3. Introduction
• Paraplegia:- impairment in motor and or sensory functions of
the lower extremities
• Paraplegia
– Spastic paraplegia
– Flaccid paraplegia
• It affects not only the motor system, sensation, and autonomic
functioning of a patient but also have serious psychosocial
squeal
4. Localization of paraplegia
• Can be caused by a lesion at
– Cerebral cortex, brain stem, Spinal cord, peripheral nerves, muscles
• Lesions causing paraplegia can be localized by using
– Sensory, motor, reflex and autonomic dysfunctions
• Sensory level can be determined by assessment of pinprick or
cold from the legs bilaterally.
7. Brain stem lesions
• Fibers of the lower limb located in the medial part of the
brainstem
• Presence of associated cranial nerve deficit used for
localization
– Palatal or vocal cord paralysis, dysarthria, horizontal or vertical
nystagmus
– Episodic dizziness or vertigo
– Tongue weakness with atrophy
8. Spinal cord lesions
• Spinal cord lesions can be localized by determining
– Sensory
– Motor
– Reflex
– Pain
– Autonomic function level
13. Foramen magnum and upper cervical
lesion
• Brainstem signs may occur
– Dysarthria, dysphonia, dysphagia
• Long-tract signs:- spastic quadriparesis
– Due injury of the corticospinal tract
• Weakness with around the clock pattern
– Ipsilateral arm ipsilateral leg contralateral leg contralateral
arm
• Lesion at C2:- pain at the posterior scalp
14. • C3-C4:- pain projected to the neck or shoulder
• C3–C5:- diaphragmatic paralysis
15. Lower cervical and upper thoracic
lesion
• C4–C6 lesion
– Radicular pain and sensory symptoms over radial side of the arm,
forearm, and hand
– Weakness in elbow flexion
– Depressed or absent biceps and brachioradialis reflexes
• C7–T1 lesion
– Pain and sensory impairments over the ulnar side of the upper
extremity
– Weakness of elbow extension & intrinsic hand muscles
– Depressed or absent triceps reflex
• Horner syndrome
16. Thoracic Lesions
• Useful clinical landmarks are
– The nipple line for T4 dermatome and
– The umbilicus for T10 dermatome
• Sensory testing may determine the most caudal dermatome of
normal sensation
• Beevor’s sign:-
– Lesions at T9-T10 resulting in upward movement of the umbilicus
17. Lumbar lesion
• L2-L4 lesion:-
– Weakness of flexion and adduction of the thigh
– Weakness of leg extension at the knee
– Loss of patellar reflex
• L5-S1 lesion:-
– Weakness of extension at the thigh
– Weakness of flexion at the knee
– Weakness of movements of the foot and ankle
– Loss of ankle jerk
18. Conus medullaris and Cauda equina
• Conus medullaris lesion:-
– Bilateral saddle anesthesia
– Prominent bladder bowel dysfunction
– Impotence
– Absent bulbocavernosus and anal reflexes
• Cauda equina lesion:-
– Low back and radicular pain
– Asymmetric leg weakness and sensory loss
– Variable areflexia in the lower extremities
– Relative sparing of bowel and bladder function
19. Myopathies
• Symmetric proximal weakness
• Malaise
• Fatigue
• No sensory complaints or paresthesia
• Preserved bowel bladder function
• Atrophy and areflexia are late finding
• Associated sign and symptoms
21. History…
• History of back pain
– total duration
– site of maximum intensity
– history of spinal surgery
– any history of trauma to the back
• Types of pain
– Radicular pain:
• usually unilateral, sharp, aggravated by movements, cough, sneezing, straining
– Central (Funicular) pain
• deep and ill defined radiates to whole or part of leg and not affected by
movement
– Vertebral pain:
• Localized, may or may not be aggravated by movement
• May be worsened with palpation or percussion
22. History…
• History of recent
vaccination
– Anti Rabies, Polio, Tetanus,
COVID 19
• History of infections
– Recent Fever
– Cough, Rx for TB
– Skin lesion/rash
– HIV status
– Previous syphilis
– Preceding GI symptoms
• Dietary history
– Dietary habits – Vegetarian /
non veg
– Alcohol intake in excess or
not
– History of ingestion of
grasspeas(Guaya)
• Decrease vision, headache,
loss of consciousness ,or
Seizure
23. • History of Malignancy
– Swellings or bone tenderness
– Surgery for tumors
– Chemotherapy or radiation
– Weight loss
• Family history (of similar illness)
• Bleeding tendency/anticoagulant use
• History of DM
• History of other symptoms
24. Patient approach- Physical examination
• V/S :
– look for signs of Dysautonomia,
fever
• HEENT: Pale conjunctiva,
dryness of mouth and eyes
• LGS: for any LAP, Thyroid
mass or Breast mass
• Chest: any clue for chest
infection
• Abdomen:
– Intraabdominal mass,
Organomegally
• GUS: Distended bladder,
CVAT, Suprapubic tenderness
• IGS: look for any skin rash,
pallor
• MSS: check for vertebral
tenderness, gibbus deformity,
scoliosis
25. Physical examination…
Neurologic examination
• Mental status
• Cranial nerve examinations
