paraplegia-aaa.ppt2

Paraplegia:

Paraplegia By dr Ahmad Amad Dr Wala`a Ismail

Functional anatomy of spinal cord:

Functional anatomy of spinal cord The spinal cord is an extension of the brain and is enclosed in and protected by the bony vertebral column . Main function = transmission of neural inputs between the periphery and the brain. The peripheral regions of the spinal cord contains neuronal white matter tracts containing sensory and motor neurons. The central region is gray matter that contains nerve cell bodies. The central canal is an anatomic extension of the fourth ventricle .

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C erebrospinal fluid - in the subarachnoid space Generally: Ventral roots – motor nerves Dorsal roots – sensory nerves The ventral and dorsal roots later join to form paired spinal nerves , one on each side of the spinal cord. Three meninges cover the spinal cord - the outer dura mater , the arachnoid membrane , and the innermost pia mater

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The spinal cord is divided into 31 different segments : 8 cervical segments 12 thoracic segments 5 lumbar segments 5 sacral segments 1 coccygeal segment At third month of fetal life the spinal cord full whole the vertebral canal - Then the vertebral column grow faster than spinal cord so------ At birth the spinal cord ends at the level of L3 In the adult , the cord ends around the L1/L2 vertebral level at the conus medullaris , with all of the spinal cord segments located superiorly to this. After segments pass the end of the spinal cord, they are considered to be part of the cauda equina that consists of nerve roots and rootlets.

Connections between brain and spinal cord:

Connections between brain and spinal cord Descending motor tracts ( pyramidal & extrapyramidal ) Ascending sensory tracts

Pyramidal tract:

Pyramidal tract The corticospinal or pyramidal tract is a massive collection of axons that travel between the cerebral cortex of the brain and the spinal cord . Consists of two separate tracts in the spinal cord: the lateral corticospinal tract and the medial (anterior) corticospinal tract . The lateral corticospinal tract : Most of the cortico-spinal fibers (about 85%) cross over to the contralateral side in the medulla oblongata ( pyramidal decussation ). The medial (anterior) corticospinal tract : The remainder of them (15%) cross over at the level that they exit the spinal cord . End as a synapse with another neuron in the ventral horn .

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Descending Spinal Cord Tract

Extrapyramidal motor pathways :

Extrapyramidal motor pathways The extrapyramidal system is a neural network located in the brain that is part of the motor system involved in the coordination of movement. Parts of extrapyramidal system: Reticulospinal tract – proprioception, voluntary movements, autonomic functions. Vestibulospinal tract – voluntary and unvoluntary movements. Tectospinal tract – head movements based of the eye and ear inputs. Olivospinal tract – from cerebellum and cortex. Coordination of movements. Rubrospinal tract – from cerebellum and motor cortex.

Sensory tracts:

Sensory tracts Dorsal column: Gracile fasciculus from lower limbs & Cuneate fasciculus from upper limbs for fine touch , vibration , proprioception , concious appreciation of body position & sense of fullness of bladder & rectum lateral spinothalamic tract & anterior spinothalamic tract for pain, crude touch & temperature. Posterior spinocerebellar tract & anterior spinocerebellar tract for unconcious proprioception

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Ascending Spinal Cord Tract

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Blood supply One Anterior spinal Branch from the vertebral artery. Arise Inside the skull Which unit to form single artery then descend on anterior median fissure. Two Posterior spinal arteries. Branch form the vertebral artery. Descend in the posterior lateral sulcus .

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Radicular arteries , branches from: In the cervical region from Vertebral artery. In the thoracic region from Posterior intercostal arteries. In the lumber region from Lumbar arteries In the sacral region from Sacral arteries . Venous derainge Form plexus along anterior & posterior midlines and along attachment of motor & sensory roots. Drained by radicular vein to epidural venous plexus.

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Dermatomic area (dermatome) is an area of skin that is supplied by a single pair of dorsal roots . The body can be divided into regions that are mainly supplied by a single spinal nerve . This innervates the body in a patterned form. Along the thorax and abdomen it is simply like a stack of discs forming a human, each supplied by a different spinal nerve. Along the arms and the legs , the pattern is different: the dermatomes run longitudinally along the limbs. Clinical significance: Dermatomes are useful in neurology for finding the site of damage to the spine.

Dermatomes:

Dermatomes What is the vertebral level? Calculated in a reverse direction From cervical segments- subtract 1 From upper thoracic segments- subtract 2 From lower thoracic segments- subtract 3 Lumbar 1-2 segments- T10 vertebra Lumbar 3-4 segments- T11 vertebra Lumbar 5 segments- T12 vertebra

Paraplegia :

Paraplegia Occurs when the level of injury is below the 1st thoracic nerve. Disability can vary from the impairment of leg movement, to complete paralysis of the legs and abdomen up to the nipple line. Paraplegics have full use of their arms and hands.

