Bilateral spastic paralysis (spastic paraplegia)

36 Bilateral spastic paralysis (spastic paraplegia)



Instruction


Carry out a neurological examination of this patient’s lower limbs.



Salient features



History




• Ask about onset, duration and course of symptoms


• Back pain: whether localized


• Ask about radicular pain


• Numbness and parasthesia particularly below the level of lesion


• Weakness: whether gradual or sudden


• Sphincter control and bladder sensation


• Functional status: wheelchair transfers, walking aids, orthotic shoes and whether house has been modified for the patient’s disability


• Take a family history (hereditary spastic paraplegia)


• Take a history of birth anoxia (cerebral palsy)


• History of urinary infections, pressure sores and deep venous thromboses.



Examination




• Increased tone in both lower limbs


• Hyperreflexia


• Ankle clonus


• Weakness in both lower limbs


• Wasting


• Then proceed to:


• Check the sensory level

• Examine the spine (spinal tenderness or deformity).

• Tell the examiner that you would like to do the following:


• Check sacral sensation

• Examine the hands to rule out involvement of upper limbs

• Check for cerebellar signs (multiple sclerosis, Friedreich’s ataxia).

• Try to localize the level of lesion using the following:


• Spasticity of the lower limb alone: lesion of thoracic cord (T2–L1)

• Irregular spasticity of lower limbs with flaccid weakness of scattered muscles of lower limbs: lesion of lumbosacral enlargement (L2–S2)

• Radicular pain: useful early in the disease, with time becomes diffuse and ceases to have localizing value

• Superficial sensation: not good for localizing as the level of sensory loss may vary greatly in different individuals and in different types of lesions.


Diagnosis


This patient has bilateral spastic paraparesis (lesion) at L1 spinal level caused by trauma (aetiology); it is complicated by bladder involvement (functional status).



Questions


What are the causes of spastic paraparesis?


Youth:



• Trauma


• Multiple sclerosis


• Friedreich’s ataxia


• HIV.


Adults:



• Multiple sclerosis


• HIV (Neurology 1989;39:892)


• Trauma (motor vehicle or diving accident)


• Spinal cord tumour (meningioma, neuroma)


• Motor neuron disease


• Syringomyelia


• Subacute combined degeneration of the cord (associated peripheral neuropathy)


• Tabes dorsalis


• Transverse myelitis


• Familial spastic paraplegia.


Elderly:



• Osteoarthritis of the cervical spine


• Vitamin deficiency


• Metastatic carcinoma


• Anterior spinal artery thrombosis


• Atherosclerosis of spinal cord vasculature.

Related posts:

  1. Permanent cardiac pacemaker/implantable cardioverter-defibrillator
  2. Wallenberg’s syndrome (lateral medullary syndrome)
  3. Abnormal gait
  4. Dystrophia myotonica

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Dec 4, 2016 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Bilateral spastic paralysis (spastic paraplegia)

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