Tetraplegia

Published on 02/04/2015 by admin

Filed under Internal Medicine

Last modified 22/04/2025

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89 Tetraplegia

Instruction

Carry out a neurological examination of this patient’s lower limbs.

Salient features

History

• Ask about bladder symptoms and check sacral sensation

• Ask about radicular pain

• Ask whether the weakness was sudden or gradual

• History of trauma, multiple sclerosis.

Examination

• Increased or decreased tone in both lower limbs

• Hyperreflexia

• Ankle clonus

• Weakness in all four limbs

• Wasted hands (cervical spondylosis, motor neuron disease or syringomyelia).

Remember: The physical examination pertinent to spinal cord dysfunction involves testing in three areas: motor function, sensory function and reflexes.

Proceed as follows:

• Remember to check the sensory level and examine the spine.

• Tell the examiner that you would like to do the following:

• Check for cerebellar signs (multiple sclerosis, Friedreich’s ataxia)
• Check BP (postural hypotension, autonomic dysreflexia).

• Try to localize the level of lesion using the following:

• Spasticity of all four limbs: lesion above the C4 spinal cord segment
• Spasticity of the lower limbs with flaccid weakness of some muscles of the upper limb: lesion of cervical cord enlargement (C5–T2)
• Deep tendon reflexes: an absent biceps jerk with a brisk supinator jerk (inversion of the supinator jerk) or an absent biceps and supinator with a brisk triceps jerk localizes the lesion to C5–6
• Radicular pain: useful early in the disease; with time becomes diffuse and ceases to have localizing value
• Superficial sensation: not good for localizing as the level of sensory loss may vary greatly in different individuals and in different types of lesion.

Note: Be prepared to discuss the Frankel classification (below).

Diagnosis

This patient has weakness in all four limbs (lesion) caused by spinal trauma (aetiology), and is wheelchair bound (functional status).

Advanced-level questions

What is autonomic dysreflexia?

It is bradycardia, sweating, rhinorrhoea, pounding headaches and severe paroxysmal hypertension, which presents quickly and can rapidly precipitate seizures and death if not relieved. Precipitating factors include blockage of urinary catheter, visceral distension from full bowel, stimulation of the skin secondary to an irritative pressure sore and vesicoureteric reflux. Labour in a high-tetraplegic female may also be complicated by it.

What non-traumatic causes are there for spinal cord dysfunction?

• Processes affecting the spinal cord or blood supply directly:

• Multiple sclerosis
• Transverse myelitis
• Spinal arteriovenous malformation/subarachnoid haemorrhage
• Syringomyelia
• HIV myelopathy
• Other myelopathies
• Spinal cord infarction.

• Compressive lesions affecting the spinal cord:

• Spinal epidural abscess
• Spinal epidural haematoma
• Discitis
• Neoplasm
• Metastatic
• Primary CNS.

Does ingestion of food affect blood pressure in tetraplegics?

The ingestion of food causes a small fall in BP and this exacerbates the postural hypotension in these patients.

How would you manage spasticity in these patients?

• Drugs: diazepam, baclofen

• Surgery: dorsal rhizotomy, neurectomy, myelotomy, orthopaedic procedures that divide and lengthen tendons of spastic muscles.

How do you localize the lesion to the fifth cervical root level?

• Muscular weakness: deltoid, supraspinatus, brachoradialis

• Deep tendon reflexes affected: biceps and supinator jerks

• Radicular pain/paraesthesia: neck, top of shoulder, outer aspect of the arm, forearm

• Superficial sensory deficit: outer aspect of the upper arm.

How do you localize the lesion to the sixth cervical root level?

• Muscular weakness: biceps, brachioradialis, extensor carpi radialis longus

• Deep tendon reflexes affected: biceps and supinator jerks

• Radicular pain/paraesthesia: neck, shoulder, outer arm, forearm, thumb and index finger

• Superficial sensory deficit: thumb and index finger.

How do you localize the lesion to the seventh cervical root level?

• Muscular weakness: triceps and most of the muscles on the dorsum of the forearm

• Deep tendon reflexes affected: triceps jerk

• Radicular pain/paraesthesia: neck, shoulder, arm, forearm to index and middle finger

• Superficial sensory deficit: mostly middle and index fingers.

How do you localize the lesion to the eighth cervical root level?

• Muscular weakness: flexors of the forearm

• Deep tendon reflexes affected: finger jerk

• Radicular pain/paraesthesia: neck, shoulder, arm, ring and little fingers

• Superficial sensory deficit: ring and little fingers.

How do you localize the lesion to the first thoracic root level?

• Muscular weakness: small muscles of the hand

• Deep tendon reflexes affected: finger jerk

• Radicular pain/paraesthesia: neck, axilla, medial aspect of the arm and forearm, little and ring finger

• Superficial sensory deficit: medial arm and little finger.

What precautions would you take when transporting patients with acute high-spinal injuries by air?

• Lung function should be stable before transfer

• Air humidifier and supplemental oxygen should be available

• Patient should be accompanied by someone trained in manoeuvres to clear airway secretions. Tracheal suction should be done regularly; this may be complicated by reflex bradycardia and cardiac arrest, and so atropine and orciprenaline should be readily available (BMJ 1990;300:1498).

What is the mode of onset in patients with the classical syndrome of foramen magnum?

First, there is weakness of the shoulder and arm, followed by weakness of the ipsilateral leg, then contralateral leg and, finally, contralateral arm. Neoplasms in this region can cause suboccipital pain spreading to the neck and shoulders.

What is Raymond–Cestan syndrome?

Raymond–Cestan syndrome is the result of the obstruction of twigs of the basilar artery causing lesions of the pontine region; it is characterized by tetraplegia, nystagmus and anaesthesia.

Can you describe Frankel’s classification of neurological deficit?

The classification is into five types:

A: absent motor and sensory function

B: sensation present, motor function absent

C: sensation present, motor function active but not useful (grades 2/5 to 3/5)

D: sensation present, motor function active and useful (grade 4/5)

E: normal motor and sensory function.

What is the role of robotics in such patients?

Animal experiments suggest that a robotic arm can be used through impulses generated by the motor cortex (Nature 2006;442:164–71, Nature 2008;453:1098–1101). Clinical trials for safety and feasibility are necessary to test the efficacy of these devices.

Sir Ludwig Guttman, FRS, fled from Nazi persecution and worked at the National Spinal Injuries Centre in Stoke Mandeville Hospital, Aylesbury. He was entrusted to look after the paraplegics and tetraplegics of the war. He was the first to show that pressure sores can be avoided by 2-hourly turning of patients.

Prof Hans Ludwig Frankel, OBE, contemporary Physician, National Hospital of Spinal Injuries, Stoke Mandeville Hospital, Aylesbury.

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