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Paraplegia can be flaccid or spastic Flaccid paralysis means lower motor neuron paralysis Acute onset of UMN type of paralysis may present flaccid instead of spastic paralysis due to shock.

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Spinal shock is the phenomena surrounding transection of the spinal cord that leads to temporary loss or depression of all or most spinal reflex activity below the level of a spinal lesion. the period of spinal shock can last from hours to 6 weeks. In the acute stage , there will be hypotone paralysis, areflexia , loss of sensory function and dysautonomia . Patient shows retention of the bladder due to the imparied reflex of emptying the bladder. In post acute stage , first autonomic reflexes come to normal. In the chronic stage , there will be hypertone paralysis, hyper- reflexia , spastic-reflex bladde . Patient at this stage shows incontinence.

Causes of flaccid paralysis:

Causes of flaccid paralysis Anterior horn cells-poliomylitis Nerve root- radiculitis,cauda equina Peripheral nerves-GB syndrome,peripheral neuropathy Myoneural junction- myasthenia gravis Muscles – myopathy hysterical

Causes of spastic paraplegia:

Causes of spastic paraplegia Compressive Extradural Pott`s disease Metastatic carcinoma from breast lung prostate Multiple myeloma Herniated disc , fracture Cervical spondylosis Intradural Meningioma , lymphoma , mets Epidural abscess Intramedullary Spinal cord tumor

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Vascular Arteriovenous malformation Antiphospholipid syndrome and other hypercoagulable states Inflammatory Multiple sclerosis Transverse myelitis Sarcoidosis Vasculitis

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Infectious Viral: HZV, HSV-1 and -2, CMV, HIV Bacterial and mycobacterial : Listeria , syphilis, Mycoplasma pneumoniae Parasitic: schistosomiasis , toxoplasmosis Metabolic Vitamin B12 deficiency ( subacute combined degeneration) Syringomyelia

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Differences Extramedullary Root pain---common UMN signs –early Sensory deficit— contralateral loss of pain and temp with ipsilateral loss of proprioception Intramedullary Rare Late Dissociated sensory loss Bowel bladder disturbances– early Vertebral tenderness may be present CSF changes – froins syndrome common Late Absent Rare

Differences between compressive and non compressive paraplegia:

Differences between compressive and non compressive paraplegia (compressive) Boney changes Root pains Upper level of sensory loss present Zone of hyperaesthesia may be present (non compressive) No boney changes No root pains No definite level Absent

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Usually gradual onset Asymetrical involvement of limbs Bladder bowel disturbance occurs Usually acute onset Symmetrical involvement of limbs Occours but late (compressive) (non compressive)

Difference between conus medularis and cauda equina syndrome:

Difference between conus medularis and cauda equina syndrome Conus leison Bilateral symmetrical of both lower limbs No root pains Bilateral saddle anaesthesia Cauda equina leion Asymmetrical involvement of both lower limbs Severe root pains Asymetrical sensory loss Bladder bowel disturbances common Relatively spared

Brief description of important lesions of spinal cord:

Brief description of important lesions of spinal cord

Transverse myelitis :

Transverse myelitis Inflammation of the spinal cord at a single level. Symptoms develop rapidly and include limb weakness, sensory disturbance, bowel and bladder disturbance, back pain, and radicular pain. Recovery generally begins within 3mo. but is not always complete. Causes: Idiopathic (thought to be autoimmune mechanism) Infection Vaccination Autoimmune disease e.g. SLE, sarcoidosis MS Malignancy Vascular e.g. thrombosis of spinal arteries, vasculitis 2° to heroin abuse, spinal A-V malformation

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INV MRI shows swelling of spinal cord Management Methylepridnisolone injection followed by oral pridnisolone Good recovery occur in 30% of cases

Spinal cord infarction:

Spinal cord infarction Anterior spinal artery infarction produces paraplegia or quadriplegia, sensory loss affecting pain/temperature but sparing vibration/position sensations (supplied by posterior spinal arteries), and loss of sphincter control. Onset sudden or evolving over minutes or a few hours. Associated conditions: aortic atherosclerosis, dissecting aortic aneurysm, hypotension. Therapy is directed at the predisposing condition.

Subacute combined degeneration (vitamin B12 deficiency):

Subacute combined degeneration (vitamin B12 deficiency) Paresthesia in hands and feet, early loss of vibration/position sense, progressive spastic/ataxic weakness, and areflexia due to associated peripheral neuropathy; mental changes and optic atrophy may be present. Diagnosis is confirmed by a low serum B12 level and a positive Schilling test. Treatment is vitamin replacement.

