<ul><li>Paraparesis </li></ul><ul><li>By Dr. Osman Sadig Bukhari </li></ul>
<ul><li>Definitions: </li></ul><ul><li>1- Paraparesis </li></ul><ul><li>2- Paraplegia </li></ul><ul><li>3- Quadriparesis o...
<ul><li>Causes: </li></ul><ul><li>1- Spinal lesions : </li></ul><ul><li>A- Spinal cord compression++++ </li></ul><ul><li>B...
<ul><li>- Familial  - Vascular dis of cord </li></ul><ul><li>- Tropical spastic paraparesis </li></ul><ul><li>- Non metast...
<ul><li>2- Cerebral lesions : </li></ul><ul><li>- Cerebral palsy  - Para sagittal cortical lesions </li></ul><ul><li>- men...
<ul><li>Spinal cord compression </li></ul><ul><li>Principal features of cord compression  are: </li></ul><ul><li>1-  Radic...
<ul><li>Cord compression is a medical emergency   and early stages of neuronal damage is  reversible, hence the importance...
<ul><li>Causes of spinal cord compression </li></ul><ul><li>1-  Extradural ( 80% of causes  ) </li></ul><ul><li>- trauma  ...
<ul><li>2- Intradural extra medullary  (15 %) </li></ul><ul><li>- meningiomas </li></ul><ul><li>- neurofibroma </li></ul><...
<ul><li>3- Intradural intramedullary  (5%) </li></ul><ul><li>- glioma </li></ul><ul><li>- ependymoma </li></ul><ul><li>- h...
<ul><li>6- Rare causes : </li></ul><ul><li>- Pagets  - Scoliosis & vertebral anomalies </li></ul><ul><li>- Parasitic cysts...
<ul><li>Clinical presentation of cord compress </li></ul><ul><li>This depends on the: </li></ul><ul><li>1-  anatomical lev...
<ul><li>Symptoms : </li></ul><ul><li>- Spinal pain & root pain  aggravated by cough, </li></ul><ul><li>sneezing or straini...
<ul><li>Signs : </li></ul><ul><li>Depends on the level of compression </li></ul><ul><li>1-  Above C5 : UMN signs & sensory...
<ul><li>5-  Quda equina : LMN signs in the LL,  dermatomal sensory loss & sphincteric  disturbances </li></ul><ul><li>6-  ...
<ul><li>Investigations: </li></ul><ul><li>Patients with short history & progressive course </li></ul><ul><li>should be urg...
<ul><li>Management: </li></ul><ul><li>1-  management of cord compression : </li></ul><ul><li>- Depends on the nature of th...
<ul><li>2- Management of paraplegia : </li></ul><ul><li>- Improve general health & morale.  - Recognize & TR infections ea...
<ul><li>- Care of the skin: avoid pressure sores by </li></ul><ul><li>using ripple mattresses & avoid pressure </li></ul><...
