Quadriplegia

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Quadriplegia is a symptom in which a human experiences paralysis affecting all four limbs, although not necessarily total paralysis or loss of function. The condition is also termed tetraplegia. Both terms mean “paralysis of four limbs”; however, tetraplegia is becoming the more commonly accepted term for this condition. “Tetra”, like “plegia”, has a Greek root, whereas “quadra” has a Latin root.

There are about 5,000 cervical spinal cord injuries per year in the United States (~1 in 60,000—assuming a population of 300 million), and about 1,000 per year in the UK (also ~1 in 60,000—assuming a population of 60 million). In 1988, it was estimated that lifetime care of a 27-year-old rendered tetraplegic was about US $1 million and that the total national costs were US $5.6 billion per year. It currently costs between $520,000 to $550,000 per year to care for a ventilator dependent tetraplegic.^[1]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Spinal cord injuries are classified as complete and incomplete by the American Spinal Injury Association (ASIA) classification. The ASIA scale grades patients based on their functional impairment as a result of the injury, grading a patient from A to D. (see table 1 for criteria) This has considerable consequences for surgical planning and therapy.^[1]

Table 1: ASIA impairment scale^[1]

Pathophysiologically, the spinal cord of the tetraplegic patient can be divided into three segments which can be useful for classifying the injury.

First there is an injured functional medullary segment. This segment has unparalysed, functional muscles; the action of these muscles is voluntary, not permanent and strength can be evaluated by the British Medical Research Council (BMRC) scale. This scale is used when upper limb surgery is planned, as referred to in the ‘International Classification for hand surgery in tetraplegic patients’ (see table 2).^[2]

A lesional segment (or an injured metamere) consists of denervated corresponding muscles. The lower motor neuron (LMN) of these muscles is damaged. These muscles are hypotonic, atrophic and have no spontaneous contraction. The existence of joint contractures should be monitored.^[2]

Below the level of the injured metamere there is an injured sublesional segment with intact lower motor neuron, which means that medullary reflexes are present, but the upper cortical control is lost. These muscles show some increase in tone when elongated and sometimes spasticity, the trophicity is good.^[2]

Incomplete spinal cord injuries result in varied post injury presentations. There are three main syndromes described, depending on the exact site and extent of the lesion.

1. The central cord syndrome: most of the cord lesion is in the gray matter of the spinal cord, sometimes the lesion continues in the white matter.^[3]
2. The Brown–Séquard syndrome: hemi section of the spinal cord.^[3]
3. The anterior cord syndrome: a lesion of the anterior horns and the anterolateral tracts, with a possible division of the anterior spinal artery.^[3]

For most patients with ASIA A (complete) tetraplegia, ASIA B (incomplete) tetraplegia and ASIA C (incomplete) tetraplegia, the International Classification level of the patient can be established without great difficulty. The surgical procedures according to the International Classification level can be performed. In contrast, for patients with ASIA D (incomplete) tetraplegia it is difficult to assign an International Classification other than International Classification level X (others).^[3] Therefore it is more difficult to decide which surgical procedures should be performed. A far more personalized approach is needed for these patients. Decisions must be based more on experience than on texts or journals.^[3]

The results of tendon transfers for patients with complete injuries are predictable. On the other hand, it is well known that muscles lacking normal excitation perform unreliably after surgical tendon transfers. Despite the unpredictable aspect in incomplete lesions tendon transfers may be useful. The surgeon should be confident that the muscle to be transferred has enough power and is under good voluntary control. Pre-operative assessment is more difficult to assess in incomplete lesions.^[3] Patients with an incomplete lesion also often need therapy or surgery before the procedure to restore function to correct the consequences of the injury. These consequences are hypertonicity/spasticity, contractures, painful hyperesthesias and paralyzed proximal upper limb muscles with distal muscle sparing.^[3] Spasticity is a frequent consequence of incomplete injuries. Spasticity often decreases function, but sometimes a patient can control the spasticity in a way that it is useful to their function. The location and the effect of the spasticity should be analyzed carefully before treatment is planned. An injection of Botulinum toxin (Botox) into spastic muscles is a treatment to reduce spasticity. This can be used to prevent muscle shorting and early contractures.^[3]

Over the last ten years an increase in traumatic incomplete lesions is seen, due to the better protection in traffic.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

In high-level cervical injuries, total paralysis from the neck can result. High-level tetraplegics (C4 and higher) will likely need constant care and assistance in activities of daily living, such as getting dressed, eating and bowel and bladder care. Low-level tetraplegics (C5 to C7) can often live independently.

Even with “complete” injuries, in some rare cases, through intensive rehabilitation, slight movement can be regained through “rewiring” neural connections, as in the case of the late actor Christopher Reeve.^[1]

In the case of cerebral palsy, which is caused by damage to the motor cortex either before, during (10%) or after birth and some tetraplegics are gradually able to learn to stand or walk through physical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

• Trauma (such as a traffic collision, diving into shallow water, a fall, a sports injury),
• Transverse myelitis
• Polio)
• Congenital disorders
• Muscular dystrophy
• Multiple sclerosis.

• Epidural injection of Dexamethasone

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

There are about 5,000 cervical spinal cord injuries per year in the United States (~1 in 60,000—assuming a population of 300 million), and about 1,000 per year in the UK (also ~1 in 60,000—assuming a population of 60 million). In 1988, it was estimated that lifetime care of a 27-year-old rendered tetraplegic was about US $1 million and that the total national costs were US $5.6 billion per year. It currently costs between $520,000 to $550,000 per year to care for a ventilator dependent tetraplegic.^[1]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

• Spinal cord injury
• Tumor affected spinal cord
• Stroke
• Cerebral palsy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

• Pressure sores
• Osteoporosis
• Fractures
• Frozen joints
• Spasticity
• Respiratory complications and infections
• Deep vein thrombosis
• Autonomic dysreflexia
• Cardiovascular disease

Delayed diagnosis of cervical spine injury has grave consequences for the victim. About one in 20 cervical fractures are missed and about two-thirds of these patients have further spinal-cord damage as a result. About 30% of cases of delayed diagnosis of cervical spine injury develop permanent neurological deficits.

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