What is the management approach for paraparesis?

Management of Paraparesis

The most effective management approach for paraparesis includes prevention of postoperative hypotension and continued cerebrospinal fluid (CSF) drainage for more than 40 hours, which can significantly reduce the incidence of paraparesis following thoracic aortic surgery. 1

Definition and Etiology

• Paraparesis refers to partial loss of voluntary motor function in the lower limbs, while paraplegia indicates complete loss of function 2
• Paraparesis can result from various causes including spinal cord lesions caudal to the second thoracic spinal cord segment 2
• Common etiologies include trauma, neoplasia, vascular disorders (like thoracic aortic disease), inflammatory conditions, and inborn errors of metabolism 3, 1
• In thoracic aortic surgery, paraparesis occurs in 2-4% of descending thoracic aortic repairs and 3-10% of thoracoabdominal aortic repairs 1

Diagnostic Approach

• MRI-based classification is recommended to determine the cause of paraparesis, with findings categorized into six patterns: extradural, intradural/extramedullary, intramedullary, intramedullary-tract specific, spinal cord atrophy, and normal appearing spinal cord 4
• Diagnostic workup should include evaluation for acquired causes (spinal cord compression, inflammatory, metabolic, infectious diseases) and hereditary spastic paraparesis 3
• For patients with bilateral motor signs, including paraparesis, consider sagittal sinus thrombosis and bihemispheric injury 1
• Screening for prothrombotic conditions is recommended in the initial clinical assessment when cerebral venous thrombosis is suspected 1

Management Strategies

Post-Thoracic Aortic Surgery

• Prevention of postoperative hypotension in the intensive care unit is crucial 1
• Continued CSF drainage for more than 40 hours is beneficial in reducing paraparesis incidence 1
• Two-thirds of patients with paraparesis will recover, and about half with paraplegia will recover to the point of walking again 1

Surgical Considerations

• For patients undergoing surgery for conditions like Scheuermann's kyphosis, thoracic stenosis should be evaluated preoperatively with MRI to prevent paraparesis 5
• Careful monitoring during surgery with somatosensory-evoked potential monitoring and wake-up tests can help detect early neurological complications 5

Rehabilitation Approach

• Patients with incomplete recovery are at risk for functional and psychological impairment 1
• Referral to appropriate specialists is recommended for:
  • Ophthalmologist for ocular complications in cases with facial nerve involvement 1
  • Physical therapy for mobility and strength training 1
  • Psychological support for emotional consequences of persistent paralysis 1

Prognosis

• Recovery depends on the underlying cause, severity, and promptness of treatment 1
• In post-thoracic aortic surgery cases, approximately two-thirds of patients with paraparesis will recover some function 1
• Early intervention for treatable causes (like thoracic stenosis) can lead to complete neurological recovery 5

Special Considerations

• For diabetic patients with neuropathy, consider screening for orthostatic hypotension which may exacerbate mobility issues 1
• Treatment of orthostatic hypotension should focus on minimizing postural symptoms through both non-pharmacologic measures (adequate salt intake, compressive garments) and pharmacologic interventions 1
• Physical activity and exercise should be encouraged to avoid deconditioning, which can worsen orthostatic intolerance 1