Quadriplegia and Quadriplegic

Paralysis can be either partial or complete. Paralysis of both the arms and legs has been traditionally been called quadriplegia. Quad comes from the Latin for four and plegia comes from the Greek for inability to move. Currently the term tetraplegia is becoming more popular, but it means the same thing. Tetra is from the Greek for inability to moveCauses of Quadriplegia

Quadriplegiais caused by damage to the cervical spinal cord segments at levels C1-C8. Damage to the spinal cord is usually secondary to an injury to the spinal vertebrae in the cervical section of the spinal column. The injury to the structure of the spinal cord is known as a lesion and may result in the loss of partial or total function in all four limbs, meaning the arms and the legs.Typical causes of quadriplegia from damage to the spinal cord are trauma (such as car crash, fall or sports injury), disease (such as transverse myelitis or polio) or congenital disorders, such as muscular dystrophy. It is possible to injure the spinal cord without fracturing the spine, such as when a ruptured disc or bony spur on the vertebra protrudes into the spinal column.

The condition quadriplegia is also termed tetraplegia. Both terms mean "paralysis of four limbs"; tetraplegia is more commonly used in Europe than in the United States. In 1991, when the American Spinal Cord Injury Classification system was revised, it was recommended that the term tetraplegia be used to improve consistency ("tetra", like "plegia", has a Greek root, whereas "quadra" has a Latin root).

Symptoms of Quadriplegia

Upon visual inspection of a quadriplegic patient, the first symptom of quadriplegia is impairment to the arms and legs. Function is also impaired in the torso. The loss of function in the torso usually results in a loss or impairment in controlling the bowel and bladder, sexual function, digestion, breathing and other autonomic functions.

Furthermore, sensation is usually impaired in affected areas. This can manifest as numbness, reduced sensation or sore burning neuropathic pain.

Quadriplegia is defined in different ways depending on the level of injury to the spinal cord. C1C4 usually affects arm sensation and movement more so than a C5C7 injury; however, all quadriplegics have or have had some kind of finger dysfunction.

A person with damage to the spinal cord at the cervical spinal cord segment C1 (the highest cervical vertebra, at the base of the skull) will probably lose function from the neck down and require permanent assistance with breathing in the form of a machine called a ventilator. A person with a C8 spinal cord injury may lose function from the chest down, but still retain use of the arms and much of the hands.

The degree of the injury to the cellular structures of the spinal cord is very important. A complete severing of the spinal cord will result in complete loss of function from that spinal segment down. A partial severing or even bruising or swelling of the spinal cord results in varying degrees of mixed function and paralysis. A common misconception with quadriplegia is that the victim cannot move legs, arms or control any of the major bodily functions; this is often not the case. Some quadriplegic individuals can walk and use their hands as though they did not have a spinal cord injury, while others may use wheelchairs although they may still have function in their arms and mild finger movement, this is dependent on the degree of damage done to the spinal cord.

Spinal Nerves and Levels

The body is supplied by a particular level or segment of the spinal cord and its corresponding spinal nerve. Function below the level of spinal cord injury will be either lost or impaired

This is approximately the same for every person:

Quadriplegia will result in complete loss or impaired function below the following cervical levels of injury.

C3,4 and 5 Supply the diaphragm (mostly C4) (the large muscle between the chest and the belly that we use to breath).

C5 also supplies the shoulder muscles (deltoid) and the muscle that we use to bend our elbow (bicep).

C6 Bends the wrist back (extension), and externally rotates the arm (supinates).

C7 Straightens the elbow and wrist (triceps and wrist flexors) straightens fingers, pronates wrist.

C8 Bends the fingers (flexion).

Injury below the spinal segments supplying the following spinal nerves will result in paraplegia. All the functions below will be lost or impaired in a quadriplegic injury.T1 Spreads the fingers and supplies small muscles of the hand.

T1 T12 supplies the chest wall (inter costal muscles) and abdominal muscles.

