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Paraplegia
Paraplegia
Spastic Paraplegia
Definition:
It is paralysis or weakness of both lower-limbs due to bilateral pyramidal
tract lesion, most commonly in the spinal cord (spinal paraplegia), and less
commonly in the brain stem or the cerebral parasagittal region (cerebral
paraplegia). Spinal paraplegia may be: 1. Focal: paraplegia with sensory level.
2. Systemic.
3. Disseminated.
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Causes of Spinal Paraplegia:
I- Focal causes:
A. Compression:
1. Vertebral:
- Fracture or fracture-dislocation of the vertebra, Disc prolapse and
spondylosis, Pott's disease, Neoplastic diseases: Primary or metastatic and
Deformity of the vertebral column as kyphoscoliosis.
2. Meningeal (extramedullary):
- Extradural e.g. leukaemic deposits.
- Dural e.g. meningioma.
- Intradural e.g. neurofibroma.
3. Cord (intramedullary): Syringomyelia .
B. Inflammatory: Transverse myelitis - Myelomeningitis - Myeloradiculitis.
C. Vascular: Anterior spinal artery occlusion.
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Causes of Cerebral Paraplegia:
A. Causes in the Parasagittal Region: (area of cortical presentation of L.L.)
1. Traumatic e.g. depressed fracture of the vault of the skull, Subdural
haematoma.
2. Vascular e.g. superior sagittal sinus thrombosis.
3. Inflammatory e.g. encephalitis, meningio-encephalitis.
4. Neoplastic e.g. parasagittal meningioma.
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difficulty of testing for tone and deep reflexes in the trunk and abdominal
muscles. If the lesion involves the cervical segments, there is quadriplegia
with evident signs of L.M.N.L. in the upper limbs.
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urination, defecation and sweating on scratching the skin over the medial side of
the thigh.
N.B: Piere Marie Foix test is done by firm passive plantar flexing of the toes
and foot. This will result in spontaneous "withdrawal reflex" i.e. spontaneous
flexion of the hip, knee and dorsiflexion of the ankle if the paraplegia is passing
from extension to flexion.
2. Sensory of Manifestations:
a) If the cause of the lesion is extramedullary, encroachment on the ascending
tracts at the site of lesion results in sensory level below which, all types of
sensations are diminished. There is early loss of sensation in the saddle area (S
3, 4, 5), as the sacral fibres lie in the outermost part of the spinothalamic tracts in the
cord.
b) If the cause of the lesion is intramedullary, there will be a jacket
sensory loss (hyposthetic area with normal sensations above and below it). The
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sensory loss is of a dissociated nature i.e. pain and temperature sensations are
lost but touch and deep sensations are preserved; this is due to the interruption of
the crossing fibers carrying pain and temperature by the midline lesion, while touch
and deep sensation fibers ascend in the posterior column without decussation. The
sensations over the saddle area are preserved (sacral spare), as the sacral fibers lie
far from the midline lesion.
Arrangement of fibers within the spinothalamic tract
3. Sphincteric Manifestations:
a. In acute lesions: There is
retention of urine in the shock stage,
followed by precipitancy of micturition.
b. In gradual lesions: There is
precipitancy of micturition which
may terminate in automatic
bladder when complete transaction
of the cord occurs.
* These changes start late in
extramedullary lesions and early in
intramedullary lesions as the
pyramidal fibres controlling the blad-
der centre lie medially in the cord.
Management of Paraplegia
I. General:
- Frequent change of the patient's posture to guard against bedsores.
- Care of the skin by frequent washing with alcohol followed by talc powder. In
case of urinary incontinence, frequent change of bed-sheets.
- Care of the bladder: If there is retention, use parasympathomimetic drugs. If this
fails, use a catheter to evacuate the bladder.
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II. Physiotherapy
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Modified from: Elwan H: Principles of Neurology.University book center, Cairo, Egypt, 2007.