Overview
Paralysis caused by spinal cord lesions occurring above the second thoracic vertebra.
Mainly caused by spinal trauma, spinal degenerative diseases, spinal cord inflammation, tumors and other diseases.
The main manifestations are weakness or even complete paralysis of the trunk and limbs below the lesion, loss of sensation, numbness, and inability to control urination and defecation.
Treatment is related to the cause of the disease and mainly includes first aid, medication, surgery and rehabilitation.
Definition
Paraplegia refers to spinal cord lesions above the second thoracic vertebrae caused by trauma, inflammation, or tumors, resulting in abnormalities in motor, sensory, and autonomic functions of the trunk and limbs.
Symptoms of neurological dysfunction after spinal cord injury and the range of involvement are related to the damaged spinal cord segment, the higher the location of the injury, the greater the range of involvement.
When the spinal cord lesion occurs in the cervical spinal cord, it is called “quadriplegia”; when it occurs above the second thoracic vertebrae, it is called “paraplegia”; when it occurs in the thoracic, lumbar and sacral segments and the cauda equina, it is called “paraplegia”. Paraplegia”.
Causes
Causes
There are many causes of spinal cord injury, and any injury that occurs above the second thoracic vertebra can cause paraplegia.
Traumatic injuries: such as car accidents, falls, sports accidents, heavy objects, firearm injuries, and stab wounds.
Degenerative diseases of the spine: such as spinal cord cervical spondylosis, spinal stenosis, herniated intervertebral disc, hypertrophy of ligamentum flavum.
Infection, inflammation: such as acute transverse myelitis, disseminated myelitis, spinal myelitis, human immunodeficiency virus-related myelopathy, etc.
Intravertebral tumor, spinal tuberculosis: such as spinal cord neurofibroma, nerve sheath tumor, spinal meningioma, etc.
Spinal vascular malformations: such as dural arteriovenous fistula, spinal arteriovenous malformation, spinal cavernous hemangioma, etc.
Neurodegenerative diseases: optic nerve myelitis.
Medical spinal cord injury: such as spinal cord injury caused by spinal cord surgery.
Pathogenesis
The spinal cord is located in the vertebral canal, with two expansions in the cervical and lumbar regions, which are related to the function of the limbs. It is lined with gray matter (containing nerve cells) and surrounded by white matter (containing nerve fibers).
The spinal cord conducts nerve impulses and brain control signals from all parts and organs of the body and performs basic activities such as defecation, urination, and tendon reflexes.
When the spinal cord is internally or externally compressed, damaged, or diseased, the communication and control of information to and from the brain becomes abnormal, resulting in dysfunction of sensation, movement, urination, defecation, and other functions below the site of injury.
Symptoms
Main Symptoms
Motor disorders
Weakness and paralysis may occur in all or some of the muscles of the trunk and limbs.
In the early stage, delayed paralysis occurs, which is characterized by muscle flaccidity and lower than normal resistance to passive movement of joints, i.e., decreased muscle tone.
In the later stage, abnormal resistance can be felt when passively moving or pulling the joints of the lower limbs. If involuntary contraction and stiffness occur, it is called increased muscle tone or spasm.
Sensory Impairment
Chest and back pain, girdling sensation (the feeling of being entangled in a band) may appear suddenly.
Sensation in the trunk, limbs, and perineum is diminished and lost, and there may be numbness and pain.
Respiratory dysfunction
Cervical spinal cord lesions can cause weakness of the respiratory muscles and diaphragm.
It is manifested as dyspnea, suffocation and shortness of breath.
Autonomic dysfunction
Poor and laborious urination and defecation; urine and stool cannot be self-controlled and flow out by itself.
Dry skin, little or no sweat, flaking, brittle or excessively thickened nails, etc.
Episodic sweating, non-infectious fever, flushed skin, sudden rise in blood pressure, bradycardia, etc.
Complications
Urinary tract infection
Urinary tract infections are mostly caused by failure to pass urine in a timely manner and urinary incontinence.
