Routine for examination of lower limbs:
Inspect (wasting, fasciculations, wheelchair/walking aid, catheter, pes cavus)
Gait and Rhomberg’s test
Tone
Power
Reflexes
Sensation (sensory level, joint position sense and vibration)
Coordination
If time allows and you suspect spastic paraparesis proceed as follows:
Eyes: eye movements (INO, nystagmus), RAPD
Mouth: tongue fasciculations
Hands and arms: small muscle wasting, fasciculations, coordination of upper limbs (past pointing, intention tremor, dysdiadochokinesis), tone, power, reflexes of upper limbs
Back: spinal surgery scars, palpate down spine for tenderness
If spastic paraparesis, cerebellar signs and dorsal column signs consider Friedreich’s ataxia and proceed as per “Station 3 Friedreich’s ataxia”
Present to the examiner:
This patient has a (symmetrical/assymetrical) spastic paraparesis as evidenced by:
Increased tone bilaterally
Pyramidal weakness bilaterally
Increased reflexes
Upgoing plantars and clonus
Spastic scissoring gait
With regards to aetiology:
- There was (no) sensory level to suggest cord compression/cord infarction/transverse myelitis
- There was (no) dorsal column sensory loss to suggest demyelination/Friedreich’s ataxia/subacute combined degeneration of the cord/taboparesis/cervical myelopathy
- There were (no) cerebellar signs to suggest demyelination/Friedreich’s ataxia
- There was (no) INO/RAPD to suggest demyelination
- There were (no) fasciculations/small hand muscle wasting to suggest motor neuron disease or cervical myelopathy
- There were (no) upper motor neuron signs in the upper limbs to suggest cervical myelopathy or bilateral strokes
To complete my examination I would like to:
- Perform a PR (anal tone, saddle anaesthesia)
- Examine upper limbs (if not already done) and cranial nerves in full as well as speech and fundoscopy
- Take a history of back pain, bladder and bowel disturbance, visual problems
Top causes of spastic paraparesis:
- Demyelination (multiple sclerosis)
- Cord compression
- Trauma
- Anterior horn cell disease (motor neuron disease)
- Cerebral palsy
Spastic paraparesis and sensory level:
- Cord compression (due to disc disease/tumour/trauma/infection such as epidural abscess, spinal TB/vascular problem such as haematoma or epidural haemorrhage)
- Cord infarction
- Transverse myelitis (due to infection, autoimmune, paraneoplastic, sarcoid, neuromyelitis optica)
Spastic paraparesis and dorsal column loss (joint position sense and vibration):
- Demyelination (Multiple sclerosis)
- Friedreich’s ataxia
- Subacute combined degeneration of the cord
- Syphilis
- Parasagittal meningioma
- Cervical myelopathy
Spastic paraparesis and spinothalamic loss (pain and temperature):
- Syringomyelia
- Anterior spinal artery infarction
Spastic paraparesis and cerebellar signs:
- Demyelination (Multiple sclerosis)
- Friedreich’s ataxia
- Spinocerebellar ataxia
- Arnold Chiari Malformation
- Syringomyelia
Spastic paraparesis and small hand muscle wasting:
- Cervical myelopathy (C5-T1)
- Anterior horn cell disease (motor neuron disease)
- Syringomyelia
Spastic paraparesis and UMN signs in upper limbs:
- Cervical myelopathy (above C5)
- Bilateral strokes
Spastic paraparesis and absent ankle jerk:
- Motor neuron disease
- Friedreich’s ataxia
- Subacute combined degeneration of the cord
- Syphilis
- Cervical myelopathy and peripheral neuropathy of any cause
- Conus medullaris
Other causes of spastic paraparesis include:
- Hereditary spastic paraparesis
- Tropical spastic paraparesis secondary to HTLV-1
- Cerebral palsy
Investigations (guided by history and examination):
MRI brain and spine (demyelination, trauma, cord compression)
Visual evoked potentials (if suspect demyelination)
Lumbar puncture (if suspect demyelination)
Bloods: FBC, U+E, LFT, bone profile, CRP, HIV, syphilis, HTLV-1, serum ACE, ESR, ANA, ANCA, antiphospholipid antibodies, immunoglobulins, AQP4 antibodies (NMO), paraneoplastic screen and serum electrophoresis, B12 (SACD of the cord)
Nerve conduction studies and EMG
Management: depends on the underlying cause. For example if it is an acute presentation, arrange an urgent MRI spine and liaise with neurosurgery team if evidence of cord compression.
Multiple Sclerosis
This is a progressive demyelinating disease of the central nervous system (brain and spinal cord)
CNS inflammation is disseminated in time and place
Involvement of spinal cord, cerebellum, brainstem, optic nerve
*does not affect peripheral nerves*
Visual evoked potentials are reduced (slow conduction in optic nerve)
CSF: increased protein, increased lymphocytes, unmatched oligoclonal bands
MRI: active inflammation, hyperintense on T2 (periventricular white matter lesions, corpus callosum, brainstem, cerebellar, spinal cord, optic nerve)
Management: MDT approach, high dose iv steroid acutely, symptom management eg. antispasmodics, disease modifying therapies
Written by Dr Sarah Kennedy
Resources used to write this document are listed in the references section of this webpage.