PARAPLEGIAPARAPLEGIA

Presented By \Presented By \

Dr. KAMAL Dr. KAMAL OSMAN MIRGANIOSMAN MIRGANI

**** Is paralysis or weakness Is paralysis or weakness ( ( paraparesisparaparesis ) of both ) of both lower limbslower limbs . .

**** It is either :Spastic paraplegia due to It is either :Spastic paraplegia due to pyramidal lesion (pyramidal lesion (U.M.N.L U.M.N.L ))

**** Flaccid paraplegia ( Flaccid paraplegia ( L . M . N. LL . M . N. L ) )

Spastic ParaplegiaSpastic Paraplegia

DefinitionDefinition: :

Paralysis or weakness of both lower limbs Paralysis or weakness of both lower limbs due to bilateral pyramidal tract lesion , mostdue to bilateral pyramidal tract lesion , mostcommonly in the spinal card (spinalcommonly in the spinal card (spinal

paraplegia ) and less commonly in the brainparaplegia ) and less commonly in the brain stem or cerebral parasagittal region ( cerebralstem or cerebral parasagittal region ( cerebral

paraplegiaparaplegia( (

Spastic ParaplegiaSpastic Paraplegia -: -:

****** it eitherit either

with sensory levelwith sensory level. .

with out sensory levelwith out sensory level. .

Spastic Paraplegia with sensory Spastic Paraplegia with sensory levellevel

causescauses: :

11 - - Cord compressionCord compression : : A-vertebralA-vertebral: :

**fracture or fracture dislocation of vertebrafracture or fracture dislocation of vertebra

**Disc prolapse and spandylosisDisc prolapse and spandylosis

**Pott’s disease of the spinePott’s disease of the spine

**Neoplasms : A Neoplasms : A 1ry – osteosarcoma1ry – osteosarcoma

haemangiomahaemangioma

MRI : acute cervical c5\6 soft disc prolapseMRI : acute cervical c5\6 soft disc prolapse

B 2ndary metastatic deposite from egB 2ndary metastatic deposite from eg

breast - lung- stomach – prostate – breast - lung- stomach – prostate – kidneykidney..

A-Extramedullary causesA-Extramedullary causes: :

**** Extradural eg , leukaemic deposits Extradural eg , leukaemic deposits **** Dural eg , menigioma Dural eg , menigioma pachymeningitis pachymeningitis **** Intradural eg , neurofibroma Intradural eg , neurofibroma

B- B- IntramedullaryIntramedullary causescauses: :

Syringiomyelia – Gloom – Ependymoma Syringiomyelia – Gloom – Ependymoma of cordof cord

22 InflammatoryInflammatory : :

transverse myelitistransverse myelitis

myelomeningitismyelomeningitis. .

33 VascularVascular: :

anterior spinal artery occlusionanterior spinal artery occlusion. .

Spinal paraplegia Spinal paraplegia with outwith out sensory sensory levellevel

Subcombined degeneration of the cordSubcombined degeneration of the cord. .

Motor neuron diseaseMotor neuron disease. .

Hereditary spastic paraplegiaHereditary spastic paraplegia. .

Friedreich ataxiaFriedreich ataxia. .

NEXT picture shows NEXT picture shows narrowing of intervertebral narrowing of intervertebral

disc spacedisc space

NEXT picture shows NEXT picture shows extramedullary , intradural extramedullary , intradural

neurofibromaneurofibroma

NEXT picture shows NEXT picture shows intramrdullary cervical cord intramrdullary cervical cord

gliomaglioma

Multiple sclerosisMultiple sclerosis..

Disseminated encephalomyelitisDisseminated encephalomyelitis..

SyphilisSyphilis. .

Causes in parasagittal region ( area ofCauses in parasagittal region ( area of

cortical presentation of L . Lcortical presentation of L . L.( .( Depressed fracture of the vault ofDepressed fracture of the vault of

skull causing subdural haematomaskull causing subdural haematoma. .

Superior sagittal sinus ThrombosisSuperior sagittal sinus Thrombosis. .

Parasagittal meningiomaParasagittal meningioma. .

e. mid brain stem tumore. mid brain stem tumor. .

REMEMBER The REMEMBER The Differences between Differences between

EXTRA- & SUB- dural EXTRA- & SUB- dural haematomashaematomas

In the NEXT PICTUREsIn the NEXT PICTUREsWHAT is your diagnosis?WHAT is your diagnosis?

That was right frontoparietal That was right frontoparietal extradural haematomadue to a extradural haematomadue to a squamous temporal fracture squamous temporal fracture

not visible on CTnot visible on CT

THAT was axial CT showing a THAT was axial CT showing a rghit-sided acute sub dural rghit-sided acute sub dural

haematoma with midline shifthaematoma with midline shift

Removal of acute Removal of acute extradural haematoma by extradural haematoma by

CraniotomyCraniotomy

CLINICAL FEATURESCLINICAL FEATURES

At the level of theAt the level of the lesionlesion **** there is localized tenderness or pain there is localized tenderness or pain

or deformity or deformity or or swelling if the swelling if the causes of vertebral causescauses of vertebral causes. .

