APPROACH TO QUADRIPLEGIA

26
10/26/2021 1
DEFINITION

• Weakness and loss of movement of all the four limbs as a result

of damage or trauma to the nervous system.

26
10/26/2021 2
 CLINICAL ANATOMY- SPINAL CORD

26
10/26/2021 3
 CLINICAL ANATOMY - CROSS-SECTION

26
10/26/2021 4
 CLINICAL ANATOMY- TRANSVERSE SECTION

26
10/26/2021 5
 CLINICAL ANATOMY

26
10/26/2021 6
 DERMATOMES

26
10/26/2021 7
 APPLIED ANATOMY

The primary cause of quadriplegia is cervical spinal cord injury.

•Upper cervical cord lesions produce quadriplegia and weakness of the diaphragm.
• Lesions at C4-C5 produce quadriplegia.
• Lesions at C5-C6, there is loss of power and reflexes in the biceps.
• Lesions at C7 weakness affects finger and wrist extensors and triceps.
• Lesions at C8, finger and wrist flexion are impaired.
•Horner's syndrome (miosis, ptosis, and facial hypohidrosis) may accompany a cervical cord lesion at any level.

• 9

26
10/26/2021 8
CAUSES
BRAIN LESIONS

• Cerebral palsy
• Bilateral brainstem lesion (Glioma)
• Cranio-vertebral anomaly(also included in high cervical cord lesion)
• Transient ischemic attacks of the brainstem
• Transient global cerebral ischemia
• Multiple sclerosis
• B/L hemiplegia due to brain lesions
• Parasagittal or foramen magnum tumors

26
10/26/2021 9
 CAUSES (CONTD..)
SPINAL CORD LESIONS

Compressive lesions
1) Extramedullary
a) Extradural b) Intradural

-Injury to the cervical spinal cord (fracture,dislocation or -Meningioma

collapse of the vertebra) -Neurofibroma
-Cervical spondylosis -AV –malformations
-Myeloma,lymphomatous or metastatic deposits -Arachnoiditis
-Patchy meningitis
-Spinal epidural abscess or haematoma
-Caries spine (not common in cervical spine)

26
10/26/2021 10
 CAUSES (CONTD..)
SPINAL CORD LESIONS

Compressive lesions
2) Intramedullary

- Glioma

- Ependymoma

- Chordoma

- Syringomyelia

- Haematomyelia

26
10/26/2021 11
 CAUSES (CONTD..)
SPINAL CORD LESIONS
Non-compressive lesions

-Multiple sclerosis -Intoxications-

Lead, Aluminium,Strychnine,Phenytoin, Electric shock
-Motor neuron disease
-Transverse myelitis
-Acute anterior poliomyelitis

-GB syndrome -Syphilitic meningomyelitis

-Diptheria -Haematomyelia

-Tetanus -Post-vaccine
-Retroviral myelopathy -Radiation myelopathy
-Lyme polyradiculitis and other tick borne paralysis
-Paraneoplastic myelitis
-Cervical myelopathy of unknown cause
-Antiphospholipid antibody syndrome

26
10/26/2021 12
CAUSES (CONTD..)

Electrolyte disturbances

- Hypokalemia

- Hyperkalemia

- Hypercalcemia

- Hypernatremia

- Hyponatremia

- Hypophosphatemia

- Hypermagnesemia

26
10/26/2021 13
 CAUSES (CONTD..)

Muscle disorders  

• Channelopathies (periodic paralyses)  

•  Metabolic defects of muscle (impaired carbohydrate or fatty acid utilization;
abnormal mitochondrial function)

Neuromuscular junction disorders

•   a. Myasthenia gravis
•   b. Lambert-Eaton myasthenic syndrome
• c. Botulism

26
10/26/2021 14
HISTORY TAKING

• H/o trauma
• Onset- Acute/subacute/chronic/recurrent
• H/o chronic neck pain/cervical pain
• Any root pain or girdle like sensation
• H/o numbness/reduced sensation
• H/o respiratory symptoms
• H/o bowel and bladder involvement
• H/o buckling of knees,slipping of sleepers,tripping on objects
• H/o wasting and fasciculations
• H/o incordination during walking/doing activities
• H/o autonomic dysfunction
• H/o changes in conciousness or cognition and with alterations of sensation

26
10/26/2021 15
PAST HISTORY

• H/o viral infection

• H/o vaccination
• H/o TB
• H/o malignancy
• H/o cerebral palsy
• H/o similar illness

26
10/26/2021 16
PERSONAL HISTORY

• Alcohol consumption
• Veg/ Non-veg
• Exposure to STDs

26
10/26/2021 17
FAMILY HISTORY

• TB
• H/o malignancy

26
10/26/2021 18
 CLINICAL EXAMINATIONS

CNS EXAMINATIONS

• Higher mental functions

• Spine and Vertebra examination

• Cranial nerves examinations

• Motor – bulk, tone, power, DTR, Superficial reflex, Plantar response

• Sensory—Cortical sensation, Dorsal column, Anterior column sensations

26
10/26/2021 19
 CLINICAL EXAMINATIONS

CNS EXAMINATIONS

• Cerebellar signs

• Signs of meningisms

• Autonomic system examination

26
10/26/2021 20
 LESION LOCALISATIONS
• Weakness from brain lesions usually is associated with changes in consciousness or
cognition,with spasticity and brisk stretch reflexes, and with alterations of sensation.

• LMN sign of segmental distribution will indicate the level of lesion

• Bilateral UMN findings below the level indicate transection of corticospinal tracts on either
sides.

• Both LMN and UMN at same segmental site indicates MND

• Both LMN and UMN at same segmental site indicates MND

• Most neuromuscular causes of generalisesd weakness are associated with normal

mental function,hypotonia,and hypoactive muscle stretch reflexes.

26
10/26/2021 21
 LESION LOCALISATIONS

Localisation of the level of compression is done by:

• Distribution of root pain- Ask for specific dermatomes involved.

• Upper border of sensory loss
• Girdle – like sensation at the level of lesion
• Zone of hyperaethesia- localise the level of lesion one segment below
• LMN signs in a segmental distribution and UMN signs below the involved segment
• Deformity or any swelling in the vertebra
• Tenderness in the vertebra
• A spinal injury above S2 will cause spastic bladder

26
10/26/2021 22
 LESION LOCALISATIONS

Features of ‘high’ cervical cord lesion:

• Quadriplegia
• Respiratory distress
• Horner’s syndrome
• Paralysis of sternomastoid and trapezius due to injury to spinal accessory nerve
• Features of injury to spinal tract of trigeminal nerve
• Vertical nystagmus (down-beating).

26
10/26/2021 23
 INVESTIGATIONS
• Routine Blood test, Electrolytes

• Special blood test

• X-ray of the spine

• Mantoux test

• Chest X-ray

• CSF examination

• MRI------head/spine

• NCV/EMG

• Miscellaneous- Muscle biopsy, muscle enzymes,VDRL and Kahn test, blood for HIV

26
10/26/2021 24
 MANAGEMENT
• Treat the underlying cause

• Care of bowel ,bladder and trophic ulcers

• Nutritious diet

• Active physiotherapy

• Prevention of secondary infections

• Proper counselling

• ventilator or electrical implant for the person to breathe

• Stem cell transplantation

• Rehabilitation

26
10/26/2021 25
 THANK YOU

26
10/26/2021 26