Quadriplegia

Quadriplegia

Overview
Tetraplegia, also known as quadriplegia, is paralysis
Paralysis
Paralysis is loss of muscle function for one or more muscles. Paralysis can be accompanied by a loss of feeling in the affected area if there is sensory damage as well as motor. A study conducted by the Christopher & Dana Reeve Foundation, suggests that about 1 in 50 people have been diagnosed...

 caused by illness or injury to a human that results in the partial or total loss of use of all their limbs and torso; paraplegia
Paraplegia
Paraplegia is an impairment in motor or sensory function of the lower extremities. The word comes from Ionic Greek: παραπληγίη "half-striking". It is usually the result of spinal cord injury or a congenital condition such as spina bifida that affects the neural elements of the spinal canal...

 is similar but does not affect the arms. The loss is usually sensory and motor, which means that both sensation and control are lost.

It is caused by damage to the brain
Brain
The brain is the center of the nervous system in all vertebrate and most invertebrate animals—only a few primitive invertebrates such as sponges, jellyfish, sea squirts and starfishes do not have one. It is located in the head, usually close to primary sensory apparatus such as vision, hearing,...

 or the spinal cord
Spinal cord
The spinal cord is a long, thin, tubular bundle of nervous tissue and support cells that extends from the brain . The brain and spinal cord together make up the central nervous system...

 at a high level C1–C7—in particular, spinal cord injuries secondary to an injury to the cervical spine.
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Encyclopedia
Tetraplegia, also known as quadriplegia, is paralysis
Paralysis
Paralysis is loss of muscle function for one or more muscles. Paralysis can be accompanied by a loss of feeling in the affected area if there is sensory damage as well as motor. A study conducted by the Christopher & Dana Reeve Foundation, suggests that about 1 in 50 people have been diagnosed...

 caused by illness or injury to a human that results in the partial or total loss of use of all their limbs and torso; paraplegia
Paraplegia
Paraplegia is an impairment in motor or sensory function of the lower extremities. The word comes from Ionic Greek: παραπληγίη "half-striking". It is usually the result of spinal cord injury or a congenital condition such as spina bifida that affects the neural elements of the spinal canal...

 is similar but does not affect the arms. The loss is usually sensory and motor, which means that both sensation and control are lost.

Causes


It is caused by damage to the brain
Brain
The brain is the center of the nervous system in all vertebrate and most invertebrate animals—only a few primitive invertebrates such as sponges, jellyfish, sea squirts and starfishes do not have one. It is located in the head, usually close to primary sensory apparatus such as vision, hearing,...

 or the spinal cord
Spinal cord
The spinal cord is a long, thin, tubular bundle of nervous tissue and support cells that extends from the brain . The brain and spinal cord together make up the central nervous system...

 at a high level C1–C7—in particular, spinal cord injuries secondary to an injury to the cervical spine. The injury, which is known as a lesion
Lesion
A lesion is any abnormality in the tissue of an organism , usually caused by disease or trauma. Lesion is derived from the Latin word laesio which means injury.- Types :...

, causes victims to lose partial or total function of all four limbs, meaning the arms and the legs. Tetraplegia is defined in many ways; C1–C4 usually affects arm movement more so than a C5–C7 injury; however, all quadriplegics have or have had some kind of finger dysfunction. So, it is not uncommon to have a quadriplegic with fully functional arms and only have their fingers that don't work.

Typical causes of this damage are trauma (such as car crash, fall or sports injury), disease (such as transverse myelitis
Transverse myelitis
Transverse myelitis is a neurological disorder caused by an inflammatory process of the spinal cord, and can cause axonal demyelination. The name is derived from Greek referring to the "spinal cord", and the suffix -itis, which denotes inflammation...

 or polio
Poliomyelitis
Poliomyelitis, often called polio or infantile paralysis, is an acute viral infectious disease spread from person to person, primarily via the fecal-oral route...

) or congenital disorder
Congenital disorder
A congenital disorder, or congenital disease, is a condition existing at birth and often before birth, or that develops during the first month of life , regardless of causation...

s, such as muscular dystrophy
Muscular dystrophy
Muscular dystrophy is a group of muscle diseases that weaken the musculoskeletal system and hamper locomotion. Muscular dystrophies are characterized by progressive skeletal muscle weakness, defects in muscle proteins, and the death of muscle cells and tissue.In the 1860s, descriptions of boys who...

 or multiple sclerosis
Multiple sclerosis
Multiple sclerosis is an inflammatory disease in which the fatty myelin sheaths around the axons of the brain and spinal cord are damaged, leading to demyelination and scarring as well as a broad spectrum of signs and symptoms...

.