There may be fever, cloudy urine, leukocytosis in routine urine examination.
Pressure sore
Patients can be unfavorable limb movement, long-term bedridden and cause skin pressure injury, i.e. pressure ulcers.
The most common sites are the sacrococcygeal region, the greater trochanter of the femur, the iliac crest and the heel.
The manifestations are redness, purplish, blisters and ulceration at the pressure site.
Heterotopic ossification
Due to prolonged bed rest and reduced activities leading to abnormal calcium and phosphorus metabolism, bones grow where they should not.
It most often involves the hip joint, followed by the knee joint, shoulder, elbow and other joints.
The symptoms include localized redness, swelling, heat and pain, restriction of passive movement of joints, and even contracture and fixation.
Deep Vein Thrombosis
Because of limb paralysis, long-term bedridden, can cause lower limb venous thrombosis.
The manifestation is limb swelling, local skin temperature is slightly high, and in severe cases, there can be distal necrosis of the limb.
Thrombus dislodgement can cause pulmonary embolism, dyspnea, cyanosis, cough, hemoptysis, etc., life-threatening.
Consultation
Department
Emergency Department
In case of traffic accidents, fall injuries, or suspicion of other serious traumatic injuries resulting in damage to the spine or spinal cord, it is recommended to visit the Emergency Department as soon as possible or call the 120 emergency number.
Neurology
If you suddenly experience symptoms such as numbness, weakness of the limbs, loss of sensation, or a feeling of girdling in the chest, you should go to the Department of Neurology immediately.
If surgery is needed, go to the neurosurgery department.
Rehabilitation
After clinical treatment, patients mainly consult the Department of Rehabilitation for long-term rehabilitation training and treatment.
Preparation
Consultation: Registration, Preparation of documents, Frequently asked questions
Tips for medical treatment
For trauma patients, avoid lifting the patient by yourself to avoid secondary injuries.
Pay attention to safety when seeking medical treatment. Family members should support and accompany the patient.
Preparation List
Symptom list
Especially need to pay attention to the time of symptom onset, special performance, etc.
Is there a feeling of tightness in the chest wrapped by the band?
How is the movement of limbs? Is there a feeling of weakness or numbness in the limbs?
Is there difficulty breathing, suffocation, shortness of breath?
Is there any abnormal sensitivity to temperature and touch?
Is there any incontinence?
Medical History Checklist
Has the spine been traumatized or operated on?
Any history of respiratory or gastrointestinal infections, vaccinations prior to onset of illness?
Is there any history of tumors, rheumatic immune system diseases, poisoning, multiple sclerosis, etc.?
Checklist
Test results in the last six months, which can be brought to the doctor’s office
Laboratory tests: blood test, cerebrospinal fluid test.
Electrophysiologic examination: visual evoked potentials, somatosensory evoked potentials, motor evoked potentials.
Imaging tests: spinal cord CT, MRI.
Medication List
Medications used in the last 3 months, if available in boxes or packages, bring them with you to the doctor’s office
Anti-inflammatory drugs: methylprednisolone, dexamethasone, prednisone, immunoglobulin, etc.
Neurotrophic drugs: methylcobalamin, rat nerve growth factor, vitamin B12, etc.
Anti-infective drugs: amoxicillin, ceftriaxone, acyclovir, ganciclovir, etc.
Diagnosis
Diagnosis is based on
Medical history
History of spinal trauma, degenerative spinal disease, intravertebral canal infection, inflammation, tumor, spinal vascular malformation, neurodegenerative disease.
History of medical operations such as intraspinal surgery and anesthesia.
Clinical manifestations
Symptoms
Weakness of trunk and limbs, dyspnea, hyperalgesia, numbness, and inability to control urination and defecation.
Physical signs
Sensory deficits: absence of sensation (pain, temperature, touch, deep sensation), which may also be manifested as hypoesthesia, and some cases of nociceptive hypersensitivity.