– Concomitant optic nerve involvement
– Look for Argyll Robertson(AR) pupils
– Facial numbness and sensory loss from damage to the descending
tract of the trigeminal nerve
– Palatal or vocal cord paralysis, dysarthria, horizontal or vertical
nystagmus, episodic dizziness or vertigo, and tongue weakness
with atrophy
33. Autonomic dysreflexia
• Lesion above T6 may impair autonomic control
• Caused by excessive and uncontrolled sympathetic output
from the spinal cord
• Result in episodes of severe hypertension or hypotension and
bradycardia
• SBP elevations of 20 to 30 mm Hg signify a dysreflexic
episode
34. • Associated symptoms include
– Headache, blurring of vision, flushed & sweaty skin above the level
of lesion, pale & cool skin below it
• Triggered by noxious stimulation below the level of injury
– Bladder distension, constipation,
– Rectal fissures, joint injury, and urinary tract infection
35. • Treatment is algorism based with measurement of BP and
pulse rate at each step
– 1st place the patient in a sitting position
– 2nd inspected for areas of constriction like clothing
– 3rd indwelling catheter
• Fast-acting short-duration antihypertensive agents
– Nifedipine, nitrates, and captopril
• Once BP is within an acceptable range
– Begin fecal disimpaction, follow for 2hrs
36. Pain
• Pain syndromes may develop as a result of compression,
inflammation, or injury to
– Vertebral column, ligaments, the dura mater, nerve roots,
– Dorsal horn, and ascending spinal cord sensory tracts
• Pain syndromes include
– Local pain, Radicular pain or Neuropathic pain
• Central neuropathic Pain include
– Paresthesia, dysesthesia, allodynia, and hyperalgesia
– They can occur at level, below level or above level
37. Pain treatment
• Pharmacologic agents
– 1st line
• Gabapentin, pregabalin, lamotrigine and topiramate
– 2nd line
• TCAs, valproate and carbamazepine
– 3rd line
• Opioids, intrathecal baclofen and morphine, SSRIs, clonidine
• Surgical options
– Decompressing nervous tissue, untethering the spinal cord
• Electrophysiological techniques
38. Spasticity
• Is one of common cause disability which will be obvious over
time.
• It may create enough intensity to expel a patient from
wheelchair.
• Occasionally, spasticity provides support for the body weight
during ambulation
41. Bladder Dysfunction
• It can be caused by lesion at the cerebral cortex, brain stem or
any level of the spinal cord
• Lesion above T12 cause detrusor–sphincter dyssynergia
• Lesion at and below T12 will cause urinary retention
• Important diagnostic history includes
– Frequency of micturition, nocturia,
– Urgency and urgency incontinence
– Bladder diary supplements the history taking
42. • Important investigations include
– Screening for urinary tract infections
– Bladder scan
– Urodynamic studies
• urine flow rate, residual volume, cystometry
– EMG
• Complication of bladder dysfunction
– Bladder wall trabeculations and diverticula
– Vesico-ureteric reflux, hydronephrosis, renal impairment
– Genitourinary tract infections, bladder stones
46. Bowel dysfunction
• Less common than bladder dysfunction
• It can be fecal incontinence or constipation
• Fecal incontinence can be treated with anticholinergics
• Constipation can be treated with
– Optimization of fiber and fluid intake
– Bulk laxatives or stool softeners
47. Sexual dysfunction
• Sexual dysfunction in neurologic patient can be
– Primary sexual dysfunction
– Secondary sexual dysfunction
– Tertiary sexual dysfunction
• Treatments
– Open discussion with partner
– PDE5 inhibitors for erectile dysfunction
– MAOI:- Yohimbine for ejaculatory dysfunction
– Sexual dysfunction in women is not well studied.
48. Venous thrombosis
• Anticoagulation with LMW-heparin is recommended.
• In cases of persistent paralysis, anticoagulation should be
continued for 3 months
49. Respiratory failure
• Risk is higher in upper cervical complete lesions
• Patients with lesion above C3 and between C3-C5
– May not survive with out mechanical ventilation
• Mechanical ventilation
– Tidal volume:- 10-15ml/kg of PBW
– PEEP 5cm H2O
• Weaning
– ????
50. Prevention and treatment of pressure
ulcer
• Prevention is a lifelong requirement
• Prevention strategies include:
– Frequent changes in position in a chair or bed
– Avoiding excess moisture in susceptible regions
– Daily skin inspection
– Using special mattresses, and cushioning
– A well-balanced diet
• Early treatment of ulcers with
– Careful cleansing, surgical debridement of necrotic tissue
51. Addressing Psychosocial problems
• In patients with paraplegia following conditions are prevalent
– Clinically significant anxiety
– Depression
• Treatment:-
– Family support
– Peer support groups
– Psychologic counseling
– Proper pain management
– Pharmacologic intervention
