Paraparesis is observed with injuries, tumors, infectious lesions of the spinal cord, diseases of the spine, hereditary pathologies, congenital anomalies, circulatory disorders, degenerative processes. The etiology is established on the basis of complaints, anamnesis data, results of a neurological examination, radiography, CT, MRI, electrophysiological techniques, lumbar puncture, and laboratory tests. Treatment includes neuroprotective agents, antimicrobial and vascular agents, active rehabilitation, and surgical interventions.
Characteristics of paraparesis
Paraparesis is a pathological condition in which there is weakness of the muscles of both upper or both lower extremities, due to neurological disorders. The lower paraparesis is more common than the upper. Pathology can develop acutely or gradually, be symmetrical or asymmetric, progressive or non-progressive.
There are flaccid, spastic and mixed paraparesis. At the level of damage to the spinal cord, flaccid, lower - spastic paresis of the muscles is found. The degree of muscle weakness varies from a slight decrease in muscle strength to a complete lack of movement. The condition is often accompanied by disturbances or loss of sensitivity, loss of control over the activity of the bladder, rectum.
Why does paraparesis occur?
Traumatic injuries
The cause of paraparesis is fractures, fracture-dislocations, partial and complete dislocations of the vertebrae, ruptures of the capsular-ligamentous apparatus and intervertebral discs in the thoracic and lumbar spine. Sometimes the disorder is provoked by bruises of the spine during high-energy impacts. The time of onset of disorders, severity and prognosis are determined by the nature of the spinal cord injury:
- Injury. Upon admission revealed complete paralysis due to spinal shock. Sometimes there is an incomplete loss of spinal functions. In the future, functions are gradually restored. Organic lesions cause residual neurological symptoms.
- Compression. Acute compression develops at the time of injury, associated with displacement of the vertebrae or their fragments. Delayed compression myelopathy is formed with instability, secondary displacement of bone fragments, increased edema, hemorrhage, and hematoma formation.
- Anatomical break . Complete damage to the spinal cord is observed with intense traumatic exposure, a significant displacement of solid structures. It is the most unfavorable in terms of prognosis, lost functions are not restored.
- Others . Paraparesis can be provoked by damage to a large vessel of the spinal cord, compression, rupture, bruising, or hemorrhage into the nerve roots.
Sudden loss of spinal functions is accompanied by the development of flaccid paraparesis, loss of sensitivity, disorders of the rectum and bladder. Subsequently, flaccid paraparesis transforms into spastic one with convulsive muscle contractions below the level of the lesion, the formation of pathological reflexes, and a tendency to form contractures.
Paraparesis
Non-traumatic compression myelopathy
Compression of non-traumatic origin often develops subacutely or chronically. Detected in the following pathologies:
- Tumors of the spinal cord. Slow progression of symptoms with further subacute decompensation is characteristic. Paraparesis can occur with benign and primary malignant neoplasia, metastasis of tumors of other localizations.
- Purulent abscesses. Formed under the dura mater, often formed with osteomyelitis, tuberculosis of the spine, sometimes become the result of open injuries and operations.
- spondylogenic compression. For rupture of the intervertebral hernia, a subacute course of myelopathy is typical. With osteochondrosis, changes increase gradually, are caused by pressure of osteophytes or hernia fragments, protrusion of the fibrous ring. In spondylolisthesis, disorders are caused by the "slipping" of the vertebrae.
Spinal circulation disorders
A spinal stroke occurs suddenly. Acute circulatory disorders in the thoracic region are manifested by lower spastic paraparesis (weakness in the legs, increased muscle tone), urinary retention, sensory disorders, and the disappearance of abdominal reflexes.
With ischemia or hemorrhage in the lumbar region, flaccid paraparesis of the proximal legs is noted, while maintaining the strength of the muscles of the distal parts of the lower extremities. An increase in Achilles reflexes and the disappearance of knee reflexes, urinary retention, and sensitivity disorders are revealed. With transient circulatory disorders, the symptoms increase gradually.
hereditary diseases
The phenomena of paraparesis are found in the following hereditary pathologies:
- Adrenoleukodystrophy. Caused by the accumulation of certain fatty acids. Lower paraparesis accompanies such forms of the disease as adrenomyeloneuropathy and symptomatic adrenoleukodystrophy.
- Machado-Joseph disease. Type 1 of this spinocerebellar ataxia manifests with spastic lower paraparesis, which is further supplemented by weakness of the upper limbs, paresis of the muscles of the pharynx and oculomotor nerves with the development of dysarthria, dysphagia, and ophthalmoplegia.
- Krabbe disease. Paraparesis is characteristic of juvenile and adult forms of glycolipidosis. Combined with hemianopsia, visual agnosia, difficulty in voluntary movements.
- Refsum's disease. Initially, there is a flaccid paresis of the distal lower extremities. In the future, weakness of the hands, cerebellar ataxia, hearing and vision impairments join.
congenital anomalies
Meningomyelocele is the protrusion of the spinal tissues outside the spinal canal. Formed in utero, detected at birth. Manifested by the presence of a hernia-like protrusion in the lumbar region. Neurological disorders progress as the child grows. With a lesion below L4 in severe cases, paraparesis is determined, above L3 - complete paraplegia.
The spinal dermal sinus is more often localized at the level of the lumbar or lumbosacral region. Significant variability in symptoms is characteristic - from an asymptomatic course to increasing neurological disorders, including flaccid paraparesis, muscle atrophy, hyporeflexia, hypoesthesia, and disorders of pelvic functions. With the syndrome of a fixed spinal cord, the changes are aggravated.
