Tetraplegia (Quadriplegia)

Tetraplegia Definition

Tetraplegia is a form of paralysis that is caused by some injury or illness and results in partial or complete loss of usage of torso and limbs. Generally both the sensory and motor nerves are affected, which means that one loses both sensation as well as control of that body part.

The condition is also known as Quadriplegia.

Tetraplegia ICD-9 Code

The ICD-9 code for this condition is 344.0.

Tetraplegia Causes

This problem arises when injury or damage is sustained by the brain or spinal cord at the levels C1 to C7. The injury to spinal cord is normally secondary to a damage suffered by the spinal vertebrae present in cervical section of spinal column. The spinal cord injury is known as lesion and may lead to the loss of total or partial functioning of all the four limbs, i.e. the arms and legs.

The general causative factors of the condition occurring from damage to spinal cord include:

  • Trauma, such as a car crash, sports injury or a fall
  • Diseases, like polio or transverse myelitis
  • Congenital disorders, like multiple sclerosis or muscular dystrophy

If the vertebrae are dislocated or fractured without the spinal cord being damaged, it is quite possible to have a broken neck even without becoming tetraplegic. One can also injure his or her spinal cord without actually fracturing the spine, like when a bony spur or a ruptured disc on the vertebra projects itself into spinal column. All quadriplegics experience finger dysfunction in some form or another. Hence, it is not really uncommon to find a quadriplegic individual having fully functional arms but having difficulty in moving fingers.

Tetraplegia Classification

According to the American Spinal Injury Association (ASIA), spinal cord injuries can be classified into two types:

  • Complete quadriplegia or complete tetraplegia
  • Partial or incomplete quadriplegia or tetraplegia

The ASIA scale allows grading of the patients based on functional impairments caused by the injury, and grading patients from class A to class D. This has significantly influenced therapy and surgical planning.

The ASIA scale is represented in the following manner:

  • Grade A: Complete: No sensory or motor functioning is preserved in sacral segments of S4-S5.
  • Grade B: Incomplete: Sensory functioning is preserved without motor functioning below neurological level; comprises the sacral segments of S4-S5.
  • Grade C: Incomplete: Motor functioning is maintained below neurological level; more than 50% of the key muscles below neurological level have muscle grade lower than 3.
  • Grade D: incomplete: Motor functioning is maintained below neurological level; at least 50% of the key muscles below neurological level have muscle grade of 3 or more.
  • Grade E: Normal: The sensory and motor functions are normal.

Complete spinal cord lesions

The spinal cord of a quadriplegic individual can be classified into 3 segments that can be used to classify the injury:

  • The injured functional medullary segment has got un-paralyzed, functional muscles whose actions are voluntary and not permanent. Evaluation of their strength can be done by the BMRC (British Medical Research Council) scale.
  • An injured metamere or a lesional segment is comprised of many denervated corresponding muscles that have a damaged LMN (lower motor neuron). These muscles are atrophic, hypotonic and show no spontaneous contractions.
  • The injured sublesional segment located below metamere segment has an undamaged lower motor neuron that shows intact medullary reflexes but has no upper cortical control.

Incomplete spinal cord lesions

Incomplete spinal cord wounds may lead to various post injury presentations. Three main syndromes are described that depend on exact site as well as the extent of a lesion.

  • Central cord syndrome: The major part of cord lesion lies in gray matter of spinal cord; the lesion might occasionally continue in white matter.
  • Anterior cord syndrome: A lesion occurring in the anterior horns as well as in the anterolateral tracts.
  • The Brown-Séquard syndrome: Affecting the hemi-section of spinal cord; also known as hemiplegia.

Spastic Quadriplegia

Spastic quadriplegia or spastic tetraplegia is a form of spastic diplegia which affects all 4 limbs (legs and arms) rather than only the legs. It is different from, and unrelated to, general quadriplegia in the sense that its central feature is spasticity whereas quadriplegia is primarily defined by paralysis.

Functional Quadriplegia

It is a term used to describe a condition of complete immobility caused by severe physical disability.

Congenital Quadriplegia

It refers to instances of quadriplegia that are caused by congenital factors. 

Transient Quadriplegia

It occurs when the cervical spinal cord of an individual suffers a temporary but serious injury. Nerve dysfunction can happen in either of the arms or legs, on one side of the body or on all four limbs. Patients may experience pain, numbness or complete paralysis. A transient quadriplegia generally takes 15 minutes to resolve but might occasionally need longer time, taking almost 48 hours.

Tetraplegia Symptoms

Flaccid arms and spastic legs are the most usual signs of quadriplegia. Although limb impairment is the most common symptom, damaged functioning is also seen in torso. This can lead to a loss of control over the bowel and bladder, digestion, sexual function, breathing as well as other autonomic functions. There is also loss of sensation experienced in the affected areas, which can manifest as reduced sensation, numbness or an intensely burning neuropathic pain.

