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Paraparesis

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

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