Reflex abnormalities: manifested by the disappearance, weakening or hyperreflexia below the plane of injury.
Pathologic reflexes: the performance varies according to the degree and location of the injury, and there may be a positive Hoffman’s sign and a positive Babinski’s sign.
Globus cavernosus reflex: anus contraction is diminished or absent when the male glans is gently pinched or the female clitoris is stimulated.
Laboratory Tests
Purpose: To assess the overall physical condition and assist in determining the cause of the disease.
Common items: blood routine, vitamin B12 in serum, internal factor antibody, aquaporin, tumor markers, etc.
Precautions: During the course of treatment, some items may need to be reviewed periodically.
Lumbar puncture examination
Purpose: To observe pathogens, proteins, cells and antibodies in cerebrospinal fluid and determine the nature of spinal cord lesions.
Findings: Infection, bleeding, and abnormal immune function can be detected.
Precautions
After the puncture is finished, remove the pillow and lie down for 4 to 6 hours to prevent headache caused by intracranial pressure change.
Keep the local skin clean and dry to prevent infection at the puncture site.
Magnetic resonance imaging (MRI) of the spinal cord
MRI can clarify the nature, scope and extent of the lesion, and can be helpful in determining the prognosis.
It can detect edema of the affected spinal cord segments, spinal cord degeneration, hemorrhage, cavities, vascular malformations, tumors and other lesions.
Precautions
Those who have metal dentures or metal implants in the body, such as cardiac stents, etc., need to inform the radiologist to decide whether MRI examination can be performed according to the specific magnetic resonance machine.
Electrophysiologic examination
Visual evoked potentials: can diagnose optic neuromyelitis optica.
Somatosensory evoked potentials: to determine the status of sensory pathways in the limbs, and this disease may show a significant decrease in wave amplitude.
Motor evoked potentials: to determine the condition of the motor pathway of the limbs, which can help to determine the efficacy and prognosis.
Electromyography: the muscles below the lesion area may show denervation.
Degree of neurological impairment
According to the clinical manifestations of spinal cord injury, the American Spinal Cord Injury Association (ASIA) classification is more commonly used.
Table. Spinal Cord Injury Classification
Level of impairment Function
A Complete injury with no sensory or motor function preserved below the level of injury.
A
Complete injury
No sensation below the level of injury, motor function preserved
B Incomplete injury below the level of injury, including lumbosacral sensation, but without motor function
B
Incomplete injury
Below the plane of injury, including lumbosacral sensation exists, but no motor function
C Incomplete injury with motor function below the level of injury, with more than half of the key muscles having a strength of less than grade 3
C
Incomplete impairment
motor function below the plane of injury, more than half of the key muscles strength less than grade 3
D Incomplete injury with motor function below the plane of injury, with more than half of the key muscles having strength greater than or equal to grade 3.
D
Incomplete impairment
motor function below the plane of injury, more than half of the key muscles strength greater than or equal to grade 3
E Normal sensory and motor function
E
Normal
Normal sensory and motor function
Differential Diagnosis
Clinicians need to make a comprehensive judgment based on history, signs, and auxiliary examinations.
Hypokalemic periodic paralysis
Similarities: both have weakness, pins and needles, or ankylosing sensation.
Differences
Hypokalemic periodic paralysis usually starts in the morning, and the weakness starts from the lower limbs and gradually spreads to the trunk and the whole body.
Serum potassium ion concentration is decreased, and there is no spinal cord neurostructural lesion on imaging.
Myasthenia gravis
Similarities: Both may present with flaccid paralysis of the limbs.
Differences
Patients with myasthenia gravis tend to present with fatigue and weakness after exercise, which is mild in the morning and severe in the evening, and resolves with rest or cholinesterase inhibitor therapy.
Muscle strength improves significantly with neostigmine injections, cerebrospinal fluid examination is unremarkable, and there are no neurostructural lesions of the spinal cord on imaging.
