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Paraplegia

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Paraplegia is a medical condition, in which the motor and sensory functions are impaired at the level of the lower extremities. As you will have the opportunity to read in the paragraphs below, this condition is often caused by congenital conditions (such as spina bifida) or by different injuries at the level of the spine. In order for the paraplegia to appear, one has to suffer from an injury at one of the following segments of the spine: thoracic, lumbar or sacral. Depending on the type of injury, the paraplegia can be spastic (rigid muscles) or flaccid (low muscle tone).

In paraplegic patients, the loss of sensation and movement appears due to the damaging of the nervous system. By identifying the level at which the injury has occurred, the doctor will be able to know exactly the parts of the body that are going to be affected (in this case, the lower extremities). In some cases, depending on the level of the injury, the patient might also present poor trunk control (due to the abdominal muscles being affected).

Symptoms of Paraplegia

These are the most common symptoms that appear in patients who suffer from paraplegia:

  • Loss of movement and sensation in the lower extremities
  • The arms are not affected (different innervation)
  • Poor trunk control (lack of abdominal muscle control)
  • In case of lower thoracic injuries, the trunk control remains good, as well as the sitting balance
  • Reduced control in the flexor muscles of the leg occurs in case of lumbar or sacral injuries
  • Dysfunction of the bowel and bladder (lumbar or sacral injuries)
  • Sexual functioning – impaired or lost
  • The fertility can be impaired as well (in men, not in women)
  • Low blood pressure
  • Inability of the body to keep the blood pressure within normal levels
  • The body temperature cannot be correctly controlled
  • Inability to sweat (this occurs below the level of the injury)
  • Chronic pain (over spine or along roots)
  • Standing and walking are impaired
  • The respiratory capacity can be affected in injuries that occur at more superior levels
  • Partial trunk movement is possible in lower injuries
  • If the injury occurs at a thoracic level, the patient might be able to walk, using a walking frame or crutches
  • Hyperesthesia at the level of the injury
  • Motor weakness
  • Increased tone
  • Loss of deep tendon reflexes at the level of the injury
  • All reflexes below the level of the injury are lost.

What Causes Paraplegia?

These are the most common causes that lead to the appearance of paraplegia:

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  • Spinal cord injury
    • Trauma
    • Inflammation that occurs after the trauma
  • Congenital conditions
    • Spina bifida
    • Spinal tumors
    • Scoliosis
  • Infectious agents
    • Severe bacterial infections
  • Poliomyelitis
    • Infectious disease, caused by poliovirus
  • Radiculitis
    • Painful syndrome, in which the pain caused by the irritation or compression of a nerve root is transmitted to other parts of the body
  • Cauda equina syndrome
    • Medical condition, in which the nerves at the end of the spinal cord are inflamed or compressed by the adjoining structures
  • Peripheral neuropathy
    • Occurs due to the damage of the peripheral nerves, leading to a wide range of symptoms (impaired sensation and movement)
  • Myasthenia gravis
    • Autoimmune disorder, characterized primarily by muscle weakness and rapid fatigue (voluntary control)
  • Lambert-Eaton syndrome
    • Rare autoimmune disorder, in which the immune system practically attacks the neuromuscular junction
  • Myopathy
    • Muscular disease in which the muscle fibers stop functioning, the skeletal muscle weakness being one of the primary symptoms
  • Meningioma
    • Meningeal tumor, affecting the membrane that surrounds the spinal cord and the brain
  • Neurofibroma
    • Benign nerve sheath tumor, localized at the level of the peripheral nervous system
  • Arachnoiditis
    • Pain disorder, in which the arachnoid, a membrane that protects the spinal cord, is inflamed
  • Pott’s disease
    • Medical condition, that is also known as tuberculous spondylitis (form of tuberculosis that occurs outside of the lungs)
  • Vertebral neoplasms (metastasis, myeloma)
  • Pachymeningitis
    • Rare condition, in which chronic inflammation leads to the thickening of the dura mater
  • Prolapsed intervertebral disc
  • Epidural abscess/hemorrhage
  • Fracture/dislocation of the vertebra
  • Pagets disease
    • Medical condition, in which the bone tissue suffers an abnormal breakdown
  • Hematomyelia
    • Hemorrhage that occurs inside the spinal cord, interfusing with the spinal cord substance
  • Intramedullary tumor
  • Ependymoma
    • Type of glial tumor, occurring at the level of the central nervous system

Treatment

These are the most common measures of treatment undertaken for patients with paraplegia:

