Paraplegia is the paralysis of both lower limbs resulting (with exceptions) from a spinal cord injury, most often the result of some sort of trauma caused by accidents, but sometimes due to medical conditions (illness). This term often encompasses both paraplegia in the strictest sense (thoracic, lumbar and sacral injuries) and quadriplegia (cervical injuries). Most individuals with paraplegia or quadriplegia are wheelchair users, but this visible disadvantage is combined with associated impairments that, even though often hidden, are nevertheless troublesome, source of complications.
What are paraplegia and quadriplegia?
Paraplegia is the result of damage to the spinal cord and nerve roots, or severe injury to the nerve roots in the cauda equina (figure 1 and figure 2): in the strict sense, paraplegia means paralysis of the lower limbs, and is most commonly caused by spinal cord injuries. Quadriplegia is when the damage is located in the cervical region of the spine; tetra means four (limbs). Quadriplegias account for one third of all spinal cord injuries.
Accidents are the most common cause of spinal cord injuries; the number of cases is between 1000 and 1500 annually. Young adults are thus the most commonly affected population (15-35 years old), and they tend to be male more often than female. Overall, the estimated number of paraplegic and quadriplegic individuals in France varies between 25,000 and 30,000, including not only spinal cord injuries, traumatic or not, that are described in this article, but also similar conditions such as spina bifida.
Figure 1: Lateral view of the spinal cord in the spinal cavity
Vertèbre : Vertebra
Dure-mère : Dura mater
Moelle : Spinal cord
Espace épidural : Epidural space
Disque intervertébral : Intervertebral disk
Nerfs rachidiens : Spinal nerves
What are the clinical signs?
There are many signs and symptoms of damage to the spinal cord related to its physiology. They include:
- Motor disorders
- Sensory disorders
- Genital and sexual disorders
- Urethral and anal sphincter disorders
- Respiratory disorders
- Autonomic nervous system disorders
- Other associated disorders
The injury affects:
- Voluntary motor control, damage involve paralysis (complete injury: no movement possible) or paresis (incomplete injury: movement is possible, but weak). Distribution of paralysis depends on the injury level (figure 2). It can homogenously spread in the affected area, or on the contrary, variably distributed, for instance between the right and left side, or in the proximal (upper back, upper limbs) and distal parts (extremities), which are the areas that are the most commonly affected in incomplete injuries (paresis);
- Autonomic motor control (regulating muscle tone). Two cases are usually possible:
- Either an increase in the muscle activity caused by disruption between the spinal cord and central nervous centers regulating motor control (brain). Then mobilization of the limbs is observed, as well as stiffness against muscle stretching that increases with speed. This stiffness or hypertonia, also called spasticity, leads to abnormal autonomic reflexes called contractures (sometimes mistaken for involuntary jerks);
- Or a loss of tonus triggering the flaccid state of muscles or hypotonia. This is referred to as flaccid paraplegia. This state is the result of either complete or partial injury associated with specific root levels. It may be a transitory (at the onset) or a persistent state. Individuals with severe muscle atrophy (muscle mass loss) have an increased risk of developing pressure sores and phlebitis.
Figure 2: Vertebral levels (Roman numerals) and spinal cord segmental levels or metameric units (neurological)
Nerfs cervicaux : Cervical nerves
Nerfs thoraciques : Thoracic nerves
Nerfs lombaires : Lumbar nerves
Nerfs sacrés : Sacral nerves
Nerf coccygien : Coccygeal nerve
Queue de cheval : Cauda equina
- Superficial sensibility (figure 3 and figure 4) associated with all cutaneous sensations: fine tactile discrimination (sense of touch), pain, hot and cold, and gross tactile discrimination. The lack of superficial sensibility is called anesthesia, whereas a partial loss of sensibility to sensory stimuli is called hypoesthesia. Multiple levels of damage may be present in a single patient, where tactile sensibility may be preserved with total loss of pain sensations, which expose the patient to the risk of unintentional injury or burn that often may go unnoticed. When there is a total loss of sensibility, patients are at greater risk of developing pressure sores;
- Deep sensibility is responsible for the knowledge of the exact position of the body in space, as well as of the pressure and shear force exerted on the skin. This explains why individuals sustaining spinal cord injuries must look at their legs or feet to know exactly where they are and why quadriplegic individuals look at their hands in order to be able to use or protect them. This form of disorder is also causing trunk balance problems, associated with paralysis of abdominal muscles, and feelings of “vertigo” or fear of heights that most of them are experiencing.
