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Four patients who developed tuberculous paraplegia during pregnancy are described. They delivered at term without complications and then underwent successful decompression for paraplegia.
A retrospective study was undertaken of 53 cases of non-traumatic paraplegia admitted to two major hospitals in Papua New Guinea (PNG) from 1975-1982; 19 of these cases were examined. The mean age of the patients was 29 years (range: 2-70 years). Spinal tuberculosis was the commonest cause of paraplegia (83%), followed by neoplasia (7.5%). Two cases of chronic idiopathic arachnoiditis were noted but nutritional myelopathy was not diagnosed. Thirty-one (70%) of the 44 tuberculosis patients responded to treatment and were ambulant at discharge but only 18% were known to have completed 18 months' chemotherapy and 23% defaulted. The introduction of short-term chemotherapy regimens using rifampicin should improve future management of spinal tuberculosis in PNG.
A 66-year-old man was admitted for shortness of breath and showed fever, abdominal fullness and paraplegia. Monocytosis amounting to 25% and an elevation of serum LDH (4,281 mIu), were remarkable in the laboratory findings. He died of pulmonary insufficiency about a month after admission. On autopsy hepatomegaly (1950 g), splenomegaly (780 g), but no lymphadenopathy and small infarction in the thoracic spinal cord causing paraplegia was noted. Histopathologically, the invasion of the tumor cells into the liver, spleen, lymph nodes, bone marrow and other organs was observed. Malignant histiocytosis was diagnosed by histologic and immunohistochemical studies (lysozyme positive, S-100 protein negative).
In one hundred patients (86 males, 14 females) with relatively recent spinal cord injuries the oxygen supporting system was evaluated during graded arm ergometry. The patients were assigned according to injury level to 5 subgroups with complete, and to 2 additional groups with incomplete injuries. Mean peak oxygen uptake (VO2) was found to be as low as 0.74 l/min in males with complete tetraplegia and 1.9 l/min in patients with conus and cauda lesions. Peak VO2 was closely correlated (r = 0.74) to the injury level. Peak VO2 was also closely correlated to peak minute ventilation (VE) in all groups. In patients with higher injury levels most of the increase in VE during maximal exercise was due to an increase in respiratory frequency (fR). In patients with tetraplegia and high paraplegia, arm cranking revealed deficient sympathetic regulation of cardiovascular functions resulting in hypotension. In both the complete and incomplete tetraplegic patients there was a relatively low peak heart rate (fH). Peak fH and VO2 varied more in patients with incomplete tetraplegia than in those with complete tetraplegia. Peak VO2 in females with mid-level thoracic paraplegia was on the average lower than in males with corresponding injury levels (16 ml/kg/min against 22 ml/kg/min, respectively). Evaluation of cardiorespiratory functions in spinal cord injured patients during high intensity endurance work performed shortly after the injury adds diagnostic and functionally useful information for the design of rehabilitation and should be recommended as clinical routine.
The presentation by computed tomography of an extramedullar epidural intraspinal hemopoisis has only been described sporadically. It has been possible to visualize by CT-scans the regression under radiotherapy of a sensory and motor paraplegia in a 17 years old patient with beta-thalassemia major. The central nervous system (thoracic and lumbar zone as well as os sacrum) was exposed to a total reference dose of 30 Gy which was administered within twenty days by a 60Co unit in single doses of 2 Gy each. From 4 Gy on, the paraplegic symptoms regressed continuously. The control CT taken after 26 Gy- the paraplegia had completely disappeared at this time-showed a significant regression of the intraspinal soft tissue masses. Radiotherapy is very important in the treatment of this disease. A direct correlation is found between clinical symptoms and CT-presentation.
Computerized axial tomography provided the diagnosis for an evolving paraplegia in a patient with a gunshot wound of the descending thoracic aorta. Successful surgical management of the aortic injury and considerations regarding the paraplegia are presented. We do not advocate arteriography and computed tomography routinely in major vascular injuries; however, in clinically stable patients with a high suspicion of associated injuries, use of both can be useful.
After a severe polytraumatism, a 14 year-old boy presents paraplegia without vertebral lesion. Angiocardiography showed rupture of aortic isthmus. Surgical treatment resulted in successful outcome. The authors insist on the rarity of traumatic rupture of aorta in children and or the particularity of the diagnosis revealed by paraplegia.
Intrathecal serotherapy appears to be effective in the treatment of tetanus, and it has been claimed that human immune globulins are innocuous. In the 4 cases reported here reversible paraplegia developed a few hours after intrathecal injection of 1500 to 2000 UI of human immune globulins prepared by the French Blood Transfusion Centre. We believe that paraplegia was related to the high doses administered. The fact that intrathecal serotherapy is normally used in severely ill patients whose impaired consciousness precludes motricity and sensitivity testing may explain why this complication has not previously been reported. The need for high doses of intrathecal immune globulins is discussed. It has recently been suggested that high doses are superior to low doses. We consider that this form of treatment is justified, even in the least severe forms of tetanus, but we feel that doses higher than 1000 IU are not without danger.
