paraplegia

1. APPROACH TO PARAPLEGIA IN
CHILDREN
Dr. C. Kannan
Post graduate
Pediatrics
MGMCRI

2. DISCUSSION
• Definition
• Etiology
• Classification
• Anatomy
• Approach to patient
• Clinical features
• Examination
• Investigations
• Conditions A/W paraplegia
• Management
• Complications

3. PARAPLEGIA
• Originates from Greek language
• Para + plēssein means ‘strike at side’
• Impairment in motor function of the lower extremities
• With or without involvement of sensory system
• Paraplegia - Complete paralysis
• Paraparesis - Partial paralysis

4. CAUSES OF PARAPLEGIA
• Cerebral
• Spinal
• Infection
• Immuno-allergic
• Inflammatory
• Demyelinating
• Heredofamilial
• Toxic myelopathy
• Vascular
• Metabolic/nutritional
• Tropical
• Para neoplastic syndromes
• Physical agents

5. CEREBRAL
1. Causes in the Parasagittal Region
• Traumatic
• Depressed fracture of the vault of the skull
• Subdural hematoma
• Vascular
• Superior sagittal sinus thrombosis
• Inflammatory
• Encephalitis
• Meningo-encephalitis
• Neoplastic
• Parasagittal meningioma
• Degenerative
• Cerebral palsy

6. Contd.,
2. Causes in the Brain Stem
• Syringobulbia and midline tumours.
• These lesions arise in the midline
• Involves the innermost fibers
• Which supplies lower limbs

7. SPINAL
1. Intramedullary
• Syringomyelia
• Hematomyelia
• Ependymoma
• Glioma
• Astrocytoma
2. Extramedullary
• Intradural
• Meningioma
• Neurofibroma
• Arachnoiditis
• Extradural

8. Contd.,
• Extradural
• Vertebral
• Fracture or fracture-dislocation of the vertebra
• Disc prolapse and spondylosis
• Deformity of the vertebral (e.g. kyphoscoliosis)
• Infective - Pott's disease
• Congenital - Spina bifida
• Neoplastic diseases - Primary(myeloma)/metastatic(leukemia)
• Paravertebral – Abscess/hematoma/aortic aneurysm

9. INFECTIVE CAUSES
• Bacterial
• Acute - Staphylococcal (extradural or intradural)
• Chronic - Tuberculosis/Syphilis
• Parasitic
• Hydatid
• Cysticercosis
• Schistosomiasis
• Viral
• Polio/Rabies/Herpes zoster/HIV

10. OTHERS
• Inflammatory
• Transverse myelitis
• Myelomeningitis/Myeloradiculitis
• Immuno Allergic causes
• Post vaccinal – Rabies/tetanus/polio
• Post exanthematous - Chicken pox/Herpes zoster
• Demyelinating
• Multiple sclerosis/Neuromyelitis optica/SACD

11. CLASSIFICATION
• Based upon nervous system involved and tone
• Paraplegia is classified into
• Spastic paraplegia
• Flaccid paraplegia.

12. SPASTIC PARAPLEGIA
• Weakness of muscles + increased tone
• Occurs in UMN diseases
• Loss of inhibition of contraction
• Increased muscle tone
• Exaggerated deep tendon reflexes
• Plantar extension with or without clonus
• Classified into
• Paraplegia in extension
• Paraplegia in flexion

13. Contd.,
Paraplegia in extension
• Occurs in initial stages of lesion
• Partial transection of spinal cord with Involvement of
pyramidal tract
• Hypertonia is more in extensor group of muscles

14. Contd.,
Paraplegia in flexion
• Occurs as the disease or lesion progresses further or
• With complete transection of spinal cord
• Extra pyramidal tracts get involved
• More hypertonia in flexor group of muscles
• Resulting in flexed posture of limbs

15. FLACCID PARAPLEGIA
• Decreased tone and contractility of muscles + weakness.
• It occurs in lower motor neuron diseases
• Occurs due to
• Loss of stimulatory innervation to muscle
• Decreased muscle tone
• Atrophied muscle
• Absent deep tendon reflexes
• Flexor or equivocal plantar with or without fasciculations

16. SEGMENTS/FUNCTION
• C1-C6 - Neck flexors
• C1-T1 - Neck extensors
• C3-C5 - Supply diaphragm (mostly C4)
• C5-C6
• Raise arm(deltoid)
• Flexion of elbows(biceps)
• C6 - Externally rotates the arm(supinator)
• C6-C7
• Extends elbow and wrist
• Triceps and wrist extensor
• Pronates arm
• C7-T1 - Flexes wrist
• C7-T1 - Supply small muscles of hand

