PARAPLEGIA
Presented By \
Dr. KAMAL OSMAN
MIRGANI
Is paralysis or weakness **
. ( paraparesis ) of both lower limbs
It is either :Spastic paraplegia due to **
pyramidal lesion (U.M.N.L )
Flaccid paraplegia ( L . M . N. L ) **
Spastic Paraplegia
: Definition
Paralysis or weakness of both lower limbs
due to bilateral pyramidal tract lesion , most
commonly in the spinal card (spinal
paraplegia ) and less commonly in the brain
stem or cerebral parasagittal region ( cerebral
) paraplegia
-: Spastic Paraplegia
it either ***
. with sensory level
. with out sensory level
Spastic Paraplegia with sensory
level
: causes
: Cord compression - 1
: A-vertebral
fracture or fracture dislocation of vertebra*
Disc prolapse and spandylosis*
Pott’s disease of the spine*
Neoplasms : A 1ry – osteosarcoma*
haemangioma
MRI : acute cervical c5\6 soft disc prolapse
B 2ndary metastatic deposite from eg
breast - lung- stomach – prostate –
.kidney
: A-Extramedullary causes
Extradural eg , leukaemic deposits **
** Dural eg , menigioma
pachymeningitis
** Intradural eg , neurofibroma
: B- Intramedullary causes
Syringiomyelia – Gloom – Ependymoma
of cord
: Inflammatory 2
transverse myelitis
. myelomeningitis
: Vascular 3
. anterior spinal artery occlusion
Spinal paraplegia with out sensory
level
. Subcombined degeneration of the cord
. Motor neuron disease
. Hereditary spastic paraplegia
. Friedreich ataxia
NEXT picture shows
narrowing of intervertebral
disc space
NEXT picture shows
extramedullary , intradural
neurofibroma
NEXT picture shows
intramrdullary cervical cord
glioma
.Multiple sclerosis
.Disseminated encephalomyelitis
. Syphilis
Causes in parasagittal region ( area of
.) cortical presentation of L . L
Depressed fracture of the vault of
. skull causing subdural haematoma
. Superior sagittal sinus Thrombosis
. Parasagittal meningioma
. e. mid brain stem tumor
REMEMBER The
Differences between
EXTRA- & SUB- dural
haematomas
In the NEXT PICTUREs
WHAT is your diagnosis?
That was right frontoparietal
extradural haematomadue to a
squamous temporal fracture
not visible on CT
THAT was axial CT showing a
rghit-sided acute sub dural
haematoma with midline shift
Removal of acute
extradural haematoma by
Craniotomy
CLINICAL FEATURES
At the level of the lesion
there is localized tenderness or pain **
or deformity or swelling if the
. causes of vertebral causes
Radicular pain only seen in **
extramedulluy causes
Below the level of the lesion ( cord
) Manifestations
Motor manifestation .1
,A .If the causes acute ( inflamtion , vascular
) traumatic
: The paraplegia passes into 2 stages
: Stage of flaccidity ] 1 [
due to neuronal Shock complete *
paralysis of L . L with absence of reflexes
lasts from 2 – 6weeks *
:Stage of spasticity ]2[
due to recovery form neuronal
shock and full picture of
, UMNL will be established eg
hypertonia , Babaniski sign +ve and
.may be clonus
B – If the cause is gradual . (eg ,
:neoplastic )
There will be progressive
weakness of the lower limb, with
. hypertonia and hypereflexia
The Anatomy Of The Spinal Cord
Sensory manifestation – 2
a . if the cause of the lesion is
extramedullary
encroachment on the ascending tract , at
the site of the lesion result in sensory
level below which all types of sensation
. are diminished
There is early loss of sensation in
the saddle area ( S 3 , 4 , 5 ) as the
sacral fibres lie in the outer most part
.of the spinothalamic tract in the cord
B. if the cause of the lesion is
: intramedullay
there will be hyposthetic area with **
normal sensation above and below the
lesion ( Jacket sensory loss )
the sensory loss is of disassociated **
nature ie pain and temperature
sensations are lost but touch and
. deep sensations are preserved **
This due to the interruption of
crossing fibers carrying pain and
temperature by midline lesion while
touch and deep sensation fibers
ascend in the posterior
column with decussating . The
sensation over the saddle area are
preserved as sacral fibers , lie far
. from the midline
Sphincter manifestation – 3
a . in the acute lesions
retention of urine in the shock
stage , followed by precipitancy of
. micturation
a . in the acute lesions
retention of urine in the shock
stage , followed by precipitancy of
. micturation
: b. In gradual lesion
Precipitancy of micturation which may
terminated in autonomic bladder when
complete transection of cord
. occurs
The changes started later in extameduallay
lesions as the pyramidal fibers controlling
. the bladder center lie medially in the cord
INVESTIGATIONS
. Complete haemogram + E S R 1
. X –ray chest 2
C. S. F analysis 3
. C. T . scan 4
. X – ray spines 5
.M R I of vertebral column 6
. Vitamin B12 assay 7
MANAGEMENT OF
PARAPLEGIA
: A General : nursing care
Frequent turning of pt to prevent bed 1
. sores and Hypostatic state
Care of skin frequent washing with 2
.alcohol and talk power
. Care of the bladder eg catheterization 3
:Physiotherapy 4
Massage to increase blood supply to **
. paralysed muscles
Positioning: the paralysed limbs **
.should be put opposite to hypertonia
Passive excercise to gurd against **
. fibrosis and stiffness of joints
. Good adequate nutrition 5
pressure sore locations
B TREATMENT :
of complications
.
C Specific treatment of the
cause
. Anituberculous for pott’s disease .1
Deep–radiation for intramedullary .2
. tumors
Surgical excision for extramedllary .3
. tumours
,,,,,,,,,,,,,,,,,,,,,,,.With My Best Wishes
Dr \ KAMAL
OSMAN
MIRGANI