Guillain-Barré syndrome
Similarities: both may present with limb weakness, decreased sensation, and difficulty in defecation and urination.
Differences
The weakness in Guillain-Barré syndrome is more distal than proximal.
Cerebrospinal fluid and serologic tests may reveal specific antibodies, and there are no neurologic lesions of the spinal cord on imaging.
Treatment
Aim of treatment: treat the primary disease, improve the spinal cord nerve function, and prevent complications.
Treatment principle: early treatment, combined with drugs, surgery, rehabilitation and other comprehensive methods.
Acute phase treatment
Emergency treatment
For patients with spinal cord trauma, the first step should be to save the patient’s life, deal with life-threatening injuries to other important organs, and at the same time prevent further damage to the spinal cord.
Moving the patient should be done flat up and down or using the rolling method. Neck braces and stretchers will be used to ensure that the patient’s head, neck and chest and waist are not displaced.
Supportive treatment
When respiratory difficulties occur, oxygen should be administered promptly to keep the airway open, sputum should be aspirated on time, and artificial assisted respiration and tracheotomy should be performed if necessary.
When urinary obstruction occurs, a catheter should be left in place, and the drain should be released once every 4 to 6 hours. When the bladder function is gradually recovered, the residual urine volume is less than 100ml when no longer catheterized.
Keep the skin clean, turn over regularly, and use air cushion or soft cushion on the pressure-prone parts to prevent pressure sores.
Use long compression stockings and inflatable compression devices to prevent deep vein thrombosis of the lower limbs.
Medication
The following medications are commonly used to treat different causes of the disease:
Relieve spinal cord edema: e.g. methylprednisolone, mannitol, etc., which can prevent and reduce spinal cord edema and alleviate secondary spinal cord damage caused by spinal cord injury.
Improve spinal cord blood supply: such as naloxone, lisdexamfetamine, nimodipine, etc., which can improve the microcirculation of the spinal cord, reduce ischemic necrosis, preserve spinal cord function, and promote the recovery of neurological function.
Nerve repair drugs: such as methylcobalamin, rat nerve growth factor, gangliosides, etc., can improve the metabolism of nerve tissue, promote nerve cell synthesis and recovery of damaged function.
Anti-spasmodic drugs: such as baclofen, tizanidine, botulinum toxin type A, etc., can reduce muscle tone and relieve muscle spasm.
Anti-infective drugs: such as acyclovir, ceftriaxone, levofloxacin, rifampicin, etc. Sensitive drugs need to be selected according to the pathogens, to treat intraspinal infections and systemic infectious complications.
Surgical treatment
Surgery should be performed when the spinal cord is compressed or involved due to intravertebral space occupation, trauma, tumor, etc. The main purpose is to remove the lesion, relieve the spinal cord compression, and restore the blood supply to the spinal cord, etc. Common surgical procedures include incision and repositioning of the spinal cord and the spinal cord.
Common surgical procedures include incision and internal fixation, tumor resection, lesion removal, and spinal cord decompression.
Complications
Pressure ulcers: Pressure ulcers need to be treated with regular debridement and dressing change, and large and deep pressure ulcers are treated with skin flap or myocutaneous flap surgery.
Urinary tract infection: keep urinary catheter and use sensitive antibiotics to control the infection.
Deep vein thrombosis: early use of low molecular heparin, rivaroxaban and other drugs to prevent; for patients who have developed deep vein thrombosis, implantation of filters, interventional thrombus extraction and other treatments.
Rehabilitation
Once the patient’s condition is stabilized, rehabilitation therapy should be started as early as possible and continue throughout the whole course of the disease.
Limb function training
Spinal shock period
Passive exercise can promote motor and sensory recovery, blood circulation and metabolism.
It helps to avoid or reduce lower limb venous thrombosis, joint contracture, pressure sores and muscle atrophy.
Recovery period
Simultaneous passive exercise and active exercise can enable patients to obtain whole body or local motor and sensory function recovery, prevent muscle contracture and maintain joint mobility.