17. Contd.,
• T1-T6 - Intercostal muscles
• T7-L1 - Abdominal muscles
• L1-L4 - Thigh flexion
• L2-L4 - Thigh adduction
• L4-S1 - Thigh abduction
• L5-S2 - Extension of leg at hip (gluteus maximus)
• L2-L4 - Extension of legs at knee(quad. femoris)
• L4-S2 - Flexion of leg at knee (hamstrings)
• L4-S1 - Dorsiflexion of foot/Extension of toes
• L5-S2 - Plantar flexion of foot/Flexion of toes

18. APPROACH TO PATIENT
History
• Onset
• Sudden
• Trauma - Fracture dislocation of vertebrae
• Infection - Epidural Abscess,
• Vascular - Thrombosis of ASA Endarteritis/Hematomyelia
• Transverse Myelitis
• Gradual
• Neoplastic- meningioma/ependymoma/glioma/astrocytoma

19. Contd.,
• Duration of symptom
• Short duration - Traumatic/infective causes
• Long duration
• Neoplastic/hereditary/ congenital/demyelinating causes
• Sensory
• Ask about pattern of sensory loss
• Sacral sparing or sacral area involved
• Radicular (root) pain indicates an extradural lesion

20. Contd.,
• Motor
• Limb involvement – Symmetrical/Asymmetrical
• Weakness - Proximal /distal muscles
• Weakness - Progressive/Static
• Associated symptoms
• Fever/Seizures/Delayed milestones
• Specific systemic symptoms e.g. vitamin deficiency
• Any preceding illness/Specific trauma/Prior vaccination/Involuntary
movements

21. Contd.,
• In younger children
• Antenatal/Natal /Post natal history
• Maternal infection
• Perinatal asphyxia
• Hyperbilirubinemia
• Hospitalization
• Ask about bladder and bowel involvement
• Significant past history and family history

22. CLINICAL FEATURES
In cerebral paraplegia
• Weakness of upper limbs and along with that
• Mental retardation
• Delayed milestones
• Seizures
• Altered sensorium

23. Contd.,
In Spinal paraplegia
• Spasticity
• Exaggerated DTR
• Radicular pain
• Depending upon level of spine
• Dermatomal sensory involvement +
• Specific motor weakness present
• If peripheral nerve involvement occurs
• Distal weakness
• Sensory loss
• Muscle atrophy
• Absent tendon reflexes

24. EXAMINATION
Neurological examination
• Higher mental function status
• Affected in cerebral and degenerative diseases
• Cranial nerve examination
• Affected in brain stem leisons
• Tone
• Increased in UMN disease
• Decreased in LMN disease
• DTR
• Exaggerated in UMN leisons
• Absent in LMN leisons and spinal shock

25. Contd.,
• Sensory examination
• To asses particular sensory level
• To find the extent of sensory loss
• Proper examination of skull and spine
• To look for any localized tenderness
• Depressed fracture
• Deformity

26. SUPERFICIAL REFLEXES
D7 lesion
• Abdominal reflexes lost in all four quadrants
• Cremastric reflexes B/L lost
• Plantar B/L extensor
D10 lesion
• Abdominal reflexes lost in lower 2 quadrants
• Cremastric reflexes B/L lost
• Plantar B/L extensor
L1 lesion
• Abdominal reflexes present in all four quadrants
• Cremastric reflexes B/L lost
• Plantar B/L extensor

29. SEGMENTS/SIGNS/SYMPTOMS
Foramen magnum & Upper cervical region
• Severe pain in the occiput &neck
• In hands
• Loss of post. column sensation
• Severe tingling/Numbness
• Pain/weakness in the limbs/wasting may occur in the upper limb
• Decreased diaphragm movements
• Compression of phrenic nerve
• Lower cranial nerve involvement/medullary involvement can occur
• Descending tract of trigeminal can be involved

30. Contd.,
• C5C6 segment lesion
• Inverted supinator reflex
• Wasting of muscles supplied by C5C6
• Deltoid/biceps/brachioradialis/rhomboids
• C8T1 Level
• Wasting of small muscle of hands
• Wasting of flexors of wrist & fingers
• Horner’s syndrome
• DTR of upper limbs preserved
• Spastic paralysis of trunk & lower limbs
• Cervical spondylosis never involves C8&T1
• So small muscle wasting rules out cervical spondylosis

31. Contd.,
• Mid Thoracic region of spinal cord
• Upper limb normal
• Wasting of intercostal muscles (supplied by involved segments)
• Movements of diaphragm normal
• Spastic paralysis of abdominal muscles &lower limbs
• 9th &10th thoracic segments
• Lower abdominal muscles are weaker
• Upper abdominal muscles are intact
• BEEVER’S SIGN positive
• when patient raises the head against resistance
• umbilicus is drawn upwards

