Seminar-Quadripplegia, Paraplegia, MND
Seminar-Quadripplegia, Paraplegia, MND
Seminar-Quadripplegia, Paraplegia, MND
2. Paraparesis
Spastic
- spinal cord compression
- multiple sclerosis
- motor neuron disease + transverse myelitis
- subacute combined degeneration of the cord
- Syringomyelia
Flaccid
3. Quadriparesis
APPROACH TO PATIENT WITH
PARAPARESIS AND
QUADRIPARESIS
(SPINAL CORD DISORDERS)
SITI NURFARHANIE BINTI SAMSUDIN
012012100203
OUTLINE
• ANATOMY OF SPINAL CORD
• ASCENDING PATHWAY
- Spinothalamic Tract
- Posterior Column Tract
• DESCENDING PATHWAY
- Corticospinal Tract
• DEFINITION OF PARAPLEGIA AND QUADRIPLEGIA
• FLACCID PARAPLEGIA
ANATOMY
NERVOUS
SYSTEM
Somatosensor Motor
y system system
(ascending (descendi
tract) ng tract)
SOMATOSENSORY SYSTEM
Nucleus
cuneatus: from
levels at T6
and above
Descending Tract (Motor System)
• Corticospinal • Subconscious
tract tract
- Corticobulbar tract - Vestibulospinal tract
- Lateral Corticospinal - Tectospinal tract
tract - Rubrospinal tract
- Anterior - Reticulospinal tract
Corticospinal tract
Fx --> Subconscious
Fx --> Conscious regulation of balance,
control of skeletal muscle tone, eye, hand,
muscles and upper limb
position
SUBCONSCIOUS TRACTS
• Vestibulospinal tract
•Send information from the inner ear to
monitor position of the head
• Tectospinal tract
• Send information to the head, neck, and
upper limbs in response to bright and
sudden movements and loud noises
• Reticulospinal tracts
•Send information to cause eye movements
and activate respiratory muscles
• Rubrospinal tracts
•Send information to the flexor and extensor
muscles
Fine touch
DEFINITIONS
SYSTEMIC DISEASE:
1. Acute porphyrias
2. Critical illness
neuropathy
3. Acute myopathy in
ICU patient
Reference :
http://jpcc.in/userfiles/2015
/0203-jpcc-jul-sep-
2015/JPCC0203049.html
Clinical Features
Features of lower motor neuron lesion:
• Weakness
• Wasting
• Hypotonia
• Reduced or absent reflexes
• Fasciculation
INVESTIGATION
• Routine blood investigation: FBC, Renal profile, etc.
• Spinal CT scan:
- Narrow disc space and look for compression with
contrast.
• MRI brain:
-To exclude other causes of weakness such as
infarction, hemorrhage, degenerative and neoplasm.
• MRI spine:
- Details view of cord compression
SPASTIC PARAPLEGIA
Causes in details
Spinal cord compression
Motor neuron disease
Transverse myelitis
SPASTIC PARAPLEGIA
Definition
Weakness or paralysis of
the muscle with increased
muscle tone
Vertebral Congenital
Meninges Infective/inflammatory
Neoplastic
Metabolic
Degenerative
SPINAL CORD
COMPRESSION
SPINAL CORD COMPRESSION
• Common neurological emergency.
• Space-occupying lesion within the spinal canal
damaging nerve tissue by:
– Directly: pressure
– Indirectly: blood supply interference
• Onset of
symptoms is slow
(weeks).
• Can be acute due
to trauma or
metastases.
Davidson’s 22nd
Edition
pg: 1220
• The signs vary
according to spinal
cord compression
level & structures
involved
• May be tenderness
to spinal percussion,
associated with local
kyphosis
Davidson’s 22nd
Edition
pg: 1221
The Brown-Séquard
syndrome
– Damage is confined to
one side of cord
(hemisection of the
cord)
– probably the result of a
compressive or
destructive lesion of the
spinal cord.
