Bulbocavernous s1-s2, and anal reflex are absent

• Bladder bowel disturbances common

• Planters extensors

• Depending upon root invlvement

• Relatively spared• Normal or not

elecitable

Episodic weakness causes

• Mysthenia gravis

• Hyperthyroidism

• Periodic paralysis( hyperkalaemia or hypokalaemia)

Investigations

• Routine blood tests• Urine test,also for

culture and sensitivity• Bllod chemistry eg

blood urea,creatinine,electrolytes

• X ray chest• Lymph node biopsy

• CSF examination• CT scan,MRI• CT –Myelography

meniscus sign intradural,brush sign extradural,expansion sign in syringomyelia

Tropical spastic paraplegia

• Females• 3rd ,4th decade• Associated with

HTLV-1 infection• This is UMN spastic

paraplegia without sensory disturbance.

• Bladder disturbances• And is non

compressive progressive myelopathy

Features of paraplegia

• Pain over spine or along roots

• Sensory loss below ,and hyperasthesia at the level

• Motor weakness• Urgency or hesitency

leading to retension of urine

• Involvement of spinothalamic and dorsal column tract.

• Loss of deep tendon reflexex at level due to root if

• All reflexes below level lost

• Tone increased,

Lathyrism

• It is due to khesari dal(lathyrus sativus)

• May involve families in locality

• The causative factor is BOAA, a neurotoxin.due to spasticity they pass through one stick stage,scissor gait,then

• Two stick stage then crawling.