4th Year 2nd Semester 2nd Module Medicine III

L4: Paraplegia and Neurogenic Bladder

Paraplegia
 Paraplegia means paralysis of both lower limbs
 It may be:
• Spastic paraplegia due to involvement of UMN or pyramidal tract.
• Flaccid paraplegia: due to involvement of LMN
• Mixed paraplegia: Involvement of both UMN & LMN eg. Amyotrophic lateral sclerosis
SPASTIC PARAPLEGIA
 Occur due to involvement of pyramidal tract lesion at level of:
- Spnial cord (spinal paraplegia) - Brain stem. - Cerebral "parasagittal”
 Spinal paraplegia may be:
- Focal (with a level).
- Multifocal (without a level).
- Systemic (without a level).
1- Spinal Paraplegia:
A) Focal causes
1. Compression:
• Vertebral:
- Pott's disease
- Fracture or fracture-dislocation.
- Deformity: as kyphoscoliosis.
- Disc prolapse and spondylosis.
- Neoplastic: - 1ry (osteosarcoma or haemangioma).
- 2ry from thyroid, breast, lung,....etc.
• Meningeal (extramedullary):
- Extradural: leukaemic deposits.
- Dural: meningioma, pachymeningitis hypertrophica of syphilis.
- Intradural: neurofibroma, cystic arachnoiditis.
• Cord (intramedullary): Syringomyelia, Glioma or Ependymoma of cord.
2. Inflammatory: - Transverse myelitis. - Myelomeningitis - Myeloradiculitis.
3. Vascular: Anterior spinal artery occlusion.
B) Multifocal causes: disseminated diseases
- Disseminated Sclerosis (D.S.) - Disseminated Encephalo-myelitis
- Disseminated Syphilitic lesions. (D.E.M.)

1 Neurology BFOM 38 Team

 4th Year 2nd Semester 2nd Module Medicine III
C) Systemic Causes:
Usually occur symmetrical and bilaterally, affecting one or more systems selectively.
1. Heridofamilial :
- Hereditary spastic paraplegia.
- Hereditary ataxias: Friedreich's or Marie's ataxia.
2. Symptomatic :
- Pellagral lateral sclerosis.
- Subacute combined degeneration.
3. Idiopathic: motor neurone disease.
2- Cerebral Paraplegia
A) Cortical Causes:
In the Parasagittal Region (area of presentation of L.L.)
• Traumatic: - Depressed fracture vault of the skull. - Subdural haematoma.
• Vascular: - superior sagittal sinus thrombosis.
• Inflammatory: - encephalitis, meningio-encephalitis.
• Neoplastic: parasagittal meningioma.
• Degenerative: cerebral palsy.
B) Brain-stem Causes;
Usually arise in the midline, so affecting the innermost pyramidal fibers which are responsible
for lower limbs as in: - Syringobulbia. - Midline brain stem tumours.
Clinical Picture: of focal paraplegia
A) At the Level of the Lesion
• Vertebral manifestations (only in vertebral causes).
- Localised deformity or swelling.
- Localised pain or tenderness.
• Radicular manifestations (only in extra-medullary causes).
1. Posterior root affection:
- Early pain in the back referred to the distribution of the affected root and described as
girdle pain (it is exaggerated by coughing, sneezing and straining).
- later on, hyposthesia or anaesthesia in dermatome supplied by the affected root.
2. Anterior root affection:
- Localised L.M.N. weakness in the muscles supplied by the affected root.
If the lesion is cervical, some muscles may be affected in I-JL (not the whole UL) so leveling is possible. but if the lesion
is below cervical segments, leveling is not clinically clear or evident, as it difficult to test for tone, deep reflexes or
wasting in trunk and abdominal wall muscles.

2 Neurology BFOM 38 Team

 4th Year 2nd Semester 2nd Module Medicine III
B) Below the Level of the Lesion.
I. Motor Manifestations
a) If the cause is acute : the paraplegia passes by (same events as hemiplegia)
- Stage of flaccidity (2-6 weeks): Immediate sudden flaccid paralysis of the LL, with
loss of tone and reflexes
- Stage of Recovery: return and gradual increase of tone and reflexes with appearence
of babiniski sign)
- Stage of spasticity: full picture of U.M.N.L. (increaase tone & reflexes, +ve Babinski
sign & may be clonus)
b) If the cause is gradual: spastic from the start
- It starts by gradual progressive weakness of UMN nature with no shock stage.
- distribution :
1. Weakness is: distal > proximal flexors > extensors.
2. Hypertonia and hyperreflexia are extensor (antigravity) > flexor group (progravity)
II. Sensory Manifestations
a) If the cause of the lesion is extramedullary :
- Encroachment on the ascending tracts at the site of lesion results in a 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:
- Jacket sensory loss (hyposthetic area with normal sensations above and below it)
- The sensory loss is of a dissociated nature i.e. pain and temp. sensations are lost but
touch and deep sensations are preserved*.
III. Sphincteric Manifestations
a) In acute lesions:
- Retension of urine in the shock stage, followed by precipitancy of micturition.
b) In gradual lesions:
- Precipitancy of micturition which may terminate in automatic bladder when complete
transection of the cord occurs
NB: These changes start late in extramedullary lesions and early in intramedullary lesions as
the pyramidal fibers controlling the bladder center lite medially in the cord.
Investigations: CT & MRI (Gold Standard)

3 Neurology BFOM 38 Team

 4th Year 2nd Semester 2nd Module Medicine III
Management of Paraplegia:
A) General treatment: Care of skin, bed sheets, bladder retension
B) Physiotherapy: Massage, passive and active exercises and positioning against hypertonia
C) Symptomatic Treatment: Analgesics and sedatives for pain, Vitamins and tonics.
D) Specific Treatment (for the cause) e.g.:
- Muscle relaxants for the spasticity.
- Antituberculous drugs in case of Pott's disease.
- Deep irradiation or chemotherapy in case of intra-medullary tumour.
- Surgical eradication in case of extra-medullary tumour.
Extramedullary lesions Intramedullary lesions
History - Gradual and painful - Gradual and painless
- Long duration - Short
Motor Usually asymmetrical Usually symmetrical
Sensory Sensory level below which all - Jacket sensory loss , dissociated
sensations are lost (loss of pain & temp with preserved touch)
Sphincter Late bladder disturbance Early bladder disturbance
Neurogenic Bladder
I. LMNL (Lesions at the level of the reflex arc)
1. Sensory Atonic Bladder (Lesion in the afferent sensory fibres).
- Absence of the sense of fullness of the bladder.
- Retention of urine with overflow.
- Ask the patient to evacuate 4 times daily.
2. Motor Atonic Bladder (Lesion in the efferent motor fibres).
- Preservation of the sense of fullness of the bladder.
- Retention of urine due to inability to evacuate the bladder voluntarily.
- Catheterization is needed.
3. Autonomic Bladder (Lesion in spinal center S2,3.4 or in both afferent & efferent fibres)
- Involuntary & Incomplete evacuation of the bladder.
- Evacuation of bladder occurs by its myogenic contraction.
II. UMNL (Lesions above the level of the arc)
1. Acute: - Retention of urine with overflow.
2. Gradual:
- Partial lesion: Precipitancy of micturition.
- Complete lesion: Automatic Bladder:
- Complete evacuation of the bladder,
- Evacuation of the bladder occurs by the spinal reflex arc
NB: For any disturbance in bladder function to occur, the lesion should be bilateral.

4 Neurology BFOM 38 Team