Spastic Paraplegia

Question 1

Where will you be asked to examine in a patient with spastic paraplegia?

Answer 1

The lower limbs

Question 2

What questions should you ask on history in spastic paraplegia?

Answer 2

Onset, duration and course

Back pain; whether localised

Numbness and paraesthesia, particularly below lesion (including pressure sores)

Sphincter control and bladder sensation

Question 3

What family history is important in spastic paraplegia?

Answer 3

Family history of paraplegia; could indicate hereditary spastic paraplegia

This will not have an association with trauma normally

Question 4

Taking a history of birth anorexia is important in spastic paraplegia why?

Answer 4

For the DDx of cerebral palsy

Question 5

Will tone in the lower limbs be increased or decreased in spastic paraplegia?

Answer 5

Increased – lower motor neuron deficit

Question 6

Will the reflexes be increased or decreased in spastic paraplegia?

Answer 6

Hyperreflexive – lower motor neuron deficit

Question 7

Will there be normal muscle strength and good muscle body size in spastic paraplegia?

Answer 7

No

Lower motor neuron deficit, therefore there will be wasting and reduced strength

Question 8

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?

Answer 8

Yes

Spinal tenderness or deformity

Question 9

Should you examine the upper limbs in spastic paraplegia?

Answer 9

Yes

At least say that you would like to examine them, to rule out their involvement

Question 10

Why should you check for cerebellar signs in spastic paraplegia?

Answer 10

To rule out MS, Fredreich’s ataxia

Question 11

What would it mean for there to be spasticity of the lower limbs alone? Ie, no urinary incontinence

Answer 11

Lesion of thoracic cord (T2-L1)

Question 12

What would it mean for there to be irregular spasticity of the lower limbs, with flaccid weakness of scattered muscles of the lower limbs?

Answer 12

Lesion of the lumbosacral enlargement (L2-S2)

Question 13

When is the presence of radicular pain useful in spastic paraplegia?

Answer 13

Early in the disease

With time becomes diffuse and loses localising value

Question 14

Is superficial sensory loss particularly useful in assessing spastic paraplegia?

Answer 14

No

Level of loss may vary greatly between individuals and in different types of lesions

Question 15

What are paediatric causes of spastic paraplegia?

Answer 15

Trauma

MS

Friedreich’s ataxia

HIV

Question 16

What are the adult causes of spastic paraplegia?

Answer 16

Trauma

MS, MND

Tabes dorsalis

Familial spastic paraplegia

Transverse myelitic syndrome

Parasagittal falx meningioma

Question 17

What are the geriatric causes of spastic paraplegia?

Answer 17

Osteoarthritis of cervical vertebrae

Metastatic carcinoma (epidural)

Anterior spinal artery thrombosis, atherosclerosis of spinal cord vasculature

Vitamin deficiency

Question 18

What is an intracranial cause of spastic paraplegia?

Answer 18

Parasagittal falx meningioma

Question 19

What is transverse myelitic syndrome?

Answer 19

Cord compression/transection involving all tracts

Question 20

What can cause transverse myelitic syndrome?

Answer 20

Trauma

Compression by bony changes or tumour

Vascular disease

Question 21

What is paraplegia-in-flexion?

Answer 21

Seen in partial spinal cord transection

Lower limb flexed at hip and knees because extensors are more paralysed than flexors

Question 22

What is paraplegia-in-extension?

Answer 22

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)

Question 23

What investigations can you do for spastic paraplegia?

Answer 23

FBE for anaemia

Serology: syphilis, vit B12, PSA

MRI of spine, CT myelography

CTB for parasagittal meningioma

Question 24

Can you have paraplegia unilaterally, and if so does that determine whether the lesion is in the brain or the spinal cord?

Answer 24

It can be unilateral

No, it is not localising

Question 25

Is hereditary spastic paraplegia autosomally dominant or recessive?

Answer 25

There are different kinds that are recessive or dominant, and also X-linked

Question 26

How would you localise a lesion to the 2nd and 3rd lumbar root level?

Answer 26

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

Question 27

How would you localise a lesion to the 4th lumbar root level?

Answer 27

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

Question 28

How would you localise a lesion to the 5th lumbar root level?

Answer 28

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

Question 29

How would you localise a lesion to the 1st sacral root level?

Answer 29

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

Question 30

How would you localise a lesion to the lower sacral root level?

Answer 30

Muscular weakness: none Reflexes affected: none (anal reflex impaired) Radicular pain/paraesthesia: buttock and back of thigh Superficial sensory deficit: saddle and perianal areas

Question 31

Can epidural metastases cause spastic paraplegia?

Answer 31

Yes

Question 32

What is the progression of symptoms in epidural metastasis?

Answer 32

First pain, over days to months Then Weakness, sensory loss and incontinence Then paraplegia over hours to days

Question 33

What are the three primary cancers that typically can lead to epidural metastases?

Answer 33

Breast, lung, prostate