Clinical Evaluation of Paraplegia : Dr. S. Aswini Kumar. MD. Professor of Medicine 1 Clinical Evaluation of Paraplegia Anatomy of spinal cord : Cranial border of atlas Lower border of L1 45 cm in adult male
42 cm in adult female Anatomy of spinal cord Corresponding spinal column 70cm Total 31 segments 2 Structure : Structure 3 Intra medullary Extra medullary intradural Extra medullary extradural Cross-sectional anatomy : Cross-sectional anatomy 4 Dermatomes : Dermatomes 5 Sensory impairment related to level of spinal cord injury Tracts : Tracts Sensory Tracts Motor Tracts 6 Blood supply : Blood supply 7 Bladder control : Bladder control 8 History taking in paralplegia : History taking in paralplegia What is the onset of paraplegia?
Is it acute – within, minutes or hours?
Is it subacute – within days or weeks?
Is it chronic – within months or years?
Was there a history of trauma?
Fall from height/road traffic accident/direct injury?
Was there a history of back pain?
Duration/maximum intensity/history of spinal surgery? 9 Any girdle pain or radicular(root) pain? : Any girdle pain or radicular(root) pain? Is there any girdle pain / sensation?
Pain around the thorax or abdomen
Is it unilateral or bilateral?
Does it increase with coughing and sneezing?
Is there a history of root pains?
Is it unilateral or bilateral?
Does it radiate to the limbs?
Does it aggravate with coughing? 10 History suggestive of tract involvement? : History suggestive of tract involvement? Any pyramidal tract involvement?
Buckling of knees/Slipping of chappals/Tripping on objects?
Any lower motor neuron involvement?
Loss of tone, wasting and fasciulations
Any dorsal column involvement?
Swaying while washing face or difficulty in walking at night?
Any cerebellar involvement?
Any swaying while walking/inability to sit upright/incordination 11 History of past illnesses : History of past illnesses History of viral infections?
Viral infections/Chicken pox/Herpes zoster/HSV-1&2/HIV/CMV/HTLV
History of vaccination?
Anti Rabies vaccination/Polio vaccination/Others?
Hisory of tuberculosis?
Any where in the body-Pulmonary/intestinal/lymphnodal/miliary
History of Malignancy?
Swellings/ surgery for tumors/Chemotherapy or radiation 12 Personal history : Personal history Any bladder involvement?
Retention /overflow incontinence/bladder sensation?
Any bowel involvement?
Constipation/bowel incontinence/bowel sensation?
Any sexual dysfunction?
Morning Erection/los of libido/sexual promiscuity?
Any autonomic dysfunction
Excessive sweating/absence of sweating 13 Complete neurological examination : Complete neurological examination Optic fundi
Lower cranial nerves
Motor system in full
Sensory system in full
Deep tendon reflexes
Spine 14 1. Does the patient have neurological problem? : 1. Does the patient have neurological problem? Yes/no
Or is it a medical condition simulating paraplegia?
Fracture dislocation of pelvis/
Polyarthritis of joints of limbs
Or is it a case of Gullain Barre Syndrome
Or is it Hysteria or malingering
If Yes what is the nature of the deficit?
cerebral diplegia/cerbral paraplegia 15 2. What is the mode of onset of paraplegia? : 2. What is the mode of onset of paraplegia? Acute
Transverse myelitis, Traumatic paraplegia, Anterior spinal artery syndrome
Pott’s paraplegia, Spinal epidural abscess, Spinal cord tumors
Familial spastic paraplegia, Amyotrophic lateral sclerosis, Cranio-vertebral junctional anomalies 16 3. What are the subjective sensory symptoms? : 3. What are the subjective sensory symptoms? Radicular (root) pain or Girdle pain
Unilateral or bilateral sharp shooting pain of dermatome distribution
Exacerbated by coughing, sneezing or valsalva
An aching pain confined to a point of spine accompanied by point tenderness
Neoplastic or inflammatory dural lesion likely
Deep seated ill defined dull ache distant from the affected cord level
Common with intra-medullary lesion 17 4. What are the objective sensory deficits? : 4. What are the objective sensory deficits? These may be in the form of
Hypesthesia (decreased touch sensation)
Hypoalgesia (decreased pain sensation)
Loss of all modalities below a level
Loss of position and vibration sense
Dissociated sensory loss
Suspended segmental loss of pain and temperature
Loss of pain & temperature below a particular level 18 5. What are the motor deficits? : 5. What are the motor deficits? Is there any muscle wasting?
Is there a disuse atrophy?
Is there a distal muscle wasting?
Small muscle wasting in syringomyelia?
Is there a proximal muscle wasting?
What is the tone of the muscles?
What is the distribution of motor weakness?
Is there any abnormal movements?
