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Quadriplegia - ( clinical aspects of)-For the benefit of medical students

                                                                      Quadriplegia

Paralysis affecting all 4 limbs.

Synonym: Tetraplegia

Partial loss of power is Quadriperesis/tetraperesis

 

Types: I. Quadriplegia of upper motor Neuron Lesion

           II. Quadriplegia of lower motor neuron lesion.

 

 

II. Lower motor lesion: Flaccid quadriplegia

CLASSIFICATION (According to the site of lesion)

SITES:

Anterior horn cells/Roots/peripheral nerves/Myoneuronal junction/Muscles.

✿Lesions of anterior horn cells:

                           Acute anterior Poliomyelitis

✿Lesions of Roots:

                         Guillain-Barre Syndrome

✿Lesions of Peripheral Nerves

                         Polyneuropathy

  • Porphyria
  • Diphtheria
  • Infective hepatitis
  • Infectious mononucleosis
  • botulism

 

✿Lesions of myoneuronal junction:

                         Myasthenia gravis

✿Lesions of Muscles:

                         Myopathy

 a) Genetic

 b) Non genetic

                          Periodic paralysis

 

  Spastic Quadriplegia

  Sites of Lesion: 

 High cervical cord/Brain stem/Cortex           

  • HIGH CERVICAL CORD LESION
  1. Trauma
    1.                                                                  i.    Fracture dislocation of cervical spine
    2.                                                                ii.    Hematomyelia
    3. Cervical spondylosis
    4. Cervical cord tumor
    5. Cranio vertebral anomalies
      1.                                                                  i.    Klippel-Feil syndrome
      2.                                                                ii.    Arnold chiari malformation
      3.                                                               iii.    Platy-basia
  • BRAIN STEM LESION
    • VBI-vertibro basilar artery insufficiency
    • Bulbar poliomyelitis
    • Syringobulbia.
    • Disseminated sclerosis
    • Motor neuron Disease
  • CORTICAL LESIONS
    • Cerebral palsy
    • Diffuse sclerosis
    • Hydrocephalus
    • Birth injuries
    • Defects in brain during fetal development

 

QuadriplegiaPredominantly involving proximal group of muscles

Conditions causing:

1. Poliomyelitis –Anterior horn cells

2. Spinal muscular atrophy

genetically determined disease of motor neurons

3. Guillain –Barre Syndrome(GBS)

4. Periodic paralysis, Myotonia

5. Myopathy

6. Myasthenia

7. Diabetic Mononeuritis multiplex

(Sciatic and femoral nerve)

8. Diabetic myopathy

-involving proximal shoulder, pelvic girdle muscles

-unilaterally or bilaterally.

 

Predominantly involving distal group of muscles

1. Distal Myopathies

2. Peroneal muscular atrophy.

3. Polyneuropathies.

-Multiple symmetrical peripheral neuropathies

(Alcoholism, diabetes, carcinoma, lead poisoning)

4. Mononeuritis multiplex

-Asymmetrical involvement of peripheral nerves.

(-Leprosy, Amyloid, PNA, neurofibroma)

 

Differential Diagnosis of Quadriplegia.

I. AS PER NEURO ANATOMICAL SITE OF LESION

  • Anterior Horn cells
    • Weakness, wasting, fasciculation.
    • Fasciculations occasionally in root lesios
  • Peripheral nerves
    • Distal distribution, sensory involvement, absent reflexes.
    • Neuromuscular junction
    • Predominant ocular and bulbar muscle involvement.
    • Diurnal variation.
    • Reflexes preserved.

 

II. TENDON REFLEXES AND QUADRIPLEGIA

  • Preserved in myopathy
  • Absent in Spinal muscular atrophy, Polio.
  • Areflexia in GBS.

 

III.Diagnosis according to chronological evolution

  • Acute onset
    • Guillain –Barre
    • Periodic paralysis.
  • Subacute onset;
    • Inflammatory polyneuropathies.
      1. Guillain- Barre.

2. Diphtheria

3. Porphyria

4. Toxic neuropathy.

5. Rarely- myasthenia

              6. Toxic myopathy.

    7. Endocrine myopathy.

IV. Diagnosis according to progression of the disability

  1. SLOWLY PROGRESSIVE.

i) Over weeks to months

  Polymyositis, Dermato myositis.

    ii) Over years

   Spinal muscular atrophy

     (Werdnig- HoffmanSyndrome, Kugleberg welander

Syndrome)

  Myasthenia

  Muscular dystrophies.

  1. SLOWLY PROGRESSIVE BULBAR WEAKNESS

Anterior horn cell Disease.

  1. Neuro muscular junction.

Less common- Myopathy

                        Oculopharyngeal

                        Polymyositis.

                        Dermato myositis.

  1. D.  SLOWLY PROGRESSIVE DISTAL WEAKNESS.
    1. a.    Peripheral nerve lesion.
    2. b.   Distal myopathy.   

                Congenital myopathy - rare

  1. c.    Myotonic dystrophy.
  2. d.   Fascio scapulohumeral can present with

-Distal weakness along with proximal.

V. Differentiation by certain presentations

  1. a.    Ocular weakness and ptosis

 Never in M.N.D./peripheral neuropathy / Eaton Lambert’s-no ocular or bulbar involvement.

  1. b.   Ocular muscle weakness typical in –

Myasthenia,  Myotonia.

Others:- Oculo pharyngeal dystrophy

              Diabetes with Mononeuritis multiplex.

  1. c.    Only ocular weakness.

        Progressive external ophthalmoplegia

   Kearns –Sayer Syndrome.

 

      d. Episodic Weakness

Periodic paralysis

Myasthenia Gravis

Eaton-Lambert’s Syndrome-No weakness of ocular /bulbar muscles.

 

Recurrent temporary flaccid paralysis.    

                                                              

  1. Myasthenia gravis
  2. Potassium deficiency.
  3.  periodic paralysis.( familial, Hypokalemic, Hyperkalemic)
  4. Primary aldosteronism.
  5. Disseminated Sclerosis.
  6. Sarcoidosis.

     7. Hypothyroidism/ Hyperthyroidism

8. Porphyria

 

 

Spastic Quadriplegia (pyramidal tract involvement in)

/Spinal cord lesion/ Brain stem lesions/cerebrallesions

Spastic diplegia-All 4 limbs are affected but lower limbs are affected more than upper limbs.

  1. Cerebral palsy/central pontine myelinosis

 

 

CAUSES OF QUADRIPLEGIA

  

ASSESSMENT

 

 

 

COMPLICATIONS

INVESTIGATIONS

Depends on site of suspected pathology

    

 

TREATMENT:

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