Figure 3: Dermatomes (areas of the skin that are mainly supplied by a single spinal nerve)
Adapted from O. Foerster and M. Maury
An explanation of figure 3 is available.
Figure 4: Testing areas used in assessing levels of cutaneous sensory loss and spinal cord injuries
Adapted from O. Foerster and M. Maury
An explanation of figure 4 is available.
Figure 5: Cross-section of spinal cord
Cordon postérieur : Posterior funiculus
Corne postérieure : Posterior horn
Racine postérieure du nerf périphérique : Posterior root of the peripheral nerve
Nerf rachidien (périphérique) : Spinal nerve (peripheral)
Cordon latéral : Lateral funiculus
Racine antérieure du nerf périphérique : Anterior root of the peripheral nerve
Cordon antérieur : Anterior funiculus
Sillon antérieur : Anterior median fissure
Canal épendymaire : Central canal of the spinal cord
Corne antérieure : Anterior horn
Différents faisceaux du cordon latéral : Various tracts of the lateral cord
The posterior part of the spinal cord or dorsal (posterior) horns transmits:
- Superficial (extreroceptive) sensations (tactile, pain, hot temperatures);
- Deep (proprioceptive) sensations (perception of the body in space, pressure, vibrations, balance, etc.);
- and visceral sensibility.
The anterior part of the spinal cord or ventral (anterior) horns transmits:
- Motor impulses to the striated muscles (which are contracted by voluntary command);
- Autonomic impulses to the nonstriated muscles of the internal organs, blood vessels, and glands.
Figure 6: Nerves involved in the sphincter function of internal organs such as rectum and anus
Centre frontal : Frontal area
Centre protubérantiel : Pons
Moelle cervicale : Cervical cord
Moelle dorsale : Dorsal cord
Chaîne sympathique latéro-vertébrale : Paravertebral sympathetic trunk
Moelle lombaire : Lumbar cord
Moelle sacrée : Sacral cord
Plexus : Plexus
Nerf hypogastrique : Hypogastric nerve
Nerf pelvien ou érecteur : Pelvic or erector nerve
Nerf honteux : Pudendal nerve
Trigone col : Fornix
Sphincter strié : Striated sphincter
Périnée : Perineum
Côlon gauche : Left colon
Sigmoïde : Sigmoid
Rectum : Rectum
Sphincter lisse : Non-striated sphincter
- Urinary function
- Bowel function
Urethral and anal sphincter disorders
Impaired motor control, sensibility and reflexes (figure 6) cause urinary bladder disorders. Following an initial period of total retention when treatment is not immediately implemented, there may be urinary and fecal overflow. These are involuntary overflow of small amounts of urine and feces caused by the overfilling of the bladder and rectum, which cannot be fully emptied. For this reason, aids in evacuation of bladder and bowel are always needed. There are usually two types of sphincter dysfunction whether spasticity is involved (presence of reflexes) or flaccidity, respectively the automatic (hypertonic bladder or rectum) or autonomic function (hypotonic bladder or rectum). Management is different in either case.
They occur in cases of high cervical and dorsal injury (level ≥ D6):
Autonomic dysreflexia (AD) or hyperreflexia: intense, sudden increase in blood pressure, associated with pounding headaches, profuse sweating with erythema (redness of skin), shivering and piloerection (‘goose bumps’). AD can be triggered in many ways: the most common triggering stimuli are urinary in nature (distended bladder, catheterization, urinary tract infection), but also related to the skin, rectum (anal fissure, hemorrhoids), and bladder.