Is there any loss of co-ordination? 19 6. What are the changes in superficial reflexes? : 6. What are the changes in superficial reflexes? Abdominal reflexes of all 4 quadrants are absent. Cremasteric reflexes absent bilaterally. Plantars are extensor bilaterally - D7 lesion
Abdominal reflexes of upper quadrants are present. Lower quadrants are absent. Beever’s sign is positive. Plantar reflexes are extensor bilaterally - D10 lesion
Abdominal reflexes of all four quadrants are present. Both cremasteric reflexes are absent. Plantar reflexes are extensor bilaterally. - L1 lesion 20 7. What are the changes in the deep reflexes? : 7. What are the changes in the deep reflexes? Loss of Deep tendon reflexes at segmental level with exaggerated DTR below the level indicate level of lesion
Biceps reflex – C5
Supinator reflex – C5
Inversion of supinator – C5 C6
Triceps reflex – C7
Knee reflex –L2 L3
Ankle reflex – L5 S1 21 8. Is it an LMN/UMN lesion or a combination? : 8. Is it an LMN/UMN lesion or a combination? LMN signs alone would indicate the possibility of
Anterior horn cell lesion (Spinal muscular atrophy)
Nerve root disease ( Radiculopathy)
Peripheral nerve lesion ( Peripheral neuritis)
Myoneural junction abnormality (Myasthenia)
Primary Muscle disease (Myopathies)
LMN signs of a segmental distribution indicates an appropriate level of lesion
Bilateral UMN findings below that level indicates a transection of corticospinal tracts on either sides
Both LMN and UMN signs at the same level suggests the possibility of motor neuron disease 22 9. What is the segmental level of lesion? : 9. What is the segmental level of lesion? It is derived from the information gathered through collection of the data as above
Sensory segmental level by
root/radicular /girdle pain
Loss of sensations as per dermatomes
Motor segmental level
Superficial reflex level
Deep tendon reflex level
Bladder function level 23 10. Are there other features of the level? : 10. Are there other features of the level? Upper Cervical Cord
QP and weakness of diaphragm
Lesion of C5-C6
Loss of power and reflex at biceps
Lesion of C7 segment
Triceps, wrist extensors and fingers
Lesion of C8-T1 segments
Finger and wrist flexion, Horners
Lesions of mid thoracic region?
Sensory level at trunk, midline back pain 9th and 10th thoracic segments
Paralysis of lower not upper abdomen
L2 – L4 segments
Flexion and abduction of thigh
L5 – S1 segments:
Flexion knee, extension thigh, foot
S3 – S4 segments:
Saddle anesthesia, bladder and bowel
Root pains, asymmetrical leg weakness 24 11. What is the vertebral level? : 11. 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
Sacral and coccygeal segments 25 12. Corresponding vertebral examination : 12. Corresponding vertebral examination Inspection:
narrowing of disc space,
Auscultation: Bruit 26 13. What are the nuclei/tracts involved? : 13. What are the nuclei/tracts involved? 1. Complete transection of spinal cord
3. Central lesion
4. Posterior and lateral column lesions
5. Posterior column disease
6. Anterior horn cell disease
7. Anterior horn cell + pyramidal
8. Plexus lesion/radiculopathy 27 14. Is it a Vascular syndrome of spinal cord? : 14. Is it a Vascular syndrome of spinal cord? Features
Abrupt onset girdle pain/radicular pain
Flaccid paraplegia within minutes /hours
Analgesia below the level
Impaired bowel and bladder control
Watershed zones C4 T4 segments L1 segment
Arteriosclerosis of spinal arteries 28 abnormally increased T2 signal is seen within the central portion of the distal spinal cord 15. Am I dealing with a spinal cord compression? : 15. Am I dealing with a spinal cord compression? Diseases of the vertibral column?
Secondaries of spine
Primary neoplasms: Sarcoma, Myeloma, Hemangioma
Spinal cord tumors 29 16. Or is it a non compressive myelopathy? : 16. Or is it a non compressive myelopathy? A. Infective:
Viral – Poliomyelitis, Herpes zoster, Rabies
Bacterial – Tuberculosis, Syphilis
Parasitic, Falciparum Malaria and Schistosomiasis
Post exanthematous –Measles, Rubella
Post vaccinial – Rabies, Polio
Transverse myelitis 30 17. Is it an extra/intra medullary lesion? : 17. Is it an extra/intra medullary lesion? Radicular pains common early
Vertibral pain is common
Funicular pain – less common
UMN signs present and early
LMN signs are unusual segmental
Parasthesia ascending progression
Sphincter involvement is late
Trophic changes are uncommon Radicular pain is unusual
Vertibral pain is also unusual
Funicular pains may occur
UMN signs are present but late
LMN signs are prominent and diffuse
Sphincter involvement is early
Trophic changes are common 31 18. Is it a conus/cauda lesion? : 18. Is it a conus/cauda lesion? Onset – symmetrical
Dissociated sensory loss - present
Root pain - rare
Fasciculation – rare
Decubitus ulcer – common
Bladder - early
Bowel - early Onset –Asymmetrical
Dissociated sensory loss – not present
Root pain - common
Decubitus ulcer – uncommon
Bladder – late
Bowel - late 32 So what the diagnosis we are aiming at? : So what the diagnosis we are aiming at? Acute
Transvere myelitis/Devic’s disease
Spinal cord injury/ Fracture
Herniation of IV Disc
Anterior spinal artery occlusion
Gullain Barre Syndrome
Tuberculosis of Spine
Intramedullary /extramedullary tumors
Subacute combined degeneration
Lathyrism Chronic degenerative
Arnold Chiari Malformation
Amyotrophic lateral slcerosis
Spinal Muscular atrophy
Thrombosis of unpaired ant cerebral
Sagital sinus thrombosis
Cervical spondylosis 33 Common causes for compressive myelopathy : Common causes for compressive myelopathy Extramedullary
Pachymeningits Prolapsed IVD
Or Central cord lesion
Hemangioblastoma 34 Summary : Summary Gross anatomy
Cross section of cord
Organization of tracts
Bladder control Complete history
Dedicated neurological examination
Level of spinal cord injury
Spinal cord syndromes
Spinal cord compression or not
Intra/extra medullary lesion
Conus/cauda lesion Knowledge about anatomy Clinical Evaluation 35 Slide 36: Thank You 36