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Approach to paraplegia in children
- 1. APPROACH TO PARAPLEGIA IN CHILDREN Dr. C. Kannan Post graduate Pediatrics MGMCRI
- 2. DISCUSSION • Definition • Etiology • Classification • Anatomy • Approach to patient • Clinical features • Examination • Investigations • Conditions A/W paraplegia • Management • Complications
- 3. PARAPLEGIA • Originates from Greek language • Para + plēssein means ‘strike at side’ • Impairment in motor function of the lower extremities • With or without involvement of sensory system • Paraplegia - Complete paralysis • Paraparesis - Partial paralysis
- 4. CAUSES OF PARAPLEGIA • Cerebral • Spinal • Infection • Immuno-allergic • Inflammatory • Demyelinating • Heredofamilial • Toxic myelopathy • Vascular • Metabolic/nutritional • Tropical • Para neoplastic syndromes • Physical agents
- 5. CEREBRAL 1. Causes in the Parasagittal Region • Traumatic • Depressed fracture of the vault of the skull • Subdural hematoma • Vascular • Superior sagittal sinus thrombosis • Inflammatory • Encephalitis • Meningo-encephalitis • Neoplastic • Parasagittal meningioma • Degenerative • Cerebral palsy
- 6. Contd., 2. Causes in the Brain Stem • Syringobulbia and midline tumours. • These lesions arise in the midline • Involves the innermost fibers • Which supplies lower limbs
- 7. SPINAL 1. Intramedullary • Syringomyelia • Hematomyelia • Ependymoma • Glioma • Astrocytoma 2. Extramedullary • Intradural • Meningioma • Neurofibroma • Arachnoiditis • Extradural
- 8. Contd., • Extradural • Vertebral • Fracture or fracture-dislocation of the vertebra • Disc prolapse and spondylosis • Deformity of the vertebral (e.g. kyphoscoliosis) • Infective - Pott's disease • Congenital - Spina bifida • Neoplastic diseases - Primary(myeloma)/metastatic(leukemia) • Paravertebral – Abscess/hematoma/aortic aneurysm
- 9. INFECTIVE CAUSES • Bacterial • Acute - Staphylococcal (extradural or intradural) • Chronic - Tuberculosis/Syphilis • Parasitic • Hydatid • Cysticercosis • Schistosomiasis • Viral • Polio/Rabies/Herpes zoster/HIV
- 10. OTHERS • Inflammatory • Transverse myelitis • Myelomeningitis/Myeloradiculitis • Immuno Allergic causes • Post vaccinal – Rabies/tetanus/polio • Post exanthematous - Chicken pox/Herpes zoster • Demyelinating • Multiple sclerosis/Neuromyelitis optica/SACD
- 11. CLASSIFICATION • Based upon nervous system involved and tone • Paraplegia is classified into • Spastic paraplegia • Flaccid paraplegia.
- 12. SPASTIC PARAPLEGIA • Weakness of muscles + increased tone • Occurs in UMN diseases • Loss of inhibition of contraction • Increased muscle tone • Exaggerated deep tendon reflexes • Plantar extension with or without clonus • Classified into • Paraplegia in extension • Paraplegia in flexion
- 13. Contd., Paraplegia in extension • Occurs in initial stages of lesion • Partial transection of spinal cord with Involvement of pyramidal tract • Hypertonia is more in extensor group of muscles
- 14. Contd., Paraplegia in flexion • Occurs as the disease or lesion progresses further or • With complete transection of spinal cord • Extra pyramidal tracts get involved • More hypertonia in flexor group of muscles • Resulting in flexed posture of limbs
- 15. FLACCID PARAPLEGIA • Decreased tone and contractility of muscles + weakness. • It occurs in lower motor neuron diseases • Occurs due to • Loss of stimulatory innervation to muscle • Decreased muscle tone • Atrophied muscle • Absent deep tendon reflexes • Flexor or equivocal plantar with or without fasciculations
- 16. SEGMENTS/FUNCTION • C1-C6 - Neck flexors • C1-T1 - Neck extensors • C3-C5 - Supply diaphragm (mostly C4) • C5-C6 • Raise arm(deltoid) • Flexion of elbows(biceps) • C6 - Externally rotates the arm(supinator) • C6-C7 • Extends elbow and wrist • Triceps and wrist extensor • Pronates arm • C7-T1 - Flexes wrist • C7-T1 - Supply small muscles of hand
- 17. Contd., • T1-T6 - Intercostal muscles • T7-L1 - Abdominal muscles • L1-L4 - Thigh flexion • L2-L4 - Thigh adduction • L4-S1 - Thigh abduction • L5-S2 - Extension of leg at hip (gluteus maximus) • L2-L4 - Extension of legs at knee(quad. femoris) • L4-S2 - Flexion of leg at knee (hamstrings) • L4-S1 - Dorsiflexion of foot/Extension of toes • L5-S2 - Plantar flexion of foot/Flexion of toes
