What are the causes and management of sudden onset paraplegia?

Sudden Onset Paraplegia: Causes and Management

Immediate Life-Threatening Causes Requiring Emergency Intervention

The most critical causes of sudden paraplegia requiring immediate recognition and treatment are spinal cord compression from malignancy, spontaneous spinal epidural hematoma, aortic dissection/rupture with spinal cord ischemia, and acute spinal subdural hematoma.

Spinal Cord Compression (Malignant)

• High-dose dexamethasone (96 mg IV daily) should be initiated immediately upon clinical suspicion, even before imaging confirmation, as this significantly improves ambulation rates (81% vs 63% at 3 months) 1
• MRI of the entire spine is the diagnostic modality of choice with sensitivity 0.44-0.93 and specificity 0.90-0.98 1
• Surgical decompression followed by radiation therapy is superior to radiation alone for patients with single level compression, neurologic deficits present <48 hours, age <65 years, or predicted survival ≥3 months 1
• Pretreatment ambulatory status is the strongest prognostic factor: ambulatory patients have 96-100% chance of remaining ambulatory after treatment, while only 30% of non-ambulatory patients regain walking ability 1
• 70% of patients lose neurologic function between symptom onset and treatment initiation, emphasizing the urgency of recognition 1

Spontaneous