It is possible to suffer a broken neck without becoming quadriplegic, such as when the vertebrae are fractured or dislocated but the spinal cord is not damaged. Conversely, it is possible to injure the spinal cord without breaking the spine, such as when a ruptured disc
Intervertebral disc
Intervertebral discs lie between adjacent vertebrae in the spine. Each disc forms a cartilaginous joint to allow slight movement of the vertebrae, and acts as a ligament to hold the vertebrae together.-Structure:...

 or bony spur on the vertebra protrudes into the spinal column.

Terminology


The condition is termed tetraplegia. Both terms mean "paralysis of four limbs"; tetraplegia is more commonly used in Europe than in the US. 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).

Classification


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.

Table 1: ASIA impairment scale
A Complete no motor or sensory function is preserved in the sacral segments S4-S5.
B Incomplete sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5.
C Incomplete Incomplete: 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.
D Incomplete Incomplete: 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.
E Normal motor and sensory function are normal.

Complete spinal-cord lesions


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
Hand strength
Hand strength measurements are of interest to study pathology of the hand that involves loss of muscle strength. Examples of these pathologies are carpal tunnel syndrome, nerve injury, tendon injuries of the hand, and neuromuscular disorders....

 (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).

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 lesions


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.

The central cord syndrome
Central cord syndrome
Central cord syndrome is an acute cervical spinal cord injury that can affect a large and diverse group of patients. It was first described by Schneider in 1954....

: most of the cord lesion is in the gray matter of the spinal cord, sometimes the lesion continues in the white matter.

The Brown-Sequard syndrome
Brown-Séquard syndrome
Brown-Séquard syndrome, also known as Brown-Séquard's hemiplegia and Brown-Séquard's paralysis, is a loss of sensation and motor function that is caused by the lateral hemisection of the spinal cord...

: hemi section of the spinal cord.

The anterior cord syndrome
Anterior cord syndrome
Anterior cord syndrome is a medical condition where the blood supply to the anterior portion of the spinal cord is interrupted. It is characterized by loss of motor function below the level of injury, loss of sensations carried by the anterior columns of the spinal cord , and preservation of...

: 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 of Botulinum toxin
Botulinum toxin
Botulinum toxin is a protein produced by the bacterium Clostridium botulinum, and is considered the most powerful neurotoxin ever discovered. Botulinum toxin causes Botulism poisoning, a serious and life-threatening illness in humans and animals...

 (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.

Symptoms, signs and complications


Although the most obvious symptom is impairment to the limbs, functioning is also impaired in the torso
Torso
Trunk or torso is an anatomical term for the central part of the many animal bodies from which extend the neck and limbs. The trunk includes the thorax and abdomen.-Major organs:...

. This can mean a loss or impairment in controlling bowel
Fecal incontinence
Fecal incontinence is the loss of regular control of the bowels. Involuntary excretion and leaking are common occurrences for those affected. Subjects relating to defecation are often socially unacceptable, thus those affected may be beset by feelings of shame and humiliation...

 and bladder
Urinary incontinence
Urinary incontinence is any involuntary leakage of urine. It is a common and distressing problem, which may have a profound impact on quality of life. Urinary incontinence almost always results from an underlying treatable medical condition but is under-reported to medical practitioners...

, sexual function, digestion, breathing and other autonomic
Autonomic nervous system
The autonomic nervous system is the part of the peripheral nervous system that acts as a control system functioning largely below the level of consciousness, and controls visceral functions. The ANS affects heart rate, digestion, respiration rate, salivation, perspiration, diameter of the pupils,...

 functions. Furthermore, sensation is usually impaired in affected areas. This can manifest as numbness, reduced sensation or burning neuropathic pain
Neuralgia
Neuralgia is pain in one or more nerves that occurs without stimulation of pain receptor cells. Neuralgia pain is produced by a change in neurological structure or function rather than by the excitation of pain receptors that causes nociceptive pain. Neuralgia falls into two categories: central...

.

Secondarily, because of their depressed functioning and immobility, quadriplegics are often more vulnerable to pressure sores
Bedsore
Bedsores, more properly known as pressure ulcers or decubitus ulcers, are lesions caused by many factors—such as unrelieved pressure, friction, humidity, shearing forces, temperature, age, continence, and medication—to any part of the body, especially portions over bony or cartilaginous areas such...

, osteoporosis
Osteoporosis
Osteoporosis is a disease of bones that leads to an increased risk of fracture. In osteoporosis the bone mineral density is reduced, bone microarchitecture is deteriorating, and the amount and variety of proteins in bone is altered...

 and fractures, frozen joints, spasticity
Spasticity
Spasticity is a feature of altered skeletal muscle performance in muscle tone involving hypertonia, which is also referred to as an unusual "tightness" of muscles...