  • Corticosteroid drugs
    • Administered immediately after the intervention
    • Purpose – reduce the inflammation at the level of the injury
    • Prevent further damage at the level of the spine
  • Surgical intervention
    • Stabilization of the spine (prevent further damage to the nerves)
    • Correct the misalignment of the spine
    • Remove the tissue that is causing compression on the nerves
    • Spinal fusion (provide stability to the spinal column) – often performed in patients with herniated discs
  • Physical therapy
    • Most essential form of treatment
    • Gain functionality and reach the best level of independence that is possible
    • Physical therapy programs work to increase the range of motion, strengthen the muscles and also to develop transfer skills
    • Learn wheelchair mobility (for some patients, this will remain the only possible form of transportation)
    • Learn basic skills to be independent again
    • Prevent the complications that might occur after the intervention on the spine
  • Massage therapy
  • Hydrotherapy
  • Gait training
    • Recommended for patients who have difficulties walking
    • Teach the patient how to walk using assistive devices (walker, cane, crutches)
  • Occupational therapy
    • Learn how to deal with activities of daily living
    • Obtain new skills and adapt the current functionality level for a maximum of independence
    • Teach the patient how to dress and bathe, how to prepare a meal, go to the toilet
  • Regeneration of the spinal cord
    • Experimental intervention
    • Olfactory cells were taken from the olfactory bulb (in the brain), grown in the lab and then implanted at the level of the impaired spinal tissue
    • The patient regained both movement and sensation in the lower limbs
  • Speech and language therapy
    • Teach the patient how to speak again
    • May include physical adaptation for writing or using a computer (using the muscle groups that are functioning)
  • Psychological counselling
    • Provides the necessary emotional support

Complications

These are the complications that can appear in patients with paraplegia:

  • Pressure sores
    • Common complication of spinal cord injuries
    • The result of excessive pressure (most commonly at the level of the buttocks)
    • They appear due to the alteration of the muscle tone and the circulatory changes
  • Pneumonia
    • Pneumonia or aspiration is common in paraplegic patients
    • Occurs after several years from the injury (progressive condition)
    • The patient has to be closely monitored, in order to reduce the risk of such complications
  • Osteoporosis and fractures
    • Appear due to the reduced activity of the muscles
    • Bone loss occurs in a progressive manner
    • The osteoporosis increases the risk for bone fractures (may be decreased by positioning the patient in special devices to maintain the orthostatic position)
  • Heterotopic ossification
    • Occurs in acute spinal cord injuries
    • Affects the large joints of the body (hips, knees)
    • Risk for the joints becoming stiff and fusing together
  • Spasticity
    • Exaggeration of the normal reflexes
    • Severe spasticity reduces the range of motion at the level of the joints
    • Physical therapy, performed on a daily basis, can reduce the level of spasticity
  • Urinary tract infections
    • The bacteria enters the bladder through the urinary catheter
    • The infection has to be treated quickly, so as to reduce the risk of progressing to other organs
    • Antibiotics represent the standard treatment for UTI
  • Autonomic dysreflexia
    • The blood pressure and heart function can no longer be correctly controlled
    • Occurred in those who have suffered from spinal injuries above the T6 level
    • Can lead to severe hypertension
  • Orthostatic hypotension
    • The circulatory system has difficulties in adapting to the standing position
    • When standing, the person might feel dizzy or even have a fainting sensation
    • Physical therapy can contribute to the improvement of this condition
  • Cardiovascular disease
    • Long-term risk of spinal cord injury
    • Caused by the sedentary lifestyle
    • Physical therapy can improve the cardiac functioning, reducing the risk of heart disease
  • Syringomyelia
    • Post-traumatic enlargement of the central canal of the spinal cord
    • Affects 1-3% of the individuals diagnosed with paraplegia
    • Primary risk – loss of function above the injury level
  • Spinal cord pain
    • Central pain – pins and needles sensation
    • Muscle tension – mechanical pain (aggravated by movement, relieved by rest)
    • Visceral pain
    • Neuropathic pain
  • Hyperthermia/hypothermia
    • Altered functioning of the autonomic nervous system
    • The tendency of the temperature to fluctuate is higher, as the level of injury is located at a higher level
    • The fluctuations are influenced by the environmental temperature

Management

In order to prevent the complications of paraplegia and keep the condition under control, physical therapy is essential to be performed on a regular basis. Aside from that, the patient should be positioned in different positions, so as to guarantee the functioning of the circulation and prevent pressure sores. Regular consultations made by the doctor are essential, so as to assess the current level of functioning. The patient has to be encouraged to remain as active as it is possible, so as to avoid depression and other similar problems.


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