PARAPLEGIA
DR GARIMA PANDEY
MEDICINE SR
AIIMS BBSR
HISTORY
History given by patient himself and is fair and reliable
28 years old , unmarried muslim male Mohammad, right handed, studied till 5th standard,
works in shoe industry presented with chief complaints of
1) Weakness of bilateral lower limb for last 10-12 days
2) Decreased sensation, below nipples for last 10-12 days
3) Difficulty in urination for last 10-12 days
HOPI
Patient was apparently asymptomatic 10-12 days back when he complained of weakness in both lower limbs
simultaneously which was acute in onset , rapidly progressing. Patient felt weakness in lower limbs in the morning,
however he somehow managed to walk with support, he was neither able to wear chappals, sit down or get up from
squatting position by himself, by the evening weakness rapidly progressed so much that he was unable to stand
even with support and became completely bed bound. He was not able to move his lower limbs at all. At night he
was taken to some local hospital where he was hospitalised and received some treatment for 5 days.
At present his weakness is mildly improved and he is able to move his toes. He feels that his legs have become
floppy.
He is not able to get up from bed or take turn sideways
However he is able to flex his neck, button unbutton his shirt and comb his hair.
There is no h/o difficulty in breathing
No history of involuntary twitching sensation anywhere in body
No h/o flexor spasm
No h/o diurnal variation of weakness or waxing and waning of weakness
No h/o similar complaints in past
Simultaneously along with weakness patient also complains of band like
sensation below the nipple region with decreased appreciation of clothes,
unable to perceive hot or cold sensation of water during sponging. Patient
also gives complain of back pain which he felt along with weakness 10-12
days back, it was severe, localised to upper part of back, not radiating, not
aggravated by coughing or sneezing.
There was no h/o heavy weight lifting, trauma, spinal surgery
No h/o electric shock like sensation on neck flexion or neck movement
Patient complained of difficulty in passing urine, he could feel full bladder as a swelling in lower
abdomen but had difficulty in passing urine following which he was catheterised
He also gives history of decreased sweating in both lower limbs
On enquiring he gives history of dengue fever 7 days back before the onset of weakness
No history of weightloss, night sweats, trauma to skull or spine
No h/o recent vaccination, dog-bite, snake bite, prolonged intake of drug,
No h/o joint pain, rash, alopecia, radiation exposure.
No h/o headache , vomiting, uprolling of eyes, seizure
No h/o impairment of smell, blurring of vision or double vision, able to chew the food normally,
sensation over face is intact. No dribbling of saliva from any side of mouth, no deviation of angle of
mouth, no hearing difficulty or tinnitus, no nasal twang or nasal regurgitation, is able to shrug his
shoulder and manoeuvre the bolus of food well inside the mouth.
Past history- no similar complains in past, no history of TB or TB contacts, HTN, DM
Family history- born of non consanguineous marriage, no h/o similar complains in family, no h/o TB
Personal history- Mixed diet, adequate sleep, currently has been catheterised, not addicted to vices
SUMMARY
28 years old presented with sudden onset , symmetrical lower limb flaccid paraplegia with sensory loss
below the nipples, with band like sensation with bladder involvement with autonomic involvement in
the form of decreased sweating in both lower limbs without cranial nerve involvement or higher
mental function involvement.
GENERAL EXAMINATION
• Patient is thin built, moderatly nourished
• Concious oriented cooperative
• Oral temp-97.8 F
• Pulse: 84/min, regular, normal in force , volume , and character no radio radial, radio femoral delay, all peripheral
pulses felt equally.