, respiratory complications and infections, autonomic dysreflexia
Autonomic dysreflexia
Autonomic dysreflexia, "AD" also known as "autonomic hyperreflexia or Hyperreflexia, is a potentially life threatening condition which can be considered a medical emergency requiring immediate attention. AD occurs most often in spinal cord-injured individuals with spinal lesions above the T6 spinal...

, deep vein thrombosis
Deep vein thrombosis
Deep vein thrombosis is the formation of a blood clot in a deep vein. Deep vein thrombosis commonly affects the leg veins or the deep veins of the pelvis. Occasionally the veins of the arm are affected...

, and cardiovascular disease.

Severity depends on both the level at which the spinal cord is injured and the extent of the injury.

An individual with an injury at C1 (the highest cervical vertebra, at the base of the skull), will probably lose function from the neck down and be ventilator-dependent. An individual with a C7 injury may lose function from the chest down but still retain use of the arms and much of the hands.

The extent of the injury is also important. A complete severing of the spinal cord will result in complete loss of function from that vertebra down. A partial severing or even bruising of the spinal cord results in varying degrees of mixed function and paralysis. A common misconception with Tetraplegia is that the victim cannot move legs, arms or any of the major function; 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 and they can still have function of their arms and mild finger movement, again, that varies on the spinal cord damage.

It is common to have movement in limbs, such as the ability to move the arms but not the hands or to be able to use the fingers but not to the same extent, as before the injury. Furthermore, the deficit in the limbs may not be the same on both sides of the body; either left or right side may be more affected, depending on the location of the lesion on the spinal cord.

Frequency


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 quadriplegic.

Upper limb paralysis


Upperlimb paralysis refers to the loss of function of the elbow and hand. When upper limb function is absent as a result of a spinal cord injury it is a major barrier to regain autonomy. There are possibilities for tetraplegic hand and elbow surgery which allow restoration of upper limb function. At the 2007 world congress in reconstructive hand surgery and rehabilitation in tetraplegia a resolution was presented and accepted that indicates that every person with tetraplegia should be examined and informed concerning the options for reconstructive surgery of the tetraplegic arms and hands. With this resolution it becomes clear that it is necessary to increase the awareness on this subject. These surgical procedures are further discussed in Tetraplegic Upper Limb Surgery.

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 quadriplegics (C4 and higher) will likely need constant care and assistance in activities of daily living
Activities of daily living
Activities of Daily Living is a term used in healthcare to refer to daily self-care activities within an individual's place of residence, in outdoor environments, or both...

, such as getting dressed, eating and bowel and bladder care. Low-level quadriplegics (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
Synaptic plasticity
In neuroscience, synaptic plasticity is the ability of the connection, or synapse, between two neurons to change in strength in response to either use or disuse of transmission over synaptic pathways. Plastic change also results from the alteration of the number of receptors located on a synapse...

, as in the case of the late actor Christopher Reeve
Christopher Reeve
Christopher D'Olier Reeve was an American actor, film director, producer, screenwriter, author and activist...

.

In the case of cerebral palsy
Cerebral palsy
Cerebral palsy is an umbrella term encompassing a group of non-progressive, non-contagious motor conditions that cause physical disability in human development, chiefly in the various areas of body movement....

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

Related conditions

  • Brown-Sequard Syndrome
    Brown-Séquard syndrome
    Brown-Séquard syndrome, also known as Brown-Séquard's hemiplegia and Brown-Séquard's paralysis, is a loss of sensation and motor function that is caused by the lateral hemisection of the spinal cord...

  • Hemiplegia
    Hemiplegia
    Hemiplegia /he.mə.pliː.dʒiə/ is total paralysis of the arm, leg, and trunk on the same side of the body. Hemiplegia is more severe than hemiparesis, wherein one half of the body has less marked weakness....

  • Locked-in syndrome
    Locked-In syndrome
    Locked-in syndrome is a condition in which a patient is aware and awake but cannot move or communicate verbally due to complete paralysis of nearly all voluntary muscles in the body except for the eyes. Total locked-in syndrome is a version of locked-in syndrome where the eyes are paralyzed as...

  • Paraplegia
    Paraplegia
    Paraplegia is an impairment in motor or sensory function of the lower extremities. The word comes from Ionic Greek: παραπληγίη "half-striking". It is usually the result of spinal cord injury or a congenital condition such as spina bifida that affects the neural elements of the spinal canal...


See also

  • Clearing the cervical spine
    Clearing the cervical spine
    Clearing the cervical spine is the process by which medical professionals determine whether cervical spine injuries exist. This process can take place in the emergency department or take place in the field by appropriately trained EMS personnel. The following is based on the NEXUS criteria...

  • List of people with quadriplegia
  • Monkey helper
  • Tetraplegic upper limb surgery

External links