Degenerative diseases
Paraparesis is detected in such degenerative lesions of the nervous system as:
- Lateral amyotrophic sclerosis. In ALS with a cervical debut, asymmetric flaccid upper paraparesis develops at the initial stage. A lower spastic paraparesis is formed, which also has an asymmetric character. Subsequently, the clinical picture is supplemented by bulbar and pseudobulbar syndromes.
- Multiple sclerosis. Paresis is considered the leading manifestation of this demyelinating pathology. Spastic lower paraparesis is most often noted, tetraparesis is less often observed. Cerebellar symptoms, hyperkinesis are revealed.
- Opticomyelitis. Autoimmune disease usually debuts with optic neuritis, which is subsequently joined by signs of myelitis: tetraparesis or lower paraparesis, ataxia, sensory disorders, pelvic dysfunction. Less commonly, optic neuritis is preceded by myelitis.
Syringomyelia
The formation of cavities in the spinal cord is congenital or provoked by traumatic injuries, infectious diseases. In most cases, syringomyelia affects sensory neurons, which is accompanied by the appearance of zones of loss of sensitivity, neurotrophic disorders. With the spread of cavities to the anterior horns, the development of lower paraparesis is observed.
infectious diseases
Paraparesis is determined in a number of neuroinfections, which include:
- Neurosyphilis. Muscle weakness in the lower extremities is detected in meningovascular neurosyphilis, meningomyelitis, gummas at the base of the brain.
- Lyme disease. Tick-borne borreliosis is accompanied by paresis at the stage of dissemination. Pulsating headaches, lacrimation, neuralgia, myalgia, photophobia, increased fatigue are noted.
- Spinal tuberculous meningitis. A rare form of damage to the meninges, which is manifested by girdle pain, pelvic disorders, mono- or paraparesis.
Diagnostics
Patients with paraparesis are examined by a neurologist. During the interview, the specialist finds out when the muscle weakness occurred, what circumstances preceded the onset of the symptom, how the disease proceeded. A neurological examination involves an assessment of reflexes, sensitivity, and muscle strength. To clarify the cause of paraparesis, the following diagnostic methods are used:
- Radiography. Mandatory basic examination for spinal cord injury. Allows you to determine the type and severity of damage, determine the scope of further examination, approximate treatment tactics.
- Tomography . CT scan of the spine and/or MRI of the spinal cord are indicated for patients with injuries, hemorrhages, neoplasms, compression myelopathy, syringomyelia, and degenerative diseases. They provide an opportunity to clarify the nature, localization and prevalence of the lesion, to plan a surgical intervention.
- Myelography. Contrast x-ray examination of the spinal canal is used to identify obstructions in the circulation of CSF. It is prescribed for hernias, traumatic injuries, volumetric processes.
- Electrophysiological Methods . ENG and EMG are performed to assess the conduction of nerve impulses, determine the level of damage, and study muscle contractility.
- Lumbar puncture. It is performed with suspicion of inflammatory diseases, neoplasms, subarachnoid hemorrhages of traumatic and non-traumatic origin to assess CSF pressure, microscopy or culture of cerebrospinal fluid.
- Laboratory tests . Studies of blood, urine and cerebrospinal fluid are used in the diagnosis of inflammatory processes, hereditary metabolic pathologies, autoimmune diseases. To establish the degree of malignancy of neoplasia, a biopsy is necessary, followed by morphological analysis.
Exercise therapy for paraparesis
Treatment
Help at the prehospital stage
A victim with a suspected spinal injury should be carefully laid on a hard surface (shield), immobilized, covered with a warm blanket, and given an analgesic. Any suddenly developed paraparesis is considered an indication for an urgent call for an ambulance or immediate transportation of the patient to a specialized hospital in compliance with all precautions.
Conservative therapy
The paraparesis treatment program includes pathogenetic and symptomatic measures, restoration of the functions of the limbs and spinal cord. Drug therapy is carried out using the following medications:
- Painkillers . Narcotic analgesics are necessary in the early period of trauma, in other processes with intense pain. Subsequently, the funds are replaced by non-narcotic analgesics, NSAIDs.
- Antimicrobial . Indicated for open injuries, infectious pathologies, local purulent processes. The selection of the drug is made taking into account the type and sensitivity of the pathogen.
- Immunosuppressors . They are included in the treatment regimen for multiple sclerosis, optomyelitis. Hormonal agents are effective for swelling of the spinal cord, the development of radicular syndrome.
- Vascular . Therapy of circulatory disorders is carried out using vasoactive drugs, venotonics, antiplatelet agents.
- Neuroprotectors . They provide activation of local metabolic processes, restoration of nervous tissue in the aftermath of injuries, myelopathy, and other pathologies.
An obligatory part of therapy is the prevention of the development of bedsores and contractures, the restoration of motor skills. Patients are provided with appropriate care with regular changes in body position, passive movements are performed to maintain joint mobility. Subsequently, verticalization is carried out, massage, mechanotherapy, special exercise therapy complexes are prescribed.
Surgery
Depending on the cause of paraparesis, the following operations may be required:
- Injuries : spinal fusion, fixation with plates and cages, vertebroplasty, Urban wedge resection.
- Circulatory disorders : embolization of AVMs and aneurysms.
- Purulent processes : sanitation of spinal abscesses, epiduritis.
- Tumors : removal of intra- and extramedullary neoplasias.
- Congenital anomalies : meningomyelocele suturing, excision of the dermal sinus.