• BP:116/74mmHg right upper arm supine position. 110/74 in left upper arm in supine position
No postural drop in BP
• JVP not raised , HJR not elicitable
• No Pallor, icterus, clubbing, cyanosis, lymphadenopathy
• No thyromegaly
• No neurocutaneous markers
• No acanthosis nigricans
• No short neck or low hairline
• No spinal tenderness, kyphosis, gibbus, scoliosis, scar, sinuses
CNS EXAMINATION
HIGHER FUNCTION
• Conscious, cooperative, well oriented to time, place & person with
normal behavior, emotional status and intelligence with intact
memory
• Sleep and speech patterns are normal
• He is right handed
CRANIAL NERVES
• All cranial nerves are normal with normal fundoscopy
MOTOR SYSTEM
• INSPECTION: no wasting, atrophy of limbs , no abnormal movements
• Attitude- lower limb- b/l hip, knee, extended, ankle planter flexed
• PALPATION:
BULK Right (cm) Left (cm)
Arm 28 27
Forearm 22 21
Thigh 52 52
Calf 30 30
TONE
• Normal tone in both upper limbs
• Hypotonia in both lower limbs around all joints
POWER
• UPPER LIMBS: grade 5 around all joints bilaterally
RIGHT LEFT
HIP EXTENSION 0 0
FLEXION 0 0
ABDUCTION 0 0
ADDUCTION 0 0
KNEE EXTENSION 0 0
FLEXION 0 0
ANKLE DORSIFLEXION 0 0
PLANTAR FLEXION 0 0
Only flickering 1 1
movement at b/l
toes
SUPERFICIAL REFLEXES
• B/l corneal reflex present
• Abdominal reflex absent
• Plantar : b/l absent
• B/l Cremasteric reflex absent
• Bulbocavernosus & superficial anal reflex (not checked)
DEEP TENDON REFLEXES
Reflexes Left Right
Biceps Normal Normal
Triceps Normal Normal
Supinator Normal Normal
Knee absent absent
Ankle absent absent
Clonus absent absent
COORDINATION AND GAIT
• Could not be tested in lower limb
• Normal in upper limb.
SENSORY SYSTEM
• Posterior column sensation like fine touch vibration and
position sense absent below T6 B/L
• Lateral column sensation like pain, temperature decreased
below T6 level
• Cortical sensation- upper limb normal, lower limb could not
be checked.
• Gait could not be checked
• MENINGEAL SIGNS: Absent
• PERIPHERAL NERVES: Neither thickened nor tender
• EXAMINATION OF CARDIOVASCULAR SYSTEM
• First heart sound and second heart sound normally
auscultated
• No murmur
• EXAMINATION OF RESPIRATORY SYSTEM
• B/L vesicular breath sound, no added sound.
• No post tussive crepitations
• ABDOMINAL EXAMINATION
• No organomegaly
• Bowel sound is present
• No ascites
• Per rectal examination --no prostatomegaly
SUMMARY
28 years old presented with sudden onset , symmetrical lower limb flaccid
paraplegia with sensory loss below the nipples, with band like sensation with
bladder involvement with autonomic involvement in the form of decreased
sweating in both lower limbs without cranial nerve involvement or higher
mental function involvement.
• On examination found to have flaccid paraparesis as evidenced by hypotonia in
both lower limbs, grade 0 power in both lower limbs at hip and knee joint and
grade 1 power at ankle joint b/l, and loss of all modalities of sensation below T6
spinal segment , with bowel and bladder involvement and absent knee and ankle
reflexes with b/l mute plantar response with absent cremasteric & abdominal
reflex. Suggestive of spinal shock.
4 TIER DIAGNOSIS
• Functionally- acute symmetrical flaccid paraperesis with bladder and autonomic
involvement
• Physiologically (STRUCTURES INVOLVED)
b/l corticospinal tract
b/l spinothalamic tract
b/l posterior column
autonomic fibres to bladder
• Anatomically (SITE OF LESION) : myelopathy at T6
(non compressive)
• Etiology- ATM most probably d/t post infective
• Differentials- to rule out compressive pathology
Cord transaction / hemicord lesion / central lesion
Sacral sparing Saddle anasthethia
Noncompressive cord disorders
• Vascular: Spinal cord infarction
• Infections: Herpes Zoster , etc
• Post-infectious: ADEM
• Post-vaccination: esp. rabies vaccine
• Inflammatory disorders: MS, NMO ,-like Systemic lupus
erythematosus, Mixed connective tissue disease, Sjögren’s
disease, Scleroderma, Rheumatoid disease, Antiphospholipid
syndrome, Sarcoidosis, Vasculitides, Ulcerative colitis, Behçet’s
disease
• Metabolic ; SACD ,Cu def , vit E def , Zn toxicity , endemic flurosis
THANKYOU