Hyper- or hypothermia: variations in the body temperature caused by the impaired regulation of vasomotion and sweating in the area below the level of injury (in the part of the body located below the spinal injury).
There are two main categories of pain:
Pain triggered by hyperstimulation: pain above the level of injury where sensibility is normal, for muscular, articular and bone origin:
- Injury pain (at the injury level), through radicular pain (nerve root injury) depending on the spinal injury, sometimes due to complex regional pain syndrome;
- Pain arising on the visceral, vascular and muscular parts that are below the injury level.
Pain induced by release of inhibition:
- Pain at the level of injury: it is located in a region with hyperesthesia (aggravated by external contact), or anesthesia (most often burning sensations);
- Pain below the level of injury: often polymorphous and associated with posterior cord pain (damage to the posterior cords of the spine causing shooting and grinding pain) and spinothalamic type of pain (damage to the sensory pathways — Cf. Physiology of the spinal cord and figure 4) with severe burning sensations.
Genital and sexual disorders
Men experience deep changes in their genital and sexual function. The reflex erection potential, which is essential to sexual intercourse, is compromised when the injury is complete and located in the sacral segment of the spinal cord (Cf. figure 2); however, psychogenic erection potential is preserved. In other cases, it is possible to achieve erections using appropriate stimulation techniques and physical stimuli. Ejaculation, which is essential to sperm banking for future procreation if desired, is only to be considered when segmental levels D11, D12, and L1 are far from the damaged level. Otherwise, appropriate techniques are implemented, often requiring an appointment with a paraplegia specialist.
In women complete analgesia of the perineum affects sensations during sexual intercourses. Orgasm remains possible as long as lumbosacral reflex pathways are intact. After 1 to 9 months without periods, which is common after sustaining traumatic spinal cord injuries, women become fertile again and can get pregnant and carry their pregnancies to term—rigorous monitoring is necessary, especially in order to treat urinary tract infections, monitor kidney function, and above all in cases of previous history of pyelonephritis (kidney infection). Delivery can be achieved through natural or vaginal birth or under epidural anesthesia, especially if there is a risk of hyperreflexia; forceps are used when the mother’s abdominal muscles are paralyzed. The decision of using contraception is considered after a careful overall physical assessment due to the increased risk of phlebitis and infections.
Couple education is recommended about the genital and sexual potential of the injured partner for, of course, this is a case-by-case matter.
These occur as a result of the impairment of respiratory muscles: abdominal and intercostal muscles are impaired, as well as the diaphragm (see table below) in the highest levels of injury (C4). At first, respiratory disorders force the use of mechanical ventilation (intubation or tracheotomy). Later, the physiotherapist ensures proper postural drainage, focusing on breathing out and forced coughing. This preventive technique is then taught to the individual who will perform it regularly and in cases of bronchopulmonary obstruction. Abdominal muscle deficiency is compensated by wearing an abdominal belt, which is critical, at least during the first months of verticalization, in cases of high cervical and dorsal damage (D6 and above).
|Respiratory damage and spinal level||Level of segmental cord damage||Respiratory muscle group affected|
|Quadriplegia||C3 to C5||Diaphragm|
|Paraplegia||D1 to D10||Intercostal muscles|
|D6 to D12||Abdominal muscles|
Besides difficulties in the initial stage, circulatory disorders are the result of cardiovascular deconditioning during physical effort, which is primarily caused by impaired venous drainage of the blood returning to the heart. Paralysis of muscles in the lower part of the body, especially when it is flaccid paralysis, leads to a venous stasis aggravated by a vasoplegic syndrome. Muscles surrounding small blood vessels are no longer regulating blood flow, which decreases and cannot increase normally under physical effort, causing extreme fatigability, hypotension, discomfort, etc. Peripheral venous stasis causes edemas, which may in return cause skin fragility and thrombophlebitis. Hence, it becomes essential to wear compression stockings on a regular basis.