**** Radicular pain only seen in Radicular pain only seen in extramedulluy causesextramedulluy causes Below the level of the lesion ( cordBelow the level of the lesion ( cord

ManifestationsManifestations( (

11 . .Motor manifestationMotor manifestation

A .If the causes acute ( inflamtion , vascularA .If the causes acute ( inflamtion , vascular,,

traumatictraumatic( (

The paraplegia passes into 2 stagesThe paraplegia passes into 2 stages: :

[ [11 ] ] Stage of flaccidityStage of flaccidity: :

* * due to neuronal due to neuronal Shock complete Shock complete paralysis of L . L with absence of reflexesparalysis of L . L with absence of reflexes

* * lasts from 2 – 6weekslasts from 2 – 6weeks

[[22 ] ]Stage of spasticityStage of spasticity::

due to recovery form neuronal due to recovery form neuronal shock and full picture of shock and full picture of

UMNL will be established egUMNL will be established eg , ,

hypertonia , Babaniski sign +ve andhypertonia , Babaniski sign +ve and

may be clonusmay be clonus..

B – If the cause is gradual . (eg , B – If the cause is gradual . (eg , neoplastic )neoplastic )::

There will be progressive There will be progressive weakness of the lower limb, with weakness of the lower limb, with

hypertonia and hypereflexiahypertonia and hypereflexia. .

The Anatomy Of The Spinal CordThe Anatomy Of The Spinal Cord

22 – – Sensory manifestationSensory manifestation

a . if the cause of the lesion is a . if the cause of the lesion is extramedullaryextramedullary

encroachment on the ascending tract , atencroachment on the ascending tract , at

the site of the lesion result in sensorythe site of the lesion result in sensory

level below which all types of sensationlevel below which all types of sensation

are diminishedare diminished. .

There is early loss of sensation in There is early loss of sensation in the saddle area ( S 3 , 4 , 5 ) as the the saddle area ( S 3 , 4 , 5 ) as the sacral fibres lie in the outer most part sacral fibres lie in the outer most part

of the spinothalamic tract in the cordof the spinothalamic tract in the cord..

B. if the cause of the lesion is B. if the cause of the lesion is intramedullayintramedullay ::

**** there will be hyposthetic area with there will be hyposthetic area with normal sensation above and below the normal sensation above and below the lesion ( Jacket sensory loss )lesion ( Jacket sensory loss )

**** the sensory loss is of disassociated the sensory loss is of disassociated nature ie pain and temperature nature ie pain and temperature sensations are lost but touch andsensations are lost but touch and

**** deep sensations are preserveddeep sensations are preserved . .

This due to the interruption of This due to the interruption of crossing fibers carrying pain and crossing fibers carrying pain and temperature by midline lesion while temperature by midline lesion while touch and deep sensation fibers touch and deep sensation fibers ascend in the posteriorascend in the posterior

column with decussating . The column with decussating . The sensation over the saddle area are sensation over the saddle area are preserved as sacral fibers , lie farpreserved as sacral fibers , lie far from the midlinefrom the midline. .

33 – – Sphincter manifestationSphincter manifestation

a . in the acute lesionsa . in the acute lesions retention of urine in the shock retention of urine in the shock

stage , followed by precipitancy of stage , followed by precipitancy of micturationmicturation. .

a . in the acute lesionsa . in the acute lesions retention of urine in the shock retention of urine in the shock

stage , followed by precipitancy of stage , followed by precipitancy of micturationmicturation. .

b. In gradual lesionb. In gradual lesion: :

Precipitancy of micturation which may Precipitancy of micturation which may terminated in autonomic bladder when terminated in autonomic bladder when complete transection of cordcomplete transection of cord

occursoccurs. .

The changes started later in extameduallay The changes started later in extameduallay lesions as the pyramidal fibers controlling lesions as the pyramidal fibers controlling

the bladder center lie medially in the cordthe bladder center lie medially in the cord. .

INVESTIGATIONSINVESTIGATIONS

11 Complete haemogram + E S RComplete haemogram + E S R. .

22 X –ray chestX –ray chest. .

33 C. S. F analysisC. S. F analysis

44 C. T . scanC. T . scan. .

55 X – ray spinesX – ray spines. .

66 M R I of vertebralM R I of vertebral columncolumn..

77 Vitamin B12 assayVitamin B12 assay. .

MANAGEMENT OF MANAGEMENT OF PARAPLEGIAPARAPLEGIA

A General : nursing careA General : nursing care: :

11 Frequent turning of pt to prevent bed Frequent turning of pt to prevent bed sores and Hypostatic statesores and Hypostatic state . .

22 Care of skin frequent washing with Care of skin frequent washing with alcohol and talk poweralcohol and talk power..

33 Care of the bladder eg catheterizationCare of the bladder eg catheterization. .

44 PhysiotherapyPhysiotherapy : :

**** Massage to increase blood supply toMassage to increase blood supply to

paralysed musclesparalysed muscles. .

**** Positioning: the paralysed limbs Positioning: the paralysed limbs should be put opposite to hypertoniashould be put opposite to hypertonia . .

**** Passive excercise to gurd against Passive excercise to gurd against fibrosis and stiffness of joints fibrosis and stiffness of joints. .

55 Good adequate nutritionGood adequate nutrition. .

pressure sore locations

                                                      

B TREATMENT : B TREATMENT : of complicationsof complications

..

C Specific treatment of the C Specific treatment of the causecause

11.. Anituberculous for pott’s diseaseAnituberculous for pott’s disease. .

22.. Deep–radiation for intramedullary Deep–radiation for intramedullary tumorstumors. .

33.. Surgical excision for extramedllary Surgical excision for extramedllary tumourstumours. .

With My Best WishesWith My Best Wishes,,,,,,,,,,,,,,,,,,,,,,,.,,,,,,,,,,,,,,,,,,,,,,,.

Dr \Dr \ KAMALKAMAL

OSMANOSMAN

MIRGANIMIRGANI