Gradually strengthening active exercise with the improvement of strength can help to enhance muscle strength to improve motor function and prevent osteoporosis of the lower limbs.
After the patient is able to walk, attention should be paid to gradually increase the training intensity.
Respiratory training
Knocking on the back and assisting phlegm expulsion: paraplegic patients will have coughing and sputum expectoration weakness. The therapist can percuss the patient’s back in the order of bottom to top and outside to inside, and then let the patient cough, and at the same time push his/her hands under both sides of the chest to assist coughing.
Abdominal breathing training: the patient is in a semi-recumbent position, keep the upper body relaxed, put the hand on the upper abdomen, and bulge the stomach when inhaling, each time for 5 to 10 minutes, 3 times a day.
Urine and bowel management
Manage and promote the recovery of urinary and fecal function through the stimulation and contraction training of anal sphincter and pelvic floor muscles, and intermittent catheterization.
Anal sphincter contraction training: through active anal lifting exercise, enhance the perception and control of urination and defecation, so as to improve the ability of defecation control.
Pelvic floor neuromuscular stimulation: electrical or manual stimulation of the patient’s pelvic floor muscles, anal sphincter and rectum to enhance sensation and control, and enhance control of urine and stool.
Intermittent catheterization: a method of inserting a urinary catheter through the urethra into the bladder at regular intervals to enable the bladder to empty urine regularly.
It is also important to develop the habit of drinking and urinating regularly as well as having bowel movements.
Physical Factor Therapy
Along with clinical drug treatment and functional training, the combination of intermediate frequency electrotherapy and myoelectric biofeedback therapy can help shorten the course of the disease and reduce the sequelae.
Cutting-edge treatment
Cell transplantation therapy: such as bone marrow stromal stem cell transplantation, olfactory sheath cell transplantation, Schwann cell transplantation, embryonic neural tissue transplantation and so on. This type of treatment is one of the most promising treatments for spinal cord injury, but it is still in the research stage.
Gene therapy: transferring a certain target gene into the body, so that the gene product it expresses can exert biological activity and promote nerve cell regeneration, thus promoting the recovery of the injured spinal cord, which is also still in the research stage.
Prognosis
Cure
The prognosis of paraplegia depends mainly on the severity of damage and treatment.
Those with spinal cord shock have a good prognosis and will not be left with any neurological sequelae.
Those with complete transection of the spinal cord do not recover neurological function.
Those with severe initial damage and dysfunction have a poorer recovery, and conversely have a better recovery.
The mortality rate of those with high complete paraplegia can reach 49.0% to 68.8%, and the main causes of death are respiratory failure and pulmonary infection.
Hazards
Weakness of limbs, contracture of joints and paralysis lead to prolonged bed rest and serious decline in quality of life.
Complications such as severe infections and deep vein thrombosis can lead to death.
Due to diminished or lost skin sensation, accidents such as skin breakouts, burns and scalds can easily occur.
Severe and irreversible disability can bring huge psychological barriers, cause mental illness, and increase the burden of family and society.
Everyday
Daily Management
Dietary management
Encourage patients to eat more food rich in group fiber to prevent constipation.
Diet should be light and reasonably matched to ensure balanced nutrition.
Eat more fresh vegetables and fruits and less spicy and stimulating food.
Drink water regularly and quantitatively according to the doctor’s requirements to reduce the occurrence of urinary tract infection.
Exercise management
Encourage early activity for patients with stabilized condition, and should insist on home rehabilitation training after discharge.
Exercise process should pay attention to safety, gradual and orderly, not too hasty, to avoid falls and injuries.
Exercise should be practiced consistently in order to have good results.
Skin management
In order to prevent the occurrence of pressure sores due to prolonged bed rest, change the body position frequently to avoid prolonged pressure on the skin.
When bathing, do not use too hot water and do not scrub or rub the skin too hard to prevent injury.