Spinal tuberculosis Pott`s disease:

Spinal tuberculosis Pott`s disease Usually occur in absence of extra spinal TB Upper thoracic spines are mostly involved in children , while lower thoracic & upper lumbar vertebrae usually affected in adults First symptom is pain over affected area which is made worse by weight bearing Collapse of vertebral bodies result in kyphosis called gibbus

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INV X-ray spine , CT ,MRI Management Immobilization , antituberculous therapy , surgical decompression if necessary.

Spinal cord tumor:

Spinal cord tumor Most are epidural in origin, resulting from metastases to the adjacent spinal bones. Almost any tumor can be responsible: breast, lung, prostate, lymphoma. Thoracic cord most commonly involved. Initial symptom is usually back pain, worse when recumbent, with local tenderness preceding other symptoms by many weeks. Spinal cord compression due to metastases is a medical emergency; in general, therapy will not reverse paralysis of 48 h duration.

Treatment:

Treatment consists of glucocorticoids (dexamethasone, 40 mg daily) to reduce interstitial edema, local radiotherapy initiated as early as possible to the symptomatic lesion, and specific therapy for the underlying tumor type. Intradural tumors are generally benign—meningiomas or neurofibromas; treatment is surgical resection.

Spinal epidural abscess:

Spinal epidural abscess Triad of fever, localized spinal pain, and myelopathy (progressive weakness and bladder symptoms); once neurologic signs appear, cord compression rapidly progresses. Two-thirds of infections spread hematogenously ; one-third spread from a nearby skin infection. Impaired immune status and IV drug abuse are risk factors. Treatment is emergency decompressive laminectomy with debridement combined with long-term antibiotic therapy.

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Guillain-Barre Syndrome Post infectious mononuclear inflammatory infiltrate of myelin Symmetric ascending paralysis Areflexic , no sensory loss Progression over 1 - 3 weeks - may be more rapid 1/3 progress to respiratory failure CSF - Albuminocytologic dissociation

Motor neurone disease (MND) :

Motor neurone disease (MND) Motor neurone disease is a degenerative disorder of unknown cause affecting motor neurones in the spinal cord, brainstem, and motor cortex. 10% have a FH. There is never any sensory loss. Patterns of disease There are 3 recognized patterns of MND: Amyotrophic lateral sclerosis (ALS) (50%) combined LMN wasting and UMN hyperreflexia . Progressive muscular atrophy (25%) anterior horn cell lesions affecting distal before proximal muscles. Better prognosis than ALS. Progressve bulbar palsy (25%) loss of function of brainstem motor nuclei (LMN lesions) resulting in weakness of the tongue, muscles of chewing/swallowing, and facial muscles. MND never affects external ocular movements (cranial nerves III, IV, VI). . Death usually results from ventilatory failure 3-5y. after diagnosis.

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Brown-Sequard syndrome The hemisection of the cord results in a lesion of each of the three main neural systems: The corticospinal lesion produces ipsilateral spastic paralysis . The lesion to fasciculus gracilis or fasciculus cuneus results in ipsilateral loss of vibration and proprioception (position sense). The loss of the spinothalamic tract leads to pain and temperature sensation being lost from the contralateral side beginning one or two segments below the lesion. Above the level of lesion – hyperesthesia (increased sensation) – irritation of dorsal horns.

Hereditary spastic paraparesis:

Hereditary spastic paraparesis Isolated progressive paraparesis runs in some families. Inheritance is variable. Additional features including cerebellar signs, wasted hands and optic atrophy are sometimes seen. The paraparesis is usually mild and progresses slowly over many years. Some cases have dystonic features and respond to levodopa.

Syringomyelia :

Syringomyelia Tubular cavities (syrinxes) form close to the central canal of the spinal cord. As the syrinx expands, it compresses nerves within the spinal cord. Typically presents with wasting and weakness of hands and arms, and loss of temperature and pain sensation over trunk and arms (cape distribution). Action: Refer to neurology.

Complications of Paraplegia :

Complications of Paraplegia Complications of paraplegia include: Skin care issues (Pressure sores) DVT Loss of bladder control & UTI Loss of bowel control Loss of sensory function Loss of motor function Depression

Complications of Paraplegia :

Complications of Paraplegia Loss of temperature control Most people with complete spinal cord injuries don't sweat below the level of the injury and many quadriplegics can't sweat above the injury either (even though they may sweat due to autonomic dysreflexia ). With loss of ability to sweat or vasoconstrict within affected dermatomes, careful control of environmental conditions becomes essential to avoid hypothermia or overheating. In hot weather, advise cooling with wet towels applied to the skin.

Treatment for Paraplegia :

Treatment for Paraplegia Treatment during the acute phase will focus on returning as much function as possible. Long-term treatment will focus on learning to compensate with disabilities, and avoidance of complications. Clinical trials are also available to the paraplegic.

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