Paraplegia and Spinal Cord Syndromes

Chapter 24 Paraplegia and Spinal Cord Syndromes

Paraplegia may result from a variety of systemic and primary CNS medical conditions, as well as trauma at all segmental levels of the spinal cord (Box 24.1). A spinal cord syndrome may develop from extramedullary and intramedullary pathological processes (Fig. 24.1). Initial symptoms may be gradual in onset and progressive, including pain, dysesthesia, or subtle upper-or lower-extremity weakness. In other cases, such as an inflammatory myelitis, acute onset of severe motor, sensory, and autonomic deficits may develop without premonitory symptoms. Trauma from a cervical flexion-extension injury, for example, may produce a central cord injury of the lower cervical spinal cord with incomplete quadriparesis, whereas a complete transection injury at the lower thoracic spinal cord from a fall may result in complete paraplegia. Thus, both the rostrocaudal segmental level of disease involvement or trauma and completeness of the lesion in the transverse plane anticipate the person’s impairments and disability. Details about the relationships between specific spinal cord segments and sensory dermatomes are reviewed in Chapter 28, and the segmental innervation of specific muscle groups are reviewed in Chapters 29 and 30. The sensorimotor clinical examination allows localization of the lesion (Fig. 24.2).

When examining a patient who presents with paraplegia, a careful neurological examination is critical for planning additional diagnostic workup and care. Identifying distinct spinal cord syndromes and determining the likely location of the underlying pathological process will guide subsequent imaging and electrodiagnostic studies. Structural information about the integrity of the spine may be obtained from radiographic plain films and computed tomography (CT) for bone pathology. Magnetic resonance imaging (MRI) and myelography are best to reveal cord pathology. A review of imaging of the spine is provided in Chapter 33A.

Acute and long-term care of patients is influenced by the clinical presentation, severity of neurological deficits, underlying pathology, and prognosis for gains over time. Patients presenting with an acute spinal cord syndrome after trauma show both early (days to 3 months) and late (up to 2 years) changes in their motor and sensory deficits (Fawcett et al., 2007). Both neurological improvements and clinical worsening may occur. When some sparing of sensation and movement is present in the first 72 hours after trauma, the prognosis for walking is rather good. Indeed, up to 90% of patients with a cervical central cord injury who have modest sensation and movement below the level of injury by 4 weeks after trauma will become functional ambulators (Dobkin et al., 2006). Thus, serial and careful neurological examinations are important to monitor the injury-related deficits, especially in the first weeks after onset. Rehabilitation of patients with paraplegia follows after the acute medical needs have been addressed. The aim is to promote as much functional independence as possible with and without assistive devices, decrease the risk of complications, and reintegrate the patient into home and community. Neurological rehabilitation for paraparesis after spinal cord syndromes is reviewed in Chapter 48.

Common Spinal Cord Syndromes

The clinical presentation of a spinal cord injury depends on whether the injury is complete or spares selected fiber tracts. A number of clinically characterized spinal cord syndromes may develop as a result of the involvement of different portions of the spinal cord gray and white matter.

Incomplete Lesions of the Spinal Cord

Jun 19, 2016 | Posted by in NEUROLOGY | Comments Off on Paraplegia and Spinal Cord Syndromes
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