- 18. APPROACH TO PATIENT History • Onset • Sudden • Trauma - Fracture dislocation of vertebrae • Infection - Epidural Abscess, • Vascular - Thrombosis of ASA Endarteritis/Hematomyelia • Transverse Myelitis • Gradual • Neoplastic- meningioma/ependymoma/glioma/astrocytoma
- 19. Contd., • Duration of symptom • Short duration - Traumatic/infective causes • Long duration • Neoplastic/hereditary/ congenital/demyelinating causes • Sensory • Ask about pattern of sensory loss • Sacral sparing or sacral area involved • Radicular (root) pain indicates an extradural lesion
- 20. Contd., • Motor • Limb involvement – Symmetrical/Asymmetrical • Weakness - Proximal /distal muscles • Weakness - Progressive/Static • Associated symptoms • Fever/Seizures/Delayed milestones • Specific systemic symptoms e.g. vitamin deficiency • Any preceding illness/Specific trauma/Prior vaccination/Involuntary movements
- 21. Contd., • In younger children • Antenatal/Natal /Post natal history • Maternal infection • Perinatal asphyxia • Hyperbilirubinemia • Hospitalization • Ask about bladder and bowel involvement • Significant past history and family history
- 22. CLINICAL FEATURES In cerebral paraplegia • Weakness of upper limbs and along with that • Mental retardation • Delayed milestones • Seizures • Altered sensorium
- 23. Contd., In Spinal paraplegia • Spasticity • Exaggerated DTR • Radicular pain • Depending upon level of spine • Dermatomal sensory involvement + • Specific motor weakness present • If peripheral nerve involvement occurs • Distal weakness • Sensory loss • Muscle atrophy • Absent tendon reflexes
- 24. EXAMINATION Neurological examination • Higher mental function status • Affected in cerebral and degenerative diseases • Cranial nerve examination • Affected in brain stem leisons • Tone • Increased in UMN disease • Decreased in LMN disease • DTR • Exaggerated in UMN leisons • Absent in LMN leisons and spinal shock
- 25. Contd., • Sensory examination • To asses particular sensory level • To find the extent of sensory loss • Proper examination of skull and spine • To look for any localized tenderness • Depressed fracture • Deformity
- 26. SUPERFICIAL REFLEXES D7 lesion • Abdominal reflexes lost in all four quadrants • Cremastric reflexes B/L lost • Plantar B/L extensor D10 lesion • Abdominal reflexes lost in lower 2 quadrants • Cremastric reflexes B/L lost • Plantar B/L extensor L1 lesion • Abdominal reflexes present in all four quadrants • Cremastric reflexes B/L lost • Plantar B/L extensor
- 29. SEGMENTS/SIGNS/SYMPTOMS Foramen magnum & Upper cervical region • Severe pain in the occiput &neck • In hands • Loss of post. column sensation • Severe tingling/Numbness • Pain/weakness in the limbs/wasting may occur in the upper limb • Decreased diaphragm movements • Compression of phrenic nerve • Lower cranial nerve involvement/medullary involvement can occur • Descending tract of trigeminal can be involved
- 30. Contd., • C5C6 segment lesion • Inverted supinator reflex • Wasting of muscles supplied by C5C6 • Deltoid/biceps/brachioradialis/rhomboids • C8T1 Level • Wasting of small muscle of hands • Wasting of flexors of wrist & fingers • Horner’s syndrome • DTR of upper limbs preserved • Spastic paralysis of trunk & lower limbs • Cervical spondylosis never involves C8&T1 • So small muscle wasting rules out cervical spondylosis
- 31. Contd., • Mid Thoracic region of spinal cord • Upper limb normal • Wasting of intercostal muscles (supplied by involved segments) • Movements of diaphragm normal • Spastic paralysis of abdominal muscles &lower limbs • 9th &10th thoracic segments • Lower abdominal muscles are weaker • Upper abdominal muscles are intact • BEEVER’S SIGN positive • when patient raises the head against resistance • umbilicus is drawn upwards
- 32. Contd., • T12L1 segments • Abdominal reflexes preserved • Cremastric reflex lost • Wasting of internal oblique & transverse abdominal muscle • L3 L4 segmental lesion • Flexion of hip is preserved • Cremastric reflex preserved • Quadriceps & adductors of hip are wasted • knee jerk is lost or diminished • But ankle jerk is present • Plantar - Foot drop