T10 - L2 Psychogenic erections (thought controlled).

L2 Bends the hip.

L1, L2, L3, L4 Thigh flexion.

L2, L3, L4 Extension of leg at the knee (quadriceps femoris)

L2, L3, L4 Thigh adduction.

L4, L5, S1 Thigh abduction.

L4, L5, S1 Dorsiflexion of foot (tibialis anterior).

L4, L5, S1 Extension of toes.

L4, L5, S1, S2 Flexion of leg at the knee (hamstrings).

L5, S1, S2 Extension of leg at the hip (gluteus maximus).

L5, S1, S2 Plantar flexion of foot.

L5, S1, S2 Flexion of toes.

S2, S3, S4 Control a man's ability to have a reflex erection.

S2, S3, S4 Ejaculation is generated by the bulbospongiosus muscle under the control of a spinal reflex via the pudendal nerve.

S3,4 and 5 supply the bladder, bowel and sex organs and the anal and other pelvic muscles.

Secondary Complications of Quadriplegia

Loss of bladder and bowel control. Because the spinal cord nerves control the function of the bladder and bowels, people with quadriplegia have various degrees of loss of control in this area. Without proper management these problems can lead to urinary tract infections and to constipation. Urinary tract infections can be fatal if not treated in time, particularly if the patient is in a weakened condition. Your health care team will help you deal with bladder and bowel control so that you will not develop an infection.

Pressure sores. When you are immobile for long periods of time, pressure from the weight of the body can cause your skin to develop sores. If you have quadriplegia you are at great risk of developing pressure sores, because you cannot shift your body weight on your own. Pressure sores can become infected and lead to serious complications, even death. For this reason, once your injuries are stable, nurses and nurses aides will turn you at regular intervals in the hospital and your caregivers at home will need to do the same thing. Special mattresses and cushions also help to prevent pressure sores. Blood clots. When you have quadriplegia, your blood circulation slows down since you are immobile. This can cause clots to develop. Clots are not always obvious; deep within the muscles are veins which can develop clots (a condition called deep vein thrombosis). An artery in the lungs can also be blocked by a clot (pulmonary embolism). Deep vein thrombosis and pulmonary embolism can be fatal. Your medical team will work to prevent clots. You may be given blood thinners to improve your circulation. Support hose and special inflatable pumps placed on the legs may also be used to increase circulation.

Respiratory problems. The nerve signals to you chest and diaphragm may be weakened or distorted by a spinal cord injury, making breathing on your own difficult or impossible. If your diaphragm is wholly paralyzed, you will be intubated and placed on a ventilator. A special pacemaker is sometimes used to simulate the diaphragms nerves and allow the patient to breath without a ventilator. Some people are able to wean away from the ventilator by learning how to consciously control their breathing. People with quadriplegia are at increased risk for pneumonia and other respiratory infections even if they have not trouble breathing on their own. Medications and respiratory exercises are used to help prevent respiratory problems when mobility is a problem.

Autonomic dysreflexia. A dangerous, occasionally fatal problem called autonomic dysreflexia can afflict people with spinal cord injuries located above the middle of the chest. This means that an irritation or pain below the site of your injury may send a signal which will not reach the brain, but will cause a nerve signal that disrupts your bodys functions. As your heart rate drops, your blood pressure may rise, putting you at risk for a stroke. Ironically, simple problems such as irritating clothes or a full bladder may trigger this reflex; fortunately, removing the cause of the irritation or changing position may relieve the negative effects.

Spastic muscles. Some people with quadriplegia experience muscle spasms which cause the legs and arms to jerk. Although you may be tempted to think that this is a sign of regaining movement or sensation, it is simply a symptom of the damaged spinal cords inability to properly relay remaining nerve signals to the brain. Most people with quadriplegia will not develop spastic muscles.