Forced immobilization leads to bone demineralization, or osteoporosis, and increased risk of urinary calculi. Thus, a significant diuresis must be induced by drinking large amounts of liquid during the first months following the injury.
What are the causes?
Traumatic causes (accidental injuries) are by far the most common: between 70 and 80% of the total number of spinal cord injuries. They lead to traumatic spinal cord injuries with para- and quadriplegia–hence, the term “spinal cord injured” used to refer to individuals who have sustained these injuries. Para or quadriplegias are often treated as the only cases of spinal cord injuries caused by trauma even though 25% of them are caused by medical malpractice.
Causes of paraplegia and quadriplegia
Traumatic causes (spinal cord injured or traumatic spinal cord injuries with para- or quadriplegia)
Car accidents are the most common causes, followed by sports accidents, suicide attempts, gunshot and stabbing injuries.
Work-related injuries may be encountered in all mentioned categories (excluding suicide attempt), but some injuries are most commonly occurring in the workplace. Workplace injuries include falls from high rise, blast injuries, electric shock injuries, diving accidents related to sudden depressurization.
Other causes: toxic causes (spinal injections), arachnoiditis (inflammation of the membrane that surround and protect the nerves of the spinal cord), pathologic fractures due to rheumatic diseases (spinal fractures caused by progressive weakening of the bone rather than by accident such as in ankylosing spondylitis, rheumatoid cyst)
Infectious or parasitic causes: spinal cord abcess, Pott’s disease (tuberculous abcess), tuberculous epiduritis, schistosomiasis or bilharziosis (parasitic disease).
Vascular causes: ischemic softening of the spinal cord (spinal cord infarction or myelomalacia), spontaneous spinal extradural hematomas, spinal arteriovenous malformations (angioma), aortic aneurysms.
Tumor-related causes: neurilemmomas, metastases to the spine from various forms of cancers, neurofibromatoses, Hodgkin’s disease and myeloma.
The occasional “surgical accidents” responsible for spinal cord injuries can either be traumatic (injuries) or medical in nature (lesions resulting from the lack of oxygen supply to the spinal cord – anoxia – during anesthesia).
How are they progressing?
Prognosis: Acute and subacute lesions of traumatic or medical nature
It is known that, in terms of prognosis, it all starts at the moment of trauma, or in the hours following the onset of paraplegia caused by a medical accident (‘acute’ means ‘sudden’). Mechanisms of injury are better understood. At the clinical level, there are more chances that individuals who have sustained an incomplete injury recover immediately compared to those with a complete injury. Incidentally, the speed of recovery is an important feature. The prognosis generally emerges in the first weeks following the injury. After two months and no sign of recovery, the recovery potential decreases very quickly over time. However, no definite conclusions can be drawn formally until after a post-traumatic follow-up period of 8 months in the case of spinal cord injuries per se and 18 months for associated root and peripheral nerve injuries.
Injuries due to slow compression of the spinal cord (neurilemmomas, meningiomas, etc.)
After compression was diagnosed and treatment has been implemented, the prognosis will depend upon the severity of the injury and the speed of intervention. In cases of complete injury prior to treatment, the prognosis is usually severe, for the more incomplete an injury is, the greater are the chances of recovery. Symptoms that usually take longer to fade away or wear off are deep sensibility disorders and spasticity.
The mechanism of injury to the spinal cord: preventive considerations (in traumatic injuries, or else acute and subacute medical injuries)
Mechanisms of injury
Three mechanisms of injury can be described:
Circulatory and hemodynamic disorders (blood pressure). Spinal cord blood flow has decreased significantly in the 15 minutes following the spinal cord trauma and will keep decreasing in the first following days. Injuries can be aggravated by blood pressure disorders;
Inflammatory reaction: white cells gather at the level of injury in 8 to 24 hours. These inflammatory phenomena are causing oedema that aggravates injuries. They also occur during the healing process;
Biochemical phenomena: there are various interactions between complex biochemical phenomena that can be described. They end up causing the progressive destruction of the nerve tissue.
