Paraplegia
4 Personal history
فتحي كامل
هلال male patient,
55 years old, from Cairo, has 3 off spring, the youngest is 3 years old, manual worker, no
special habits of medical importance, Rt. handed.
4 c/o
Heaviness of both lower limbs of
22 years duration.
4 HPI
The condition
started 22 years ago when he fell from a height of 3 meters on his back. At 1st
the patient suffered from complete paralysis of both lower limbs with
flaccidity and girdle pain at the level of the umbilicus increased
by work, coughing, sneezing relieved by rest. Then the patient was admitted to
hospital and investigated by X-ray with contrast and Exploratory operation was
done.
4 weeks later, the patient experienced gradual onset, progressive course of weakness
associated with stiffness, with no wasting or twitches. This weakness
was distal more than proximal, in
the abductor muscles more than adductors, in flexor more than extensors with no
involuntary movements. This weakness was associated with diminished
sensation in both lower limbs and
the patient felt as if he walks on cotton.
No symptoms of sphincteric
affection.
No symptoms of increased
I.C.T.
No symptoms of speech disorders.
No symptoms suggesting other
system affection.
4 Past history
-
No past history of
fever, bilharziasis , drugs or operations.
4 Family history
-
No similar
condition in family.
-
No consanguinity.
-
No common disease
in family.
4 General exam
-
Temperature: 37.2o c.
-
Bl. Pressure: 130/70.
-
Pulse: regular, 70 beat/minute, average volume, no special character, vessel
wall not felt, equal in both sides with intact peripheral pulsation.
-
Mentality: The patient is fully conscious, well oriented for time, place and
person. Average mood and memory. The patient is co-operative with average
intelligence.
4 Examination of Speech: Normal
4 Examination of Cranial
Nerves: Normal
4 Examination of Motor
System :
4 Inspection__
-
There is extension
in both lower limbs(paraplegia in extension ).
-
No skeletal abnormalities, no
trophic changes, no involuntary movement no muscle wasting.
4 Examination of
Tone__
-
There is normal tone in both upper
limbs .
-
Bilateral asymmetrical Hypertonia in
lower limbs in the form of
spasticity affecting antigravity muscles. it is more on Lt. lower limb (suggesting UMNL).
4 Percussion__
No fasciculation or myotonia.
4 Examination of Muscle
Power
-
There is normal
muscle power in both upper limbs,
-
Bilateral asymmetrical
Weakness in lower limbs. It is distal more than proximal, abductors more than
adductors, flexors more than extensors. It is
more on Lt. lower limb.
4 Coordination
Coordination cannot be
examined on both lower limbs because of weakness.
Normal coordination in both
upper limbs confirmed by finger to nose, finger to finger, finger to doctor's
finger in both eye opening and eye closure.
4 Reflexes
-
There is
normoreflexia in both upper limbs.
-
In Both lower limbs:
hyperreflexia with +Ve pathological reflexes (Patellar, Adductor), no ankle or
patellar clonus.
-
+ve Babniski on both
sides.
-
Abdominal reflex :
lost below the level of the umbilicus .
4 Sensory:
- Superficial sensations: Sensory Level
at T10.
- Deep sensation: lost
- Cortical sensation : can't be examined
in both lower limbs.
4 Back: Scar of exploration at the level of T7.
4 Gait: Scissoring gait.
4 No affection in other system examination.
4 Investigation
-
Plain X-Ray ,
Myelography .
4 Treatment
Physiotherapy.
4 Diagnosis :
Organic Paraplegia
Of Spinal Focal Compression Type. It's due to Extramedullary lesion at the
level of T10. The patient is in the spastic stage (in Extension).
4 Paraplegia (UMNL
Bilateral Δ ) : Affect
both L.L. + Organic
- Hypertonia in antigravity +
spasticity.
- Muscle Weakness: distal,
progravity, abductors.
- Hyperreflexia + pathological
reflexes.
- +Ve Babniski in both L.L.
- Sensory Level at umbilicus.
- no cranial nerve affection.
4 Spinal:
v Not Cortical: Rare, Need parasagittal lesion, no coma
convulsion or aphasia.
v Not brainstem: no affection of Resp. Center
4 Focal: Level .
4 Compression: No history
of fever (inflammation), +Ve history of trauma.
4 Extramedullary:
v Sensory Level.
v Asymmetrical Power, reflexes.
v Girdle pain.
v No Sphincteric affection.
4 Level of
T10:
v History: girdle pain, exploration at T7.
v Sensory level at T10.
v Abdominal Reflex lost at T10.
v Vertebral :scar.
4 Spastic
Stage:
v Hypertonia
v Hyperreflexia
4 Extension: Patient's Position.
4 N.B
Inflammatory
paraplegia differs from traumatic one in the following :
- Fever at the
onset.
- Regressive course.
- Corticosteroids
in TTT.
4 N.B: Retention of
urine may occur at the onset of acute
lesions.
