"Internal Medicine", Neurology, “Clinical approach, Paraplegia, Aswini

1. Dr. S. Aswini Kumar. MD. Professor of Medicine 1 Clinical Evaluation of Paraplegia

2. Anatomy of spinal cord Cranial border of atlas 45 cm in adult male 42 cm in adult female Corresponding spinal column 70cm Lower border of L1 Total 31 segments 2

3. Structure 3 Intra medullary Extra medullaryintradural Extra medullaryextradural

4. Cross-sectional anatomy 4

5. Dermatomes 5 Sensory impairment related to level of spinal cord injury

6. Tracts Sensory Tracts Motor Tracts 6

7. Blood supply 7

8. Bladder control 8

9. History taking in paralplegia What is the onset of paraplegia? Is it acute – within, minutes or hours? Is it subacute – within days or weeks? Is it chronic – within months or years? Was there a history of trauma? Fall from height/road traffic accident/direct injury? Was there a history of back pain? Duration/maximum intensity/history of spinal surgery? 9

10. Any girdle pain or radicular(root) pain? Is there any girdle pain / sensation? Pain around the thorax or abdomen Is it unilateral or bilateral? Does it increase with coughing and sneezing? Is there a history of root pains? Is it unilateral or bilateral? Does it radiate to the limbs? Does it aggravate with coughing? 10

11. History suggestive of tract involvement? Any pyramidal tract involvement? Buckling of knees/Slipping of chappals/Tripping on objects? Any lower motor neuron involvement? Loss of tone, wasting and fasciulations Any dorsal column involvement? Swaying while washing face or difficulty in walking at night? Any cerebellar involvement? Any swaying while walking/inability to sit upright/incordination 11

12. History of past illnesses History of viral infections? Viral infections/Chicken pox/Herpes zoster/HSV-1&2/HIV/CMV/HTLV History of vaccination? Anti Rabies vaccination/Polio vaccination/Others? Hisory of tuberculosis? Any where in the body-Pulmonary/intestinal/lymphnodal/miliary History of Malignancy? Swellings/ surgery for tumors/Chemotherapy or radiation 12

13. Personal history Any bladder involvement? Retention /overflow incontinence/bladder sensation? Any bowel involvement? Constipation/bowel incontinence/bowel sensation? Any sexual dysfunction? Morning Erection/los of libido/sexual promiscuity? Any autonomic dysfunction Excessive sweating/absence of sweating 13

14. Complete neurological examination Optic fundi Lower cranial nerves Motor system in full Sensory system in full Superficial reflexes Deep tendon reflexes Cerebellar signs Spine 14

15. 1. Does the patient have neurological problem? Yes/no Or is it a medical condition simulating paraplegia? Fracture dislocation of pelvis/ Polyarthritis of joints of limbs Or is it a case of GullainBarre Syndrome Or is it Hysteria or malingering If Yes what is the nature of the deficit? Paraplegia/quadriplegia/ cerebral diplegia/cerbral paraplegia 15

16. 2. What is the mode of onset of paraplegia? Acute Transverse myelitis, Traumatic paraplegia, Anterior spinal artery syndrome Sub acute: Pott’s paraplegia, Spinal epidural abscess, Spinal cord tumors Chronic Familial spastic paraplegia, Amyotrophic lateral sclerosis, Cranio-vertebral junctional anomalies 16

17. 3. What are the subjective sensory symptoms? Radicular (root) pain or Girdle pain Unilateral or bilateral sharp shooting pain of dermatome distribution Exacerbated by coughing, sneezing or valsalva Vertebral pain: An aching pain confined to a point of spine accompanied by point tenderness Neoplastic or inflammatory dural lesion likely Funicular pain Deep seated ill defined dull ache distant from the affected cord level Common with intra-medullary lesion 17

18. 4. What are the objective sensory deficits? These may be in the form of Segmental hyper-aesthesia Hypesthesia (decreased touch sensation) Hypoalgesia (decreased pain sensation) Loss of all modalities below a level Loss of position and vibration sense Dissociated sensory loss Suspended segmental loss of pain and temperature Loss of pain & temperature below a particular level 18

19. 5. What are the motor deficits? Is there any muscle wasting? Is there a disuse atrophy? Is there a distal muscle wasting? Small muscle wasting in syringomyelia? Is there a proximal muscle wasting? What is the tone of the muscles? What is the distribution of motor weakness? Is there any abnormal movements? Is there any loss of co-ordination? 19

20. 6. What are the changes in superficial reflexes? Abdominal reflexes of all 4 quadrants are absent. Cremasteric reflexes absent bilaterally. Plantars are extensor bilaterally - D7 lesion Abdominal reflexes of upper quadrants are present. Lower quadrants are absent. Beever’s sign is positive. Plantar reflexes are extensor bilaterally - D10 lesion Abdominal reflexes of all four quadrants are present. Both cremasteric reflexes are absent. Plantar reflexes are extensor bilaterally. - L1 lesion 20

21. 7. What are the changes in the deep reflexes? Loss of Deep tendon reflexes at segmental level with exaggerated DTR below the level indicate level of lesion Biceps reflex – C5 Supinator reflex – C5 Inversion of supinator – C5 C6 Triceps reflex – C7 Knee reflex –L2 L3 Ankle reflex – L5 S1 21