Related injuries. People with quadriplegia may experience an injury, such as a burn, without realizing it, since they have no sensation in their limbs. For this reason it is important that your caregivers do not place a heating pad or electric blanket on you.

Pain. Although people with quadriplegia may not feel external sensations, it is possible to feel pain within your arms, legs, back, and other areas which do not respond to external stimuli. Pain medications prescribed by your doctor can relieve the pain.

spasticity, osteoporosis and fractures, frozen joints,pneumonia, respiratoryomplications and infections, kidney stones and cardiovascular diseaseDiagnosisHistory:Individuals who have experienced spinal cord injury may present with various levels of impairment and may describe reduced or completely absent sensory or motor function in the extremities and torso. In cases of paralysis, individuals may report a history of traumatic injury,brain tumororabscess, orinfection. The individual may report weakness of muscles in the limbs, loss of sensation, increased muscle tone (spasticity), or loss of muscle tone (flaccidity).

Individuals with paraplegia may report a history of a traumatic injury; brain tumor; or diseases of the spinal cord, nerve roots, or peripheral nerves. The individual may report weakness of the muscles of both lower extremities, loss of pain and temperature sensation below a particular level, and loss of position and vibratory sense.

Quadriplegic individuals may report weakness of the muscles of all four extremities. Flaccidity of the arms and spasticity of the legs are typical patterns of paralysis. The individual may also experiencepain in the neckand shoulders, numbness of the hands, and, if mobile, may report or exhibit staggering gait and postural imbalance (ataxia).

A complete health history is obtained, including current and prior disease conditions or injuries.

Physical exam:A complete physical examination may reveal the presence of recent multiple injuries sustained in trauma. Paralysis and / or restricted movement of extremities may be seen. Motor strength and sensory testing is usually done using an impairment scale (ASIA or Frankel scales). The neurological exam may reveal spinal cord damage and localize the level of injury in individuals with paralysis. Spastic movement and increased tendon reflexes may be evident. Peripheral nerve damage is indicated by muscle wasting (atrophy) and weakness with reduced tendon reflexes. Affected muscles may reveal involuntary contraction or twitching of groups of muscle fibers (fasciculation).

In individuals who are paraplegic, the neurological exam may reveal spinal cord damage and localize the level of injury. A rectal examination may be done to check motor function or sensation of the anal musculature; if function is fully present and the sacral function is intact, as in a sacral-sparing spinal injury, normal or near normal bladder and rectal function may be present. In other individuals, the bladder and sphincter muscles may be affected and result in loss of bladder and rectal function.

Sensory loss is more prominent in the distal segments of the limbs. In hereditary spastic paraplegia, the individual may have normal upper extremity muscle tone with weakness in the legs; muscle wasting may be seen as well as signs of diminished sensation in the lower extremities, gait disturbances, high arched feet, and pathologic increases in lower extremity reflexes.

In quadriplegia, the neurological exam may revealbrain damageor lesions of the cervical spinal cord. In diplegia, the legs are more affected than the arms. There may be dislocation of spinal cord segments, especially in the presence of rheumatoid arthritis. In individuals with triplegia, the exam may reveal spastic weakness of one limb followed by involvement of the other limbs in a "round the clock" pattern. Loss of pain and temperature sensation may be observed.

Tests:For paralysis, paraplegia, and quadriplegia, diagnostic tests includex-rays,CT scan, orMRI. The diagnostic tests may reveal a spinal cord injury or tumor in individuals with paralysis, lesions of the spinal cord or an extrinsic mass that narrows the spinal canal in individuals with paraplegia, atrophy of the spinal cord and cerebral cortex in hereditary spastic paraplegia, and lesions of the cervical spinal cord in individuals with quadriplegia.Electromyographytests the electrical activity of the muscles. Alumbar puncture(spinal tap) may be performed to rule out infection, and it often demonstrates a dynamic block and increase in cerebrospinal fluid protein. Complete blood count, serum chemistry panel, and urinalysis can be helpful in determining health status and possible underlying disease processes. Rheumatoid factor may be assayed to confirm rheumatoid arthritis. Genetic testing may be needed to help diagnose hereditary spastic paraplegia

ASIA impairment scale

Spinal cord injuries are classified 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

ACompleteno motor or sensory function is preserved in the sacral segments S4S5.