Four cases of adrenomyelopathy, the adult form of adrenoleukodystrophy, three of which were familial, were reported. The neurological disease consisted of progressive spasmodic paraplegia, sphincter disorders, peripheral neuropathy, occasional deep sensibility impairment and psychiatric disturbances in one case. Adrenal insufficiency was confirmed after the appearance of the neurological signs in two cases; in another case it had been diagnosed in childhood. Gonadal insufficiency was present in all cases and clinically apparent in two patients. Detailed genetic studies were carried out in two patients of the same family. Histocompatibility tests showed A2 and B15 antigens in three out of four cases. The diagnosis was confirmed in three cases by measurement of serum long chain fatty acid with increased C26 levels and C26/C22 ratios. Peripheral nerve biopsy in 1 patient showed characteristic inclusion bodies in the Schwann cells. The authors discuss the relationship between ALD and familial spasmodic paraplegia, the mode of genetic transmission of the disease and the diagnostic value of neuromuscular biopsy and measurement of serum long chain fatty acid levels.
Well-known complications of abdominal aortic aneurysm surgery include haemorrhage, arterial occlusion, infection and aortoduodenal fistula. Less well known is the occurrence of paraplegia. At present there is no estimate of its incidence, and only isolated cases have been reported. We report 2 cases of paraplegia following elective aortic surgery and 2 others following acute occlusion of the abdominal aorta.
Familial spastic paraplegia is described in four Cook Island children. Prior to the onset of the disease at age six or seven years, the children were apparently normal. Disease was characterised principally by progressive spastic paraplegia of the lower extremities, in addition to tremor and slow articulation. The disease in these children was probably due to the expression of an autosomal recessive gene. The disorder is of interest because the findings in these children appear to overlap the pure spastic and ataxic heredofamilial syndromes.
A group of 40 clients with complete paraplegia, selected on a number of criteria (such as extent and location of the spinal cord lesion, age, financially responsible agency) had been followed up from the onset of paralysis. At the end of the 5th year post-onset, the following was stated in the 37 survivors: 28 of the 37 paraplegics (75.7 percent) have achieved vocational resettlement (in the broadest possible meaning of that term); of these 28, 16 (43.3 percent) were employed in standard-remuneration occupations; 6 (16.2 percent) had entered training or retraining programmes; 6 (16.2 percent) were engaged in domiciliary activities for at least 5 hours a day or employed in a sheltered setting. None of the paraplegics drew unemployment benefits at the report time; 9 (24.3 percent) had not been resettled vocationally. The article reports on those factors of paraplegia that have comparatively favourable effect on a return to occupational activity (such as use of both arms, absence of psycho-organic syndromes, stability of the neurological syndrome), on permanently detrimental consequences of omitted or insufficient early treatment, as well as on the importance of secondary prevention measures following discharge from inpatient treatment.
Tuberculosis of the spine associated with neurologic deficit has fortunately become an uncommon disease. Of 48 patients with Pott's paraplegia seen over a 20-year period, 28 were adequately followed up. Ten patients in this series died, most of causes not directly related to the tuberculosis, and ten patients were lost to follow-up. Most of the patients in this study were in the older age group which, in part, accounts for the mortality. Of those who did survive, the outlook for recovery from the paraplegia was very good with or without surgical intervention.
A case of paraplegia occurring during surgery for coarctation of the aorta in a 28 month-old child is reported. Paraplegia was due to medullary ischemia, probably related to insufficient collateral circulation. Such ischemic accidents generally remain unforeseeable and no good prevention is available. This rare operative complication should not alter the present management of coarctation of the aorta.
The association of pes cavus deformity and neurological disorder is well known. Varus deformity of the heel is often associated with, and may even precede the development of pes cavus. Clinical and radiographic examinations of the feet of members of three kindreds of hereditary spastic paraplegia, a rare neurologic disorder, suggested that the autosomal dominant form manifests a significantly higher incidence and degree of heel varus deformity than the autosomal recessive form of the disease. Therefore, heel varus deformity may be a sign suggestive of autosomal dominant inheritance of hereditary spastic paraplegia.
We describe the special features and complications connected with the acute phase and long-term course in 28 children with traumatic paraplegia seen for an average duration of 9 1/2 years. Recognition of spinal cord injury was delayed in a third of the cases due to skull and brain trauma and/or multiple injuries. There was subsequently a partial improvement in the neurological status of 7 of 23 children who were initially considered to have sustained complete paraplegia. The extent of independence, education, further training and social integration achieved is impressive and emphasizes the enormous significance of rehabilitation which is particularly complex and laborious in the case of paraplegic children.
A 61-year-old patient with pre-existing but asymptomatic spinal stenosis was placed in the lateral position on the operating table for hip surgery. The lumbar spine was in a position of extension and lateral bend. This position, combined with severe spinal stenosis (proven later at surgery), caused enough compression on the neural elements to produce permanent paraplegia. Similar cases have been reported but remain an infrequent cause of postoperative paraplegia.
A series of 19 patients suffering Pott's paraplegia was reviewed in a ten-year period. Ever since their admission they were submitted to an antiphthisic and orthopedic medical treatment for 3 to four weeks. A medullar decompression by reaching the focus through different surgical technics was performed on 16 of them. 3 did not require such procedure; 14 recovered completely; 2 partial recovery and 3 did not recover at all. The degree of kyphosis together with affected vertebrae and area, plus ossifluent abscess, the lack of sphincter control and pre-treatment evolution were correlated with recovery from paraplegia.