32. Contd.,
• T12L1 segments
• Abdominal reflexes preserved
• Cremastric reflex lost
• Wasting of internal oblique & transverse abdominal muscle
• L3 L4 segmental lesion
• Flexion of hip is preserved
• Cremastric reflex preserved
• Quadriceps & adductors of hip are wasted
• knee jerk is lost or diminished
• But ankle jerk is present
• Plantar - Foot drop

33. Contd.,
• S1S2 segments
• Wasting & paralysis of intrinsic muscles of feet
• Wasting & paralysis of calf muscles, Plantarflexion impaired
• But dorsiflexion of foot is preserved
• In the hip all muscles of hip are preserved
• Except flexors & adductors
• In the knee flexors of knee are wasted
• Knee jerk is preserved, ankle jerk is lost
• Plantar reflex is lost. No foot drop
• Anal & Bulbocavernous reflexes are preserved

34. Contd.,
• S3S4 segments
• Large bowel & bladder are paralysed.
• There is retention of urine and feces due to
• Unopposed action of internal sphincters
• The external sphincters are paralyzed
• Anal and bulbo cavernous reflex are lost
• Saddle shaped anaesthesia occurs
• No paraplegia

35. INVESTIGATIONS
• Routine blood tests (CBC, PS, CRP & C/S)
• Blood chemistry (blood urea, creatinine, electrolytes etc.)
• Routine urine exam, urine for culture and sensitivity
• Plain X-ray Spine (Lateral and oblique view)
• CSF Analysis
• To R/O infection-bacterial/tubercular/viral meningitis
• CSF culture and sensitivity testing
• C.S.F.-Electrophoresis to show oligoclonal bands of multiple sclerosis
• CT Cranium/Brain

36. Contd.,
• MRI brain is more informative than CT
• It helps in diagnosing
• Degenerative/neoplastic/vascular/infective lesions
• Spinal MRI
• Sagittal views - differentiates
• Syringomyelia from intramedullary tumours/transverse myelitis
• It also shows cord compression whether internal or external
• Myelogram

37. CONDITIONS A/W PARAPLEGIA
Compressive myelopathy
• Dorsal nerve root
• U/L or B/L pain aggravated by sudden rapid body movement
• Ventral nerve root
• LMN type of paraparesis
• Corticospinal tract
• Produce weakness(asymmetrical)
• Stiffness of lower limbs
• Posterior column
• Produce loss of position/vibration

38. Contd.,
• Syringomyleia
• Cystic dilatation of the spinal cord
• Obliteration of the flow of CSF
• From within spinal canal to its point of absorption
• Hematomyelia
• Haemorrhage into the substance into spinal cord occurs due to
• Trauma/vascular malformations/bleeding disorders/neoplasms/

39. Contd.,
• Epidural abscess
• Form anywhere along spinal canal
• Two third from haematogenous spread of infection
• One third from direct extension of local infections
• Pott’s disease
• Also known as spinal TB/tubercular spondylitis
• Haematogenous spread in most cases
• Small no. of cases from adjacent paravertebral lymph nodes

40. Contd.,
• Anterior spinal artery infarction
• It supplies the ant. two thirds of the spinal cord
• Its infarction causes anterior cord syndrome
• Paraplegia or quadriplegia
• Dissociated sensory loss
• Affecting pain and temp sensation
• But sparing vibration and position sense
• Loss of sphincter control

41. Contd.,
• Subacute combined degeneration
• AV malformation of spinal cord
• Hereditary spastic paraplegia
• Hydrocephalus
• Parasagittal meningioma
• Guillain barre syndrome
• Transverse myelitis

42. MANAGEMENT OF PARAPLEGIA
1. General
• Frequent change of posture to guard against bedsores
• Care of skin
• Frequent washing with alcohol and
• Applying talc powder
• Care of the bladder
• If there is retention,
• Use parasympathomimetic drugs
• If this fails, use a catheter to evacuate the bladder

43. Contd.,
• In case of urinary incontinence
• Frequent change of bed-sheets
2. Physiotherapy
3. Symptomatic Treatment
• Analgesics and sedatives for pain
• Muscle relaxants for the spasticity
• Vitamins and mineral supplementation

44. Contd.,
4. Specific Treatment (treatment of the cause)
• ATT + supportive measures in Pott's disease
• Drainage of paraspinal abscess
• Traumatic spine stabilisation
• Surgical management of some tumors
5. Rehabilitation
• Management of complications
• Occupational therapy
• Gait retaining
• Community re- integration

45. COMPLICATIONS OF PARAPLEGIA
• Bed sores
• Contractures
• Urinary tract infection
• Pneumonia
• Deep venous thrombosis

46. REFERENCES
• Nelson’s text book of pediatrics first south Asia edition
• Ghai essential pediatrics 8th edition
• Scott pedia – Tricks textbook

47. THANK YOU!!