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A CLINICAL APPROACH TO FLACCID QUADRIPARESIS/ QUADRIPLEGIA L.J Basumatary, MD,DM neuro trainee,GMCH,guwahati mailto:drbasumatary@gmail.

com Definition: Weakness means a reduction of normal power of one or more muscles.Paresis means weakness that is mild to moderate.Plegia means weakness that is so severe that it is complete or near complete.Quadri- refers to all four limbs. So if all the four limbs are having paresis or plegia it is said asquadriparesis or quadriplegia.Tone: It is defined as a state of partial sustained contraction of muscle. It is of two typehypertonic and hypotonic states. Hypertonic state is caused by Upper motor neuron type of palsy and hypotonic state is caused by Lower motor neuron type of palsy, Upper motor neurontype of palsy in shock state and myopathies. Proposed sites where lesion can cause flaccid quadriplegia. UMNP in shock Anterior horn cells. Ventral or motor root. Spinal nerve. Peripheral nerve. Neuromuscular junction. Muscle

o The motor cranial nerves e.g. III, IV, V, VI, VII, IX, X, XI and XII are to be examinedthoroughly to look for involvement. o The other cranial nerves are to be examined for involvement. Motor system: o

Bulk of the muscle The bulk is reduced due to disuse atrophy. o Tone of the muscles There will be hypotonia or flaccidity of the muscles of the four limbs. o Power of the muscle There will be decrease to complete absence of muscle power depending upon the degree of weakness. o Abnormal movements of the muscles Fasciculations are seen or can be induced if it islower motor neuron type of palsy. The fasciculations are prominent in anterior horn celldisease and in peripheral neuropathy. It is absent in UMNP in shock state. Sensory system: o The posterior column- Involvement of predominantly the posterior column and to someextent the antero-lateral system signifies the lesion is in the peripheral nerves. If thedisease is in the anterior horn cells, neuromuscular junction or in the muscles thereshould be no sensory involvement. o Co-ordination test- It cannot be tested if the muscle power is 3 or less. But if the power ismore than 3 inco-ordination may be detected if the sensory system is involved. o Deep tendon reflex They are normal to decreases in anterior horn cell disease, neuro-muscular junctional disease and myopathies but is absent in peripheral neuropathy. o Gait A patient with predominant distal weakness have high stepping gait due to footdrop.A patient with predominant proximal weakness have Waddling gait. 9 A patient with peripheral neuropathy have stumping gait. Cerebellum: Cerebellar functions should be intact. Respiratory system: The system is to be examined to look for involvement of the respiratory muscles. A single breathcount test of less than normal signifies respiratory involvement. The cardiovascular system and abdominal system is also to be examined. Investigations:

Routine blood examination. Fasting and post-prandial blood sugar estimation. Cerebro-spinal fluid examination. CT scan of the brain and spinal cord. MRI of the brain and spinal cord. X ray of the cervical vertebrae. Electromyelography. Muscle biopsy. Nerve biopsy. Conclusion: Cases of flaccid quadriplegia of LMN type encountered in the OPD or casualty is less. References: 1. Harrisons principles of internal medicine 12 th edition. 2. Davidsons principles and practice of Medicine 19 th edition. 10

3. Brains disease of the nervous system 11 th edition. 4.

Adams and Victors Principles of Neurology, 7 th edition. 5. Guytons Textbook of medical physiology 8 th edition. 6. Ganongs Review of medical physiology 12 th edition. 7. Hutchinsons clinical methods 21 st edition. 8. Macleods Clinical Examination 10 th edition. Quadriplegia (Yes / No)C o n s c i o u s U n c o n s c i o u s U M N P L M N P Ant. Horn Cell Ventral RootPeripheral Neuromuscu lar Muscleo r S p i n a l n e r v e N e r v e j u n c t i o n

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