22. 8. Is it an LMN/UMN lesion or a combination? LMN signs alone would indicate the possibility of Anterior horn cell lesion (Spinal muscular atrophy) Nerve root disease ( Radiculopathy) Peripheral nerve lesion ( Peripheral neuritis) Myoneural junction abnormality (Myasthenia) Primary Muscle disease (Myopathies) LMN signs of a segmental distribution indicates an appropriate level of lesion Bilateral UMN findings below that level indicates a transection of corticospinal tracts on either sides Both LMN and UMN signs at the same level suggests the possibility of motor neuron disease 22

23. 9. What is the segmental level of lesion? It is derived from the information gathered through collection of the data as above Sensory segmental level by root/radicular /girdle pain segmental hyperaesthesia Loss of sensations as per dermatomes Motor segmental level Superficial reflex level Deep tendon reflex level Bladder function level 23

24. 10. Are there other features of the level? Upper Cervical Cord QP and weakness of diaphragm Lesion of C5-C6 Loss of power and reflex at biceps Lesion of C7 segment Triceps, wrist extensors and fingers Lesion of C8-T1 segments Finger and wrist flexion, Horners Lesions of mid thoracic region? Sensory level at trunk, midline back pain 9th and 10th thoracic segments Paralysis of lower not upper abdomen L2 – L4 segments Flexion and abduction of thigh L5 – S1 segments: Flexion knee, extension thigh, foot S3 – S4 segments: Saddle anesthesia, bladder and bowel Caudaequina Root pains, asymmetrical leg weakness 24

25. 11. What is the vertebral level? Calculated in a reverse direction From cervical segments- subtract 1 From upper thoracic segments- subtract 2 From lower thoracic segments- subtract 3 Lumbar 1-2 segments- T10 vertebra Lumbar 3-4 segments- T11 vertebra Lumbar 5 segments- T12 vertebra Sacral and coccygeal segments 25

26. 12. Corresponding vertebral examination Inspection: Deformity, narrowing of disc space, gibbus, meningocoele Palpation: Tenderness Percussion: Tenderness Auscultation: Bruit 26

27. 13. What are the nuclei/tracts involved? 1. Complete transection of spinal cord 2. Hemi-section 3. Central lesion 4. Posterior and lateral column lesions 5. Posterior column disease 6. Anterior horn cell disease 7. Anterior horn cell + pyramidal 8. Plexus lesion/radiculopathy 27

28. 14. Is it a Vascular syndrome of spinal cord? Features Abrupt onset girdle pain/radicular pain Flaccid paraplegia within minutes /hours Thermo anesthesia Analgesia below the level Impaired bowel and bladder control Watershed zones C4 T4 segments L1 segment Causes: Arteriosclerosis of spinal arteries 28 abnormally increased T2 signal is seen within the central portion of the distal spinal cord

29. 15. Am I dealing with a spinal cord compression? Diseases of the vertibral column? Trauma, Tuberculosis, Secondaries of spine Primary neoplasms: Sarcoma, Myeloma, Hemangioma Infiltrations: Leukemis deposits Reticulosis Cystic lesions Spinal cord tumors 29

30. 16. Or is it a non compressive myelopathy? A. Infective: Viral – Poliomyelitis, Herpes zoster, Rabies Bacterial – Tuberculosis, Syphilis Parasitic, Falciparum Malaria and Schistosomiasis B. Immuno-allergic Post exanthematous –Measles, Rubella Post vaccinial – Rabies, Polio Transverse myelitis 30

32. Vertibral pain is also unusual

33. Funicular pains may occur

34. UMN signs are present but late

35. LMN signs are prominent and diffuse

36. Paraesthesia-descending progression

37. Sphincter involvement is early

38. Trophic changes are common31

40. Dissociated sensory loss – not present

41. Root pain - common

42. Fasciculation –common

43. Decubitus ulcer – uncommon

44. Bladder – late

45. Bowel - late32

46. So what the diagnosis we are aiming at? Acute Transveremyelitis/Devic’s disease Spinal cord injury/ Fracture Herniation of IV Disc Anterior spinal artery occlusion GullainBarre Syndrome Subacute Tuberculosis of Spine Intramedullary /extramedullary tumors Vertebral secondaries Subacute combined degeneration Lathyrism Chronic degenerative Arnold Chiari Malformation Fredirichs Ataxia Amyotrophic lateral slcerosis Spinal Muscular atrophy Miscellaneous TabesDorsalis Thrombosis of unpaired ant cerebral Parasagitalmeningioma Sagital sinus thrombosis Cervical spondylosis 33

47. Common causes for compressive myelopathy Extramedullary Intradural Meningioma Neurofibroma Arachnoiditis Extradural Pott’s disease Vertebral tumor Pachymeningits Prolapsed IVD Epidural abscess Intramedullary Or Central cord lesion Syringomyelia Hematomyelia Ependymoma Glioma Astrocytoma Hemangioblastoma 34

48. Summary Gross anatomy Development Vertebral relation Cross section of cord Organization of tracts Dermatomes Myotomes Bladder control Complete history Dedicated neurological examination Level of spinal cord injury Spinal cord syndromes Spinal cord compression or not Intra/extra medullary lesion Conus/cauda lesion Knowledge about anatomy Clinical Evaluation 35

49. Thank You 36