Myelography + CSF analysis Complete spinal block = normal cell count with
increased protein
Degenerative Infective
Inflammatory
AETIOLOGY
Metabolic Vascular
Neoplastic
(A) CONGENITAL
Clinical features
• LMN features, deformity and legs sensory loss
• Impaired sphincter function
Diastematomyelia • Hairy patch or pit over low back
(spina bifida) Investigation
MRI spine splitting of spinal cord
Management
Surgery
Clinical features
• Adult onset
• Slowly progressive UMN features, legs > arms
Hereditary Spastic • Little or no sensory loss
Paraplegia
Investigation
(autosomal
MRI thinning of corpus callosum
dominant)
Genetic testing
Management
Baclofen (improve spasticity), rehab, genetic counselling
(B) VASCULAR
Clinical features
• Acute paraplegia
• Loss of spinothalamic sensation
Anterior Spinal • Sparing of posterior column sensation below lesion
Artery Infarct Investigation
MRI spine hyperintense lesion = ischaemia)
Management
Physiotherapy & rehabilitation
Clinical features
• UMN, LMN features, sphincter disturbance
• Not localised to AVM sites
Spinal arteriovenous
Investigation
malformation
• MRI spine swelling of cord, enlarged arteries & veins
(Spinal AVM)
• Spinal angiography
Management
Therapeutic: Endovascular embolization during angiography
(C) NEOPLASTIC
Clinical features
• Weakness and sensory loss
• Pain
• UMN features below lesion
• LMN features in conus
• Impaired sphincter function
Glioma, Investigation
ependymoma • Neuroimaging (CT head, MRI)
Management
• Gliomas may recur
• Partial excision (debulking) may be useful
• Radiotherapy and chemotherapy
Causes:
Abnormalities in superoxide dismutase (SOD1) gene 20%
Expanded repeat sequence in C9ORF72 gene on chromosome
9
Most common form is amyotrophic sclerosis (ALS)
INVESTIGATION
MRI Distinguish TM from external lesion affecting
spinal cord
Static Develop
deficit MS
Recover with
no relapse
• Onset: insidious
Vitamin B12 Def:- causes
78
-posterior column dysfunction decreases
vibratory sensation and proprioception (joint
sense).
-Lateral corticospinal tract dysfunction
produces spasticity + UMN sign
CLINICAL FEATURES OF
SUBACUTE COMBINED DEGENERATION
a. Numbness and tingling of fingers and toes
b. Distal sensory loss (proprioception, light touch & vibration
c. ataxia
d. Absent ankle reflex (LMN)
e. Absent knee reflex (LMN)
f. Positive Babinski sign (umn)
g. Optic atrophy and retinal hemorrhage may occur
h. Dementia
3
MULTIPLE SCLEROSIS
4
MULTIPLE SCLEROSIS AFFECT:
>
The ratio is
increasing worse
now prognosis
MS is more
common in
temperate
regions, such as
northern
Europe and
North America,
but much rarer
in the tropics.
87
MULTIPLE SCLEROSIS
• Cause- UNKNOWN
• But, there is a linked that:
ENVIRONMENT:
sunlight exposure, vitamin D deficiency exposure to Epstein
Barr Virus (EBV)-mechanism became unclear
GENETIC:
↑ risk in first degree relative. Twin.
The risk of developing MS is associated with certain class I
and class II alleles of the major histocompatibility complex
(MHC), particularly the HLA-DRB1 locus
95
OUTLINE
• Causes
• Clinical presentation according to the level of lesion
• Quadriplegia
Paralysis affecting all 4
limbs
Also called as tetraplegia
# lesion above T1
vertebra cause
quadriplegia
CAUSES
• Traumatic
- Motor vehicle accident
-Falls
-Sport injuries
-Gunshot and stabbing injury
• Non Traumatic
C1-C4 Quadriplegia
• C1 – C2 : may have functional phrenic nerves
• C3: impaired breathing, ventilator dependent
• C4: may be free from advanced respiratory
support but require functional equipment
need as C3
C5 Quadriplegia
Muscular weakness • Deltoid
• Supraspinatus
• Brachoradialis
Deep tendon reflexes • Biceps
affected • Supinator
Radicular • Neck
pain/paraesthesia • Top of shoulder
• Outer aspect of arm & forearm
Superficial sensory • Outer aspect of the forearm
deficit
How to localize the lesion to the 7th cervical root
level?
C7 Quadriplegia
Muscular • Triceps
weakness • Most of the muscles on
the dorsum of forearm
Deep tendon • Triceps jerk
reflexes affected
Radicular • Neck
pain/paraesthesia • Shoulder
• Arm
• Forearm to index &
middle fingers
Superficial sensory • Mostly middle & index
deficit finger
How to localize the lesion to the 8th cervical root
level?
C8 Quadriplegia
Muscular • Flexors of the forearm
weakness
Deep tendon • Finger jerk
reflexes affected
Radicular • Neck
pain/paraesthesia • Shoulder
• Arm
• Ring & little finger
Superficial sensory • Ring & little finger
deficit
REFERENCES
• 250 CASES IN CLINICAL MEDICINE, 4TH ED, R.R BALIGA (PG 89)
• MEDSCAPE
• WWW.HOPKINSMEDICINE.ORG
• WWW.DISABLED-WORLD.COM
THANK YOU