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Paraparesis

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Paraparesis

  1. 1. <ul><li>Paraparesis </li></ul><ul><li>By Dr. Osman Sadig Bukhari </li></ul>
  2. 2. <ul><li>Definitions: </li></ul><ul><li>1- Paraparesis </li></ul><ul><li>2- Paraplegia </li></ul><ul><li>3- Quadriparesis or Tetraparesis </li></ul><ul><li>4- Quadriplegia or Tetraplegia </li></ul><ul><li>** These are sequelae of bilateral damage to </li></ul><ul><li>the corticospinal tracts. </li></ul>
  3. 3. <ul><li>Causes: </li></ul><ul><li>1- Spinal lesions : </li></ul><ul><li>A- Spinal cord compression++++ </li></ul><ul><li>B- Spinal cord diseases: </li></ul><ul><li>- Multiple sclerosis - Myelitis </li></ul><ul><li>- Motor Neurone disease </li></ul><ul><li>- SACD of the cord </li></ul><ul><li>- anterior spinal artery occlusion </li></ul><ul><li>- Syringomyelia - Syphilis </li></ul>
  4. 4. <ul><li>- Familial - Vascular dis of cord </li></ul><ul><li>- Tropical spastic paraparesis </li></ul><ul><li>- Non metastatic manifestation of malig. </li></ul><ul><li>- HIV associated myelopathy. - Radiation myelopathy </li></ul><ul><li>- Fredereick's ataxia - Lathyrism </li></ul>
  5. 5. <ul><li>2- Cerebral lesions : </li></ul><ul><li>- Cerebral palsy - Para sagittal cortical lesions </li></ul><ul><li>- meningiomas </li></ul><ul><li>- venous sinus thrombosis </li></ul><ul><li>- Hydrocephalus </li></ul><ul><li>- Multiple cerebral infarcts </li></ul><ul><li>3- Peripheral Nerves e.g. GB </li></ul><ul><li>4- Muscle diseases </li></ul><ul><li>5- Hysteria </li></ul>
  6. 6. <ul><li>Spinal cord compression </li></ul><ul><li>Principal features of cord compression are: </li></ul><ul><li>1- Radicular pain at the level of compression sp. worse on coughing & straining. </li></ul><ul><li>2- Spastic paraparesis or quadriparesis. The </li></ul><ul><li>course depends on the underlying pathology </li></ul><ul><li>3- Sensory loss below the compression- sensory level </li></ul><ul><li>4- Retention of urine & constipation. </li></ul>
  7. 7. <ul><li>Cord compression is a medical emergency and early stages of neuronal damage is reversible, hence the importance of early diagnosis and TR. Cord damage is due to : </li></ul><ul><li>1- Direct ly by pressure </li></ul><ul><li>2- Indirect ly by edema from venous obstruct </li></ul><ul><li>and ischemia from arterial obstruction </li></ul><ul><li>leading to impaired neuronal fn & cord </li></ul><ul><li>necrosis. </li></ul>
  8. 8. <ul><li>Causes of spinal cord compression </li></ul><ul><li>1- Extradural ( 80% of causes ) </li></ul><ul><li>- trauma - chronic degenerative & disc prolapse </li></ul><ul><li>- Tb - metastatic tumours </li></ul><ul><li>- myeloma - granulomas - extradural abscess </li></ul>
  9. 9. <ul><li>2- Intradural extra medullary (15 %) </li></ul><ul><li>- meningiomas </li></ul><ul><li>- neurofibroma </li></ul><ul><li>- ependymoma </li></ul><ul><li>- metastasis </li></ul><ul><li>- epidural abscess & haemorrhage </li></ul><ul><li>- lymphomas & leukaemias </li></ul>
  10. 10. <ul><li>3- Intradural intramedullary (5%) </li></ul><ul><li>- glioma </li></ul><ul><li>- ependymoma </li></ul><ul><li>- haemangioblastoma </li></ul><ul><li>- lipoma </li></ul><ul><li>- teratoma </li></ul><ul><li>Extra medullary tumours (extra & intra dural) </li></ul><ul><li>cause gradual cord compression over Ws and </li></ul><ul><li>Ms with root pain & sensory level. </li></ul><ul><li>Intra medullary tumours have slow progressive </li></ul><ul><li>course with early sphincter disturbance and suspended anaethesia. </li></ul>
  11. 11. <ul><li>6- Rare causes : </li></ul><ul><li>- Pagets - Scoliosis & vertebral anomalies </li></ul><ul><li>- Parasitic cysts </li></ul><ul><li>- aneurysmal bone cyst </li></ul><ul><li>- vertebral angioma - haematomyelia </li></ul><ul><li>- arachnoiditis - osteoporosis with fracture </li></ul><ul><li>- A/V malformation. </li></ul>