- 33. Contd., • S1S2 segments • Wasting & paralysis of intrinsic muscles of feet • Wasting & paralysis of calf muscles, Plantarflexion impaired • But dorsiflexion of foot is preserved • In the hip all muscles of hip are preserved • Except flexors & adductors • In the knee flexors of knee are wasted • Knee jerk is preserved, ankle jerk is lost • Plantar reflex is lost. No foot drop • Anal & Bulbocavernous reflexes are preserved
- 34. Contd., • S3S4 segments • Large bowel & bladder are paralysed. • There is retention of urine and feces due to • Unopposed action of internal sphincters • The external sphincters are paralyzed • Anal and bulbo cavernous reflex are lost • Saddle shaped anaesthesia occurs • No paraplegia
- 35. INVESTIGATIONS • Routine blood tests (CBC, PS, CRP & C/S) • Blood chemistry (blood urea, creatinine, electrolytes etc.) • Routine urine exam, urine for culture and sensitivity • Plain X-ray Spine (Lateral and oblique view) • CSF Analysis • To R/O infection-bacterial/tubercular/viral meningitis • CSF culture and sensitivity testing • C.S.F.-Electrophoresis to show oligoclonal bands of multiple sclerosis • CT Cranium/Brain
- 36. Contd., • MRI brain is more informative than CT • It helps in diagnosing • Degenerative/neoplastic/vascular/infective lesions • Spinal MRI • Sagittal views - differentiates • Syringomyelia from intramedullary tumours/transverse myelitis • It also shows cord compression whether internal or external • Myelogram
- 37. CONDITIONS A/W PARAPLEGIA Compressive myelopathy • Dorsal nerve root • U/L or B/L pain aggravated by sudden rapid body movement • Ventral nerve root • LMN type of paraparesis • Corticospinal tract • Produce weakness(asymmetrical) • Stiffness of lower limbs • Posterior column • Produce loss of position/vibration
- 38. Contd., • Syringomyleia • Cystic dilatation of the spinal cord • Obliteration of the flow of CSF • From within spinal canal to its point of absorption • Hematomyelia • Haemorrhage into the substance into spinal cord occurs due to • Trauma/vascular malformations/bleeding disorders/neoplasms/
- 39. Contd., • Epidural abscess • Form anywhere along spinal canal • Two third from haematogenous spread of infection • One third from direct extension of local infections • Pott’s disease • Also known as spinal TB/tubercular spondylitis • Haematogenous spread in most cases • Small no. of cases from adjacent paravertebral lymph nodes
- 40. Contd., • Anterior spinal artery infarction • It supplies the ant. two thirds of the spinal cord • Its infarction causes anterior cord syndrome • Paraplegia or quadriplegia • Dissociated sensory loss • Affecting pain and temp sensation • But sparing vibration and position sense • Loss of sphincter control
- 41. Contd., • Subacute combined degeneration • AV malformation of spinal cord • Hereditary spastic paraplegia • Hydrocephalus • Parasagittal meningioma • Guillain barre syndrome • Transverse myelitis
- 42. MANAGEMENT OF PARAPLEGIA 1. General • Frequent change of posture to guard against bedsores • Care of skin • Frequent washing with alcohol and • Applying talc powder • Care of the bladder • If there is retention, • Use parasympathomimetic drugs • If this fails, use a catheter to evacuate the bladder
- 43. Contd., • In case of urinary incontinence • Frequent change of bed-sheets 2. Physiotherapy 3. Symptomatic Treatment • Analgesics and sedatives for pain • Muscle relaxants for the spasticity • Vitamins and mineral supplementation
- 44. Contd., 4. Specific Treatment (treatment of the cause) • ATT + supportive measures in Pott's disease • Drainage of paraspinal abscess • Traumatic spine stabilisation • Surgical management of some tumors 5. Rehabilitation • Management of complications • Occupational therapy • Gait retaining • Community re- integration
- 45. COMPLICATIONS OF PARAPLEGIA • Bed sores • Contractures • Urinary tract infection • Pneumonia • Deep venous thrombosis
- 46. REFERENCES • Nelson’s text book of pediatrics first south Asia edition • Ghai essential pediatrics 8th edition • Scott pedia – Tricks textbook
- 47. THANK YOU!!