Spastic Paraplegia Flashcards
Where will you be asked to examine in a patient with spastic paraplegia?
The lower limbs
What questions should you ask on history in spastic paraplegia?
Onset, duration and course
Back pain; whether localised
Numbness and paraesthesia, particularly below lesion (including pressure sores)
Sphincter control and bladder sensation
What family history is important in spastic paraplegia?
Family history of paraplegia; could indicate hereditary spastic paraplegia
This will not have an association with trauma normally
Taking a history of birth anorexia is important in spastic paraplegia why?
For the DDx of cerebral palsy
Will tone in the lower limbs be increased or decreased in spastic paraplegia?
Increased – lower motor neuron deficit
Will the reflexes be increased or decreased in spastic paraplegia?
Hyperreflexive – lower motor neuron deficit
Will there be normal muscle strength and good muscle body size in spastic paraplegia?
No
Lower motor neuron deficit, therefore there will be wasting and reduced strength
in addition to asking about back pain in the history of spastic paraplegia, is it important to look at the back for any obvious lesion on examination?
Yes
Spinal tenderness or deformity
Should you examine the upper limbs in spastic paraplegia?
Yes
At least say that you would like to examine them, to rule out their involvement
Why should you check for cerebellar signs in spastic paraplegia?
To rule out MS, Fredreich’s ataxia
What would it mean for there to be spasticity of the lower limbs alone? Ie, no urinary incontinence
Lesion of thoracic cord (T2-L1)
What would it mean for there to be irregular spasticity of the lower limbs, with flaccid weakness of scattered muscles of the lower limbs?
Lesion of the lumbosacral enlargement (L2-S2)
When is the presence of radicular pain useful in spastic paraplegia?
Early in the disease
With time becomes diffuse and loses localising value
Is superficial sensory loss particularly useful in assessing spastic paraplegia?
No
Level of loss may vary greatly between individuals and in different types of lesions
What are paediatric causes of spastic paraplegia?
Trauma
MS
Friedreich’s ataxia
HIV
What are the adult causes of spastic paraplegia?
Trauma
MS, MND
Tabes dorsalis
Familial spastic paraplegia
Transverse myelitic syndrome
Parasagittal falx meningioma
What are the geriatric causes of spastic paraplegia?
Osteoarthritis of cervical vertebrae
Metastatic carcinoma (epidural)
Anterior spinal artery thrombosis, atherosclerosis of spinal cord vasculature
Vitamin deficiency
What is an intracranial cause of spastic paraplegia?
Parasagittal falx meningioma
What is transverse myelitic syndrome?
Cord compression/transection involving all tracts
What can cause transverse myelitic syndrome?
Trauma
Compression by bony changes or tumour
Vascular disease
What is paraplegia-in-flexion?
Seen in partial spinal cord transection
Lower limb flexed at hip and knees because extensors are more paralysed than flexors
What is paraplegia-in-extension?
Seen in total spinal cord transection
Both flexors and extensors are paralysed, leading to there being no flexion (paraplegia-in-extension is more a lack of paraplegia-in-flexion)
What investigations can you do for spastic paraplegia?
FBE for anaemia
Serology: syphilis, vit B12, PSA
MRI of spine, CT myelography
CTB for parasagittal meningioma
Can you have paraplegia unilaterally, and if so does that determine whether the lesion is in the brain or the spinal cord?
It can be unilateral
No, it is not localising
Is hereditary spastic paraplegia autosomally dominant or recessive?
There are different kinds that are recessive or dominant, and also X-linked
How would you localise a lesion to the 2nd and 3rd lumbar root level?
Muscular weakness: hip flexors and quadriceps
Deep tendon reflexes affected: knee jerk
Radicular pain/paraesthesia: anterior aspect of thigh, groin and testicle
Superficial sensory deficit: anterior thigh
How would you localise a lesion to the 4th lumbar root level?
Muscular weakness: quadriceps, tibialis anterior and posterior
Reflexes affected: Knee jerk
Radicular pain/paraesthesia: anteromedial aspect of leg
Superficial sensory deficit: anteromedial aspect of leg
How would you localise a lesion to the 5th lumbar root level?
Muscular weakness: hamstrings, peroneus longus, extensors of the toes
Reflexes affected: none
Radicular pain/paraesthesia: buttock, posterolateral thigh, anterolateral leg, dorsum of foot
Superficial sensory deficit: dorsum of the foot and anterolateral aspect of the leg
How would you localise a lesion to the 1st sacral root level?
Muscular weakness: plantar flexors, extensor digitorum brevis, peroneus longus and hamstrings
Reflexes affected: ankle jerk
Radicular pain/paraesthesia: buttock, back of thigh, calf and lateral border of the foot
Superficial sensory deficit: lateral border of the foot
How would you localise a lesion to the lower sacral root level?
Muscular weakness: none
Reflexes affected: none (anal reflex impaired)
Radicular pain/paraesthesia: buttock and back of thigh
Superficial sensory deficit: saddle and perianal areas
Can epidural metastases cause spastic paraplegia?
Yes
What is the progression of symptoms in epidural metastasis?
First pain, over days to months
Then Weakness, sensory loss and incontinence
Then paraplegia over hours to days
What are the three primary cancers that typically can lead to epidural metastases?
Breast, lung, prostate