  12. 12. <ul><li>Clinical presentation of cord compress </li></ul><ul><li>This depends on the: </li></ul><ul><li>1- anatomical level of compression </li></ul><ul><li>2- nature of path. </li></ul><ul><li>Onset : </li></ul><ul><li>Symptoms develop over Ms, days or hours </li></ul><ul><li>depending on the cause. It may be acute in traumatic & metastatic compression. </li></ul>
  13. 13. <ul><li>Symptoms : </li></ul><ul><li>- Spinal pain & root pain aggravated by cough, </li></ul><ul><li>sneezing or straining. </li></ul><ul><li>- Paraesthesia, numbness or cold sensation </li></ul><ul><li>starting distally & ascending proximally to the </li></ul><ul><li>level of compression. </li></ul><ul><li>- Weakness, heaviness or stiffness of the limbs </li></ul><ul><li>- Urgency or hesitancy of micturition & eventual </li></ul><ul><li>retention of urine. Constipation . </li></ul>
  14. 14. <ul><li>Signs : </li></ul><ul><li>Depends on the level of compression </li></ul><ul><li>1- Above C5 : UMN signs & sensory loss in </li></ul><ul><li>all limbs </li></ul><ul><li>2- C5—T1 : LMN signs & segmental sensory loss </li></ul><ul><li>in the upper limbs & UMN signs and </li></ul><ul><li>sensory loss in the lower limbs. </li></ul><ul><li>3- Thoracic cord : Spastic paraparesis & sensory </li></ul><ul><li>loss below the level of compression </li></ul><ul><li>with sphincteric disturbances. </li></ul><ul><li>4- Conus medullaries : LMN signs in the LL, </li></ul><ul><li>extens planter response, loss of sensation in the sacral area & sphin disturbance </li></ul>
  15. 15. <ul><li>5- Quda equina : LMN signs in the LL, dermatomal sensory loss & sphincteric disturbances </li></ul><ul><li>6- Brown Sequard (cord hemi section): band of </li></ul><ul><li>hyperaesthesia at the level at the level of the lesion, ipsilateral loss of proprioception & UMN signs with contra lateral loss of spinothalamic sensations. </li></ul>
  16. 16. <ul><li>Investigations: </li></ul><ul><li>Patients with short history & progressive course </li></ul><ul><li>should be urgently investigated. </li></ul><ul><li>1- Plain X ray spine </li></ul><ul><li>2- CT scan </li></ul><ul><li>3- MRI : single most imp investigation. It localize </li></ul><ul><li>the site, extent & nature of za lesion. </li></ul><ul><li>4- CXR </li></ul><ul><li>5- CSF + (myelography- rarely used now). </li></ul><ul><li>Features of compression & spinal block are </li></ul><ul><li>xanthochromia, protein/ cell dissociation and </li></ul><ul><li>+ve Quickensteds test. </li></ul>
  17. 17. <ul><li>Management: </li></ul><ul><li>1- management of cord compression : </li></ul><ul><li>- Depends on the nature of the underlying lesion </li></ul><ul><li>- Early recognition of cord compression & early decompression is vital. </li></ul><ul><li>- Early surgical exploration is frequently </li></ul><ul><li>necessary & the result of early removal of benign tumours are encouraging. </li></ul>
  18. 18. <ul><li>2- Management of paraplegia : </li></ul><ul><li>- Improve general health & morale. - Recognize & TR infections early e.g. UTI. </li></ul><ul><li>CRF is the commonest cause of death in </li></ul><ul><li>paraplegics. </li></ul><ul><li>- Skilled nursing care: </li></ul><ul><li>- Bladder : catheterization to avoid stasis, </li></ul><ul><li>UTI & bladder calculi. </li></ul><ul><li>- Bowel: avoid constipation & faecal impact </li></ul><ul><li>by enema & manual removal till reflex </li></ul><ul><li>rectal emptying develop later. </li></ul>
  19. 19. <ul><li>- Care of the skin: avoid pressure sores by </li></ul><ul><li>using ripple mattresses & avoid pressure </li></ul><ul><li>palsies. - Physiotherapy, prevent contractures, baclofen and diazepam for spasticity. </li></ul><ul><li>- Rehabilitation: psychotherapy, walking aids, </li></ul><ul><li>occupational therapy & social support. </li></ul>
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