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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 move
Causes of Quadriplegia
Quadriplegia is 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. C1
C4 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
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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.
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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
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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 disease
Diagnosis
History: 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 tumor orabscess, or infection. 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.
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 reveal brain damage or 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.
B Incomplete
sensory but not motor function is preserved below the neurological level and
includes the sacral segments S4S5.
Incomplete: motor function is preserved below the neurological level, and more
C Incomplete than half of key muscles below the neurological level have a muscle grade less
than 3.
Incomplete: motor function is preserved below the neurological level, and at least
D Incomplete half of key muscles below the neurological level have a muscle grade of 3 or
more.
E Normal
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
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Prognosis
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. 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 ADL, 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 of cerebral 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.
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