Paraplegia (2/3) - Audio Clinical Cases [Dr. Vaidya] – Transcript

00:00Coming to the examination of the central nervous system. On examination of the higher functions, the patient is conscious, well-oriented in time, place and person, he is right-handed, speech is normal, memory, short-term and long-term memory is normal, no hallucinations or delusions.

00:19On examination of the cranial nerves, all cranial nerves are normal, that is, smell and vision are normal, external ocular movements are normal, pupils are central, circular, equal on both the sides, reacting to light, accommodation and celiospinal reflex, there is no dosis or nystagmus, corneal and conjunctival reflexes are normal, jaw bite and jaw jerk is normal, there is no deviation of the angle of the mouth, eye closure and wrinkling of

00:48the forehead is normal, movements of the tongue and uvula are normal, gag reflex is normal and there is no weakness of the trapezius and sternomastoid. On examination of the motor system, there is no muscle wasting in the upper and lower limbs, the tone of all the muscles in the lower limb is reduced, that is, in the flexors and extensors of the knee and ankle and flexors, extensors, adductors and abductors of the hip.

01:15What does the hypotonia suggest? That it is either a lower motor neuron type of paralysis or since the history is very short, that is just four days, it may be upper motor neuron type of paralysis in the state of neuronal shock.

01:30How do you test the tone of the muscles? By moving the joints passively and noting the resistance offered by the muscles to passive movements. Secondly, by palpating the muscle mass, if the tone is reduced, the muscles will feel flabby and if it is increased, the muscles will feel firm.

01:49In which conditions do you get increased tone of the muscles? In all upper motor neuron type of legions, that is pyramidal and extra pyramidal disorders, deserberate rigidity, then tetanus and tetanine, stricken in poisoning and hysterical conditions, proceed.

02:07The power of all the muscles in the lower limbs is grade zero, coordination cannot be tested, beaver sign is positive. What is beaver sign? On raising the head and neck, if the umbilicus is pulled up, it indicates paralysis of the lower recti, that is a positive beaver sign will indicate the level of the legion to be around T10.

02:28Go ahead. Reflexes. The deep reflexes, that is the knee and the ankle jerk, are absent on both the sides. Deep reflexes are normal in the upper limbs. Testing the superficial reflexes, the planters are absent on both the sides.

02:44In which conditions do you get an absent planter reflex? Firstly, if the sensations of the sole are lost, and secondly, if there is a lower motor neuron legion at S1, then paralysis of the extensor heliocis longus, or helix rigidas, may also give a false impression of an absent planter reflex.

03:04But here, the contraction of the tensor facialata will be present and felt. What is babinski sign? Babinski sign is an extensor planter response with extension of the great toe, extension and fanning of the other toes, and dorsiflexion of the ankle.

03:22It is also associated with contraction of the tensor facialata. Yes, how do you elicit it? By stroking the lateral border of the sole, from the heel to the ball of the foot, and then across to the ball of the great toe. It can also be elicited by squeezing the tendo Achilles or the calf muscles, or by stroking the anterior medial surface of the upper third of tibia.

03:45What is the significance of a positive babinski sign? It indicates a pyramidal trach legion, but it may also be seen in absence of pyramidal legions in infants under two years of age during deep sleep or sedation, during coma due to metabolic causes like hypoglycemia, and transiently after convulsions due to epilepsy or ECT therapy.

04:10What is the cause of this abnormal response? In the normal reflex arc of the planter reflex, on stimulating the lateral border of the foot, both the flexors and extensors of the toes are stimulated, but the flexor contraction is more powerful and the toes go into flexion.

04:27But when the higher influence over the arc is removed in the pyramidal trach legions or in coma, then the extensor contraction becomes more powerful and overpowers the flexors giving a positive babinski sign. Proceed. Coming to the other superficial reflexes, abdominals are present in the upper half and absent in the lower half on both the sides.

04:49The bulbo cavernosis, that is cremastric and anal reflexes are absent. What are the root values of these reflexes? For superficial reflexes, abdominal reflex is T6 to T10 above the umbilicus and T10 to T12 below the umbilicus.

05:07In the lumbo sacral part, planter reflex is S1, bulbo cavernosis reflex is S234 and anal reflex is S45. For deep reflexes, the biceps and supinator reflexes are C56, while triceps is C78.

05:25The knee jerk is lumbar, L234 and ankle jerk is sacral, S12. Yes, how did you test the knee jerk? I placed my left hand under the knee, raising the knee and flexing it by 20 degrees.

05:42Then I asked the patient to keep the leg completely relaxed and then struck the patellar tendon with the percussion hammer giving a sharp blow. There was no contraction of the quadriceps. So I asked the patient to hook the fingers of both his hands together, pulling them out strongly, and then repeated the hammer blow.

06:02Even with this reinforcement, there was no contraction of the quadriceps. So I interpreted the jerk as absent. Why did you ask the patient to pull his fingers? To reinforce the reflex, a strong voluntary act will increase the muscle tone throughout the body and also divert the patient's mind from the site of examination.

06:24This can also be achieved by asking the patient to clench his teeth or raise his head. Yes, how do you grade the reflexes? Normal reflex is graded as 2 plus, a brisk reflex is 3 plus, and a clonus is 4 plus.

06:40On the other side, a depressed reflex is 1 plus, and absent reflex is grade 0. If it can be elicited only with reinforcement, it is charted as plus minus. What does the clinical picture suggest now?

06:55There is a reduced tone of the lower limb muscles with power 0 and absent deep and superficial reflexes. So it is probably a lower motor neuron type of lesion, the level being around T10. Or it could be an early upper motor neuron lesion in a state of neuronal shock.

07:14And what would the picture be in a fully developed upper motor neuron type of lesion at the same level? There will be hypertonia of the lower limb muscles with clasped knife type of rigidity. The deep reflexes, that is the knee and the ankle jerks, will be exaggerated with clonus, and the planters will be extensors.

07:33Proceed. On examination of the sensory system, the cutaneous sensations of touch, pain, and temperature are normal on both lower limbs. The perineal sensations are normal, that is no saddle anesthesia. Deep sensations of vibration and joint position are normal.

07:51Tactile localization, tactile discrimination, and stereognosis is normal. What is tactile localization? It is the power of localization of the area of skin touched based purely on touch sensation, that is, with the eyes closed. How did you test it?

08:07I asked the patient to keep the eyes closed, then touched different areas of the body with my pen, and asked him to put his finger on the same point. The patient can show the point with one to two inch accuracy, so the tactile localization is normal.

08:24And how did you test the touch sensation? I tested the touch sensation with a wisp of cotton wool. I asked the patient to close the eyes and say yes whenever he felt the touch of cotton wool. Then I tested on symmetrical areas on both sides of the face, neck, chest, abdomen, and legs, avoiding hairy areas.

08:44Why? Because hairy surfaces can conduct touch sensations through special receptors in the hair roots. Proceed. The touch sensation was normal and equal on both the sides. Then I tested for pain sensation in a similar fashion using a pinprick.

09:00How did you do that? Using a sharp ordinary pin, I held it with its tip pointing just beyond my fingers and struck it firmly to elicit a painful sensation. I asked the patient to close the eyes and say yes whenever he felt the pain of the pinprick.

09:17Then I tested the temperature sensation using two metal tubes, one filled with warm water and one with cold water. Then asking the patient to close the eyes, I tested symmetrical areas of skin, asking the patient what feeling he gets when the tube is touched.