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

00:00My diagnosis is acute paraplegia of lower motor neuron type at about T10 level without sensory and bladder involvement due to Guillain-Barre syndrome. My diagnosis is acute paraplegia of lower motor neuron type at about T10 level without sensory and bladder involvement due to Guillain-Barre syndrome.

00:24Why do you say that it is due to Guillain-Barre syndrome? There is history suggestive of viral fever one week prior to the onset of paraplegia. The onset of weakness is ascending type distal to proximal. On examination it is a lower motor neuron type of paraplegia with no sensory involvement, no bladder and bowel involvement, no cranial nerve involvement.

00:46This is a clinical picture of Guillain-Barre syndrome. Why not tuberculosis of spine? First of all the onset is acute in contrast to tuberculosis of spine where the onset is gradual. There is no past history suggestive of pulmonary tuberculosis.

01:01On examination the spine shows no gibbous, tenderness or cold abscess. And the paraplegia is lower motor neuron type. In tuberculosis of spine there will always be upper motor neuron type of paraplegia. Can it be transverse myelitis?

01:17No sir, firstly this is a lower motor neuron type of paralysis and secondly there is no sensory involvement, no bladder and bowel involvement. So this cannot be acute transverse myelitis. Can it be hysterical? Sir in this patient there is no sensory loss and the deep and superficial reflexes are absent.

01:37So it cannot be hysterical paraplegia. In hysterical paraplegia the reflexes may be normal or exaggerated but never absent. What are the other features of hysterical paraplegia? The planters are never extensors. Bladder and bowel are usually not involved and if the sensory loss is present it does not correlate the anatomical distribution of nerves.

02:01What type of neurogenic bladder will you see after a spinal cord injury? A reflex or automatic bladder if the injury is above the sacral segments that is a upper motor neuron legion. And an autonomous bladder if the injury is in the sacral portion of the spinal cord that is a lower motor neuron legion.

02:20A reflex or automatic bladder if the injury is above the sacral segments and an autonomous bladder if the injury is in the sacral portion of the spinal cord. What is a reflex bladder? There is no bladder sensation nor any voluntary control but the local reflex arc of the bladder is present.

02:40So if bladder is stimulated by pressure over the hypogastrium or by pinching over the area the reflex will be activated and the bladder will be evacuated completely but without any voluntary control. This is reflex or automatic bladder.

02:56Then what is autonomous bladder? In autonomous bladder or lower motor neuron type of bladder there is neither voluntary control nor reflex control as the local reflex arc is destroyed. So the patient has no bladder sensation cannot evacuate the bladder voluntarily but he can press over the hypogastrium and empty the bladder partly by pressure.

03:19The bladder will never empty completely and will become large with lot of residual urine. There may also be stress incontinence on coughing and straining. This is autonomous bladder due to injury to the sacral segments conus medullaris or coda equina.

03:36How is the bladder normally innervated and controlled? The parasympathetic supply S23 and 4 causes emptying of the bladder by contracting the dead ruser and relaxing the internal sphincter. The sympathetic supply L234 will prevent bladder evacuation till circumstances are favorable by relaxing the dead ruser and contracting the internal sphincter.

04:00The pudendal now S23 controls the external sphincter for voluntary control of mixturation and the afferent fibres of pain and stretch sensation that is sensation of fullness of the bladder go with the parasympathetic nerves that is S23 and 4.

04:19Now tell me what is uninhibited bladder? Uninhibited bladder is a bladder without cortical inhibition that is without the voluntary control to start or stop mixturation just like the bladder of an infant. Imagine an infant as soon as the bladder becomes full there is an urge to pass the urine and the bladder gets evacuated.

04:40The patient cannot hold it till he goes to the toilet. Also when the patient goes to the toilet he cannot initiate mixturation voluntarily and takes a long time to stimulate the reflex. This is the uninhibited bladder. When will you suspect a spinal tumor?

04:57Whenever there is a gradually progressing compressive myelopathy without any vertebral column lesion I will suspect a spinal tumor. Compressive myelopathy means a progressive spastic paraplegia with sensory loss, root pains and sometimes sphincter involvement.

05:16How will you differentiate between extra medullary and intra medullary tumors? Extra medullary tumors present with root pains, muscle spasms, marked spasticity and no muscle atrophy. The sensory involvement is rare and sphincter involvement is also late.

05:34In contrast, intra medullary tumors rarely ever have root pains. There are no muscle spasms. Muscle spasticity is minimal but there is a marked muscle atrophy and sensory involvement is always there with dissociate anesthesia, trophic changes and sphincter disturbances.

05:54If brown sequad syndrome is seen it is only with extra medullary tumors. What is brown sequad syndrome? It is a syndrome of hemisection of the spinal cord comprising of spastic paralysis of one leg that is on the affected side with loss of pain and temperature on the opposite side.

06:13Touch sensation is not affected and deep sensations of position and vibration sense are lost on the affected side. When will you suspect a lesion of conus medullaris? When there is saddle anesthesia and partial weakness of the legs, that is paraparesis.

06:31How will you differentiate between a lesion of conus medullaris and a cauda equina legion? If there are root pains with marked asymmetric muscle wasting and weakness, then it is a lesion of cauda equina. And if there is mainly sensory loss with saddle shaped anesthesia in the perinium and early involvement of bladder and bowel sphincters, it is a lesion of conus medullaris.

06:57Coming to reflexes, in conus medullaris lesion only the ankle jerk is lost, knee jerk and planter reflex are normal. While in cauda equina legion, all reflexes are affected. Knee jerk is lost, ankle jerk is lost and planters are either extensors or absent. Good. Thank you, sir. This is the end of the discussion on paraplegia.