yogabook / pathologie / paraplegia

paraplegia (spinal paraplegic syndrome, paraplegic lesion, transverse syndrome, quadriplegia)

Definition of

Paraplegia is not a disease in its own right but a complication of damage to the cross-section of the spinal cord resulting in the loss of motor, sensory or vegetative functions. Incidence in Germany: 1000 / a, 80% male. Formerly in 80% of cases spinal trauma with vertebral fracture, mostly traffic-related, today the proportion of diseases of the spinal cord is increasing. In Bangladesh, for example, falls with a load on the head are the main cause. 6-10% of all spinal cord injuries are also spinal emergencies with a threat to vital functions. Plegia are complete motor paralysis, paresis are incomplete motor paralysis, flaccid paralysis can turn into spastic paralysis. Reflexes (intrinsic or extrinsic reflexes) may be reduced or absent, sensitivity may be impaired or absent, as may innervation of the bladder or rectum (incontinence). Classification of neurological damage according to the International Standards for Neurological Classification of Spinal Cord Injury of the American Spinal Injury Association (ASIA):

1. A: Complete paralysis: no motor or sensory function in segments S4/5
2. B: Sensitive incomplete paralysis: Preserved sensitivity in the sacral segments S4/5
3. C: Motor incomplete paralysis: residual motor function below the neurological level and more than half of the characteristic muscles below the neurological level have a strength level of less than 3
4. D: Motor incomplete paralysis: residual motor function below the neurological level and at least half of the characteristic muscles below the neurological level have a strength level greater than or equal to 3
5. E: Normal: normal motor function of the identification muscles and normal sensitivity. Pathological reflexes may persist

Distinguish paraplegia or paraparesis (paralysis of the lower extremities with damage to deeper sections of the spinal cord, approx. 60 % of cases) from tetraplegia or tetraparesis (paralysis of all four extremities with damage to the cervical cord, approx. 40 % of cases). The level of the lesion is defined by the last intact segment of the spinal cord, characterized by the dermatomes (deficits are examined by cold stimulation, touch or pinprick irritation) and the characteristic muscles:

1. C5 : M. biceps brachii(flexion in the elbow joint)
2. C6 : M. extensor carpi radialis(dorsiflexion in the wrist and flexion in the elbow)
3. C7 : M. triceps brachii (extension in the elbow)
4. C8 : M. abductor digiti minimi (spreading of the little finger)

Damage from and above C4 leads to failure of the phrenic nerve, which energizes the diaphragm, but usually also all intercostal nerves, so that artificial respiration must be provided immediately. According to aetiology, a distinction can be made between acute and chronic causes; the paraplegic syndrome itself is basically chronic

Cause

1. Spinal trauma with damage detectable by X-ray or CT: displacement of femoral condyles against each other, compression fractures (e.g. by jumping headfirst into shallow water), burst or comminuted fractures with displacement of bone material into the spinal canal
2. Spinal cord trauma without damage detectable by X-ray or CT (SCIWORA: spinal cord injury without radiographic abnormality)
3. Spinal ischemia, spinal infarction
4. Spinal hemorrhage
5. Herniated disc (mostly cervical spine, rarely thoracic spine)
6. Inflammation of the spinal cord (spinal myelitis)
7. Spondylodiscitis (infection of the vertebral bodies)
8. Tumors, mostly metastases, in WK or spinal canal; less frequently tumors of the nervous system itself
9. Autoimmune diseases
10. psychogenic
11. iatrogenic, e.g. during scoliosis correction surgery or through repositioning maneuvers
12. Spinal canal stenosis

Predisposing

1. Reduced or suppressed immune system is predisposed to spondylodiscitis

Symptoms

1. fully developed spinal cord syndrome with high lesion shows three phases:
   1. 1: Hypertension: only a few minutes
   2. 2: Spinal shock (this is not a shock in the proper sense), weeks or months: failure of regulatory mechanisms, dilation of the vessels due to flaccid vascular muscles, hypotonic crises, flaccid paralysis in dependent segments, loss of muscle reflexes, loss of bladder and rectal control, duration: weeks to months
   3. 3: Spasticity, hyperreflexia: spastic excessive muscle tone, excessive regulation and self-reflexes, autonomic hyperreflexia, e.g. with blood pressure spikes when manipulating the bladder
2. The full picture of the deficits is present immediately after the triggering spinal trauma. If further deficits are added, this indicates, for example, hemorrhages
3. Phase 3: progressive contractures
4. If the triggering event is below L1, phase 3 does not apply
5. In the case of paraplegia caused by disease rather than trauma, the symptoms often appear slowly

Complications

1. Phase 2: acute renal failure, shock lung (ARDS)
2. Phase 1: Circulatory collapse, cardiac arrest
3. Failure of circulatory adaptation to changes in position (getting up from a wheelchair), after months secondary regulatory mechanisms improve the position
4. Phase 3: vegetative dysregulation (usually due to overstretching of hollow organs such as the bladder, rectum, gall bladder) with blood pressure spikes, headaches, hyperhidrosis, facial flushing, etc.
5. Thrombosis
6. Decubitus
7. paralytic ileus
8. Ossifications

Therapy

1. Immediately after the incident: Ensure and monitor vital functions
2. Gentle transport, usually by helicopter, to a polytrauma center
3. The image and location of the damage can be clarified while the patient is awake
4. Even immediate surgical pressure relief does not usually lead to healing, as the actual damage lies in the triggering event
5. Prophylaxis of secondary complications, e.g. due to gibbus
6. Orthoses, wheelchair,.
7. Attempts to stimulate nerve regeneration with medication, e.g. Cordaneurin; stem cell therapy being researched
8. Life expectancy with paraplegia or tetraplegia is approximately normal, with high tetraplegia requiring ventilation it is considerably reduced, in developing countries or countries with shortages even more so, as in some cases even single pressure points can lead to severe septic courses or inadequate bladder emptying measures can lead to kidney damage.