Research and perspectives
Neurophysiologists continue to work on the spinal cord regeneration issue. Recent studies have shown that, on the one hand, peripheral nerve grafting might lead to the axonal regeneration of central neurons of the spinal nerve and that, on the other hand, the implantation of brain tissue or embryonic cells through an experimental cavity in the spinal cord are followed by peripheral nerve regeneration through a nerve graft. Current experimental studies on spinal cord lesions show some promising treatments:
Preventing complications of second traumatic spinal cord injuries through early use of medication. It is not impossible that a product may be discovered in the upcoming years that would stop or at least limit the progression of paraplegia;
Stimulating the neural regeneration by reducing the wound-barrier layer, through adding growth factors and controlling of synaptogenesis (formation of new synapses). The latter is to take long years before showing any hard results.
At first, the risk of death is present in traumatic spinal cord injuries with para- and quadriplegia in the very first hours and during the resuscitation phase, especially in cases of multiple traumas. It is critical to avoid any complications of the spinal cord injuries (during casualty collection and transportation, as well as in positioning of the patient for complementary examinations). Immobilizing patients in positioning devices such as eggshell mattresses is the standard for any transportation until fractures are reduced and fixed (with lateral restraint devices or through osteosynthesis). Prevention of pressure sores should start at the same time in the desensitized areas (special mattresses, frequent position changes every 2 or 3 hours), particularly as blood pressure and thermal disorders may be present. In quadriplegia, protecting patients against bronchial obstruction is often a priority due to paralyzed abdominal muscles and inability to cough). Subsequent onset of pulmonary atelectases (area of the lung that is no longer ventilated) causing infection is very common. They can be prevented once again by frequent position changes and by sessions of guided breathing exercises and chest percussion therapy.
Afterwards, the complications that may become frequent are urinary tract (pyelonephritis, cystitis) and genito-urinary infections (prostatitis, urethritis), kidney and bladder calculi, as well as thrombophlebitis. Other rare complications include: osteomas (abnormal bony outgrowths) or paraosteoarthropathies (POA) in large joints (risk of ankylosis), pathologic fractures occurring at the level of injury and causing minor trauma due to bone demineralization and the postponed diagnosis due to analgesia, as well as bowel obstruction caused by a lack of proper fecal discharge.
What are the suggested treatments and management strategies?
There is still no specific treatment for spinal cord injuries per se.
This is the treatment of the causes of the injury. It encompasses the reduction and fixation of fractures, as well as the assessment of spinal and nerve injuries in cases of trauma and treatment of compression in some medical injuries, which are surgery techniques.
The physiatrist and all the rehabilitation unit team carry on with treatment by implementing specialized rehabilitation care. The goal of the treatment is to enable the injured individual to regain the fullest level of independence possible, using all the residual force potential of the muscles located above the level of injury, and learning to control residual functions located at the level of injury and below.
Kinesitherapy addresses the range of motion of joints located in affected areas, prevent muscle shortening caused by contractures, and reinforces non-paralyzed muscles. Treatment is carried out progressively with a set of customized routine exercises based on the individual’s capacity: how to get out of bed the first few times, proper positioning in the wheelchair, work on balance in seating position, independent seat and wheelchair skills. Whenever possible, exercises of rehabilitation in the standing position (most often combined with bracing) and gait training are used.
Occupational therapy is especially useful to the tetraplegic patient: learning and advanced training in personal hygiene care, dressing and eating), review of the technical aids, as well as home and transportation adaptations required (powered wheelchair, adapted car).
Sports play an important role in the rehabilitation process. Swimming, basketball, competitive sports, ping-pong, but also tennis, archery, canoe and kayak, as well as skiing are practicable and recommended, both during the active phase of the rehabilitation process and in further training.