BIncompletesensory but not motor function is preserved below the neurological level and includes the sacral segments S4S5.

CIncompleteIncomplete: motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade less than 3.

DIncompleteIncomplete: motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of 3 or more.

ENormal

Complete spinal-cord lesionsPathophysiologically, 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 theBritish 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.

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.

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.

Incomplete spinal-cord lesionsIncomplete 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. Thecentral cord syndrome: most of the cord lesion is in the gray matter of the spinal cord, sometimes the lesion continues in the white matter.

2. TheBrownSquard syndrome: hemi section of the spinal cord.

3. Theanterior cord syndrome: a lesion of the anterior horns and the anterolateral tracts, with a possible division of the anterior spinal artery.

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). 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.

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. 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. 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 ofBotulinum toxin(Botox) into spastic muscles is a treatment to reduce spasticity. This can be used to prevent muscle shorting and early contractures.

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

Trauma Care

Immediate treatment of quadriplegia consists of treating the spinal cord injury or other condition causing the problem. In the case of a spinal cord injury, you will immobilized with special equipment to prevent further injury, while medical personnel work to stabilize your heart rate, blood pressure, and over all condition. You may be intubated to assist your breathing. This means that flexible tube carrying oxygen will be inserted down your throat. Imaging tests will be used to determine the extent of your injury.

Surgery may be needed to relieve pressure on the spine from bone fragments or foreign objects. Surgery may also be used to stabilize the spine, but no form of surgery can repair the damaged nerves of the spinal cord. Unfortunately, the nerve damage caused by the initial spinal cord injury has a tendency to spread. The reasons for this tendency are not completely understood by researchers, but it is related to spreading inflammation as blood circulation decreases and blood pressure drops.

The inflammation causes nerve cells not directly in the injured area to die. A powerful corticosteroid, methylprednisolone (Medrol) can sometimes help prevent the spread of this damage if it is given within eight hours of the original injury; however, methylprednisolone can cause serious side effects and not all doctors are convinced that it is beneficial.

Rehabilitation

Rehabilitation for quadriplegia once consisted primarily of training to learn how to deal with your new limitations. Passive physical therapy was given to help prevent the muscles from atrophying. Today, many new options are offering quadriplegia patients new hope. These new options combine older methods with new technology with encouraging results.

While passive physical therapy once consisted solely of the therapists manipulating the patients arms and legs in an effort to increase circulation and retain muscle tone, today therapists can use electrodes to stimulate the patients muscles and give them an optimal workout. This technology is called functional neuromuscular stimulation (FNS). FNS stimulates the intact peripheral nerves so that the paralyzed muscles will contract.

The contractions are stimulated using either electrodes that have been placed on the skin or that have been implanted. With FNS, the patient may ride a stationary bicycle to improve muscle and cardiac function and prevent the muscles from atrophying. An implantable FNS system has been used to help people with some types of spinal injury regain use of their hands.

This is an option for people with quadriplegia, who have some voluntary use of their arms. The shoulders position controls the stimulation to the hands nerves, allowing the individual to pick up objects at will. Tendon transfer is another option which allows some people with quadriplegia more use of the arms and hands. This complicated surgery transfers a nonessential muscle with nerve function to the shoulder or arm to help restore function. FNS may be used in conjunction with tendon transfer.

Other forms of treatments for quadriplegia are still in the experimental stage. Many clinical trials of new treatment options are run every year. If you or a loved one suffers from quadriplegia, you may want to consider one of these trials. Ask your doctor to help you find a suitable trial.

PrognosisDelayed 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. 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 inADL, 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,

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

9