Due to their reduced functioning and immobility, Tetraplegics are frequently more vulnerable to conditions like:

  • Osteoporosis
  • Fractures
  • Pressure sores
  • Spasticity
  • Frozen joints
  • Deep vein thrombosis
  • Autonomic dysreflexia
  • Respiratory infections and complications
  • Cardiovascular disorders

Severity or intensity of the quadriplegic condition depends on the level of injury of the spinal cord as well as the extent of injury. A person having an injury at the level of C1 (highest cervical vertebra located at the skull’s base), will most likely lose functionality from neck down and be dependent on ventilation. An individual having a C7 injury might lose functionality from chest down and yet retain the ability to use hands and arms.

The extent or intensity of the injury is also a vital factor. A total splitting of spinal cord can result in a complete loss of functionality downwards from the vertebra. A partial splitting or bruising of spinal cord leads to varying degrees of paralysis and mixed functions. Although there is a common misconception regarding Tetraplegia that the patient cannot move his or her arms, legs or carry out any other major functions, this is generally not the case. Many tetraplegic patients can use their hands and walk around, as if they didn’t even have any spinal cord injury. Some of the patients may become dependent on wheelchairs and still retain some arms and finger movement and functionality, although this depends on the extent of spinal cord damage.

A common symptom of this condition is that a person might have movement in the limbs, like he or she may be able to move arms and yet not move the hands or have finger-moving ability although not as efficiently as earlier. The limbic deficiencies also might not be same on either sides of the body, affecting either the left or the right side more strongly. The location of injury on spinal cord determines the symptoms in such cases.

Tetraplegia Diagnosis

CT scans, MRIs and X-Rays are normally used to diagnose this condition.

Tetraplegia Treatment

The treatment for the condition consists of curing the injury of the spinal cord or any other condition that might have caused the problem. While treating spinal cord injury, a patient is kept immobilized by using special equipments that help to prevent additional injury. Medical personnels work to stabilize the blood pressure, heart rate, as well as the overall health condition. A doctor might use intubation to facilitate breathing. Intubation involves inserting one flexible oxygen-carrying tube down the throat of a patient.

Surgery might be required to relieve the pressure on spine from the bone fragments or any other foreign objects. A surgical procedure can stabilize the patient’s spine although the injured nerves of spinal cord cannot be repaired by surgery.

The nerve damage that is caused by initial injury of the spinal cord has a propensity to spread. The underlying reason for this tendency is not fully understood by researchers, although it is believed to be clearly associated with spreading of inflammations as the blood circulation reduces and the blood pressure drops. Methylprednisolone is a powerful corticosteroid that can be sometimes used to prevent spreading of the condition, if it is administered within 8 hours of the actual injury. However, not all doctors advocate the usage of methylprednisolone as it can give rise to serious side effects.

Rehabilitation was once used to train patients how to effectively deal with their obstacles. Atrophication of the muscles was prevented by giving passive physical therapy. Nowadays, many new treatment options are available that offer new hope to quadriplegic patients. These new methods combine older modes of treatment with new technology to produce encouraging results. Therapists use a technology known as functional neuromuscular stimulation or FNS in which electrodes are employed for stimulating the patient’s muscles thereby giving them the optimal workout. The undamaged peripheral nerves are stimulated by FNS which causes contraction of the paralyzed muscles. While undergoing FNS, an individual may also ride a standing bicycle for improving cardiac and muscle function and prevent atrophication of the muscles. Alternatively, implantable FNS may also be used in case of people who have retained some voluntary usage of their arms.

A complicated surgical procedure, known as tendon transfer, can be carried out to facilitate more usage of arms and hands. A nonessential muscle having nerve function is transferred in this process to the arm or shoulder to help restore functionality.

Tetraplegia Complications

Tetraplegic patients may experience the following complications:

  • Pain
  • Stinging
  • Impotence
  • Blood clots
  • Pneumonia
  • Frozen joints
  • Kidney stones
  • Pressure sores
  • Shooting pains
  • Muscle spasms
  • Renal problems
  • Deep vein thrombosis
  • Autonomic dysreflexia
  • Respiratory complications
  • Loss of bowel and bladder control

Tetraplegia Prognosis

If diagnosis of the cervical spine injury is delayed, it can have serious consequences for the patient. About 5% cervical fractures are not noticed and nearly 2/3rd of these patients suffer from further damage of the spinal cord. In almost 30% cases where diagnosis has been delayed, the cervical spine injury has been found to progress to permanent neurological deficits. Total paralysis from neck down can result from high-level cervical injuries. Tetraplegics of an advanced stage (C4 or higher) tend to require constant caring and assistance, while handling various day-to-day activities. Low-level tetraplegics (from C5 to C7) are often able to live independently. In cases of cerebral palsy, physical therapy can gradually enable some tetraplegics to learning standing or walking. Life expectancy for tetraplegia is normal and includes the remaining years of his or her life.

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