Bladder and urethral sphincter retraining exercises are used to restore a normal continence/micturition cycle that is compatible with social life and achieve complete bladder emptying with each act of urination. In cases of an automatic or reflex bladder function, techniques are used to trigger urination reflex through suprapubic tapping. When no reflex is achieved, urine flow may be provoked by applying suprapubic pressure. During the rehabilitation phase, bladder emptying is achieved through catheterization by a nurse, or whenever required and possible, by patients themselves. Intermittent self-catheterization is commonly used and safe when properly performed. When there is urine leakage, urinal bags are fixed to the penis of men with pressure sensitive adhesives, and women have to wear diapers. In some cases, indwelling catheters are necessary (attached around the thigh in women and to the penis in men, maintaining it into vertical position).
Bowel retraining works on restoring the normal defecation reflex through appropriate stimulation techniques. When reflex is impaired, manual bowel evacuation techniques are used. Balanced diet rich in fibers and large amounts of liquids usually help the intestinal transit, as well as regular abdominal massages 15 minutes prior to having a bowel movement.
Prevention of pressure sores involves that patients themselves learn prevention and monitoring techniques. Patients must take meticulous care of their skin, change clothes and garnitures in cases of unexpected leaks. When redness of the skin occurs, the golden rule is to eliminate all pressure on this area until redness disappears or fades significantly. It is essential in any case to look for the underlying cause in order to apply the appropriate prevention strategy. Insensible body parts should be kept far from heat sources such as radiators, hot water pipes or central heating plinth heaters, particularly to protect legs and feet from burns. Special attention should be taken to cigarette ashes, and to the hot steaming cup of tea placed in the lap, even when using a tray!
Preparation for returning home is settled immediately after the prognosis is known and was announced to both patients and his/her family.
The first step to preventing pressure sores is to achieve the proper positioning of the patient in the wheelchair.
- Improper positioning in wheelchair; the patient’s knees are too high, risk of ischiatic pressure sores.
- Improper pressure distribution on a single ischiatic bone due to pelvic obliquity.
- Proper pressure distribution.
Basic rules to prevent intestinal stasis (by preventing stasis, you also prevent incontinence)
Adjusted diet and large amounts of liquids.
Stimulation and facilitation of bowel movement (position changes; activities: wheelchair skills, wheelchair sports, verticalization techniques; massage and tapping of the large intestine).
Regular attempts to bowel movements.
Non-aggressive provocation maneuvers to trigger bowel movement.
Prevention of pressure sores in the para- and tetraplegic patients
Relief and pressure changes:
- seating position: lift buttocks regularly;
- lying position: change positions regularly (if unable, try using water or inflatable mattresses).
- Avoid sitting on hard surfaces, always use a cushion (foam, gel, inflatable cushions).
- Skin check: routine inspection of the skin with a mirror or by palpating gently the areas at risk.
- Personal hygiene: always keep the skin dry and clean, especially in the perineal area.
Living with paraplegia or tetraplegia
Organization of daily life starts with home accommodation (or else by looking up for accessible housing or considering the building of one): entrance, kitchen, bathrooms, restrooms, bedrooms and living rooms must be accessible. Individuals who cannot achieve full independence will require assistance for personal care and for daily living tasks.
Prevention of complications and medical follow-up. Circulatory disorders edemas, phlebitis, embolisms) are generally avoided by wearing compression stockings, placing the person in a slight sloping position during the night (elevated feet), as well as avoiding clothes that are very tight around the knees and hips. Monitoring by a specialized physician should be made once every year or two, or more if required. As for general follow-up, an attending physician who is aware of the clinical history should be helpful for every intervention at home and in treating intercurrent conditions.
Wheelchairs are prescribed by the rehabilitation team and adjusted so that pressure be distributed to the fullest extent possible (figure 7)—by adjusting the height of foot plates for instance—and driving be easy and safe for the user (risk of rear tipping).
Transportation. The most common mode of transportation is the car, which can be use either by adapting the driving space for paraplegic patients (hand controls), or adapting the car to allow wheelchair access.
Leisure, vacations, sports.