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Causes of Paraplegia By Dr Bashir Ahmed Dar Associate Professor of Medicine Chinkipora Sopore Kashmir

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Information about Causes of Paraplegia By Dr Bashir Ahmed Dar Associate Professor of...
Health & Medicine

Published on December 4, 2008

Author: drbashir

Source: slideshare.net

Description

There are number of causes of weakness of both lower limbs.the topic is made simple and easy for medical students
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PARAPLEGIA By Dr 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

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.

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

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

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

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.

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

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

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

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

(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

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

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

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.

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.

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

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

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)

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

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 3 rd ,4 th decade Associated with HTLV-1 infection This is UMN spastic paraplegia without sensory disturbance. Bladder disturbances And is non compressive progressive myelopathy

Females

3 rd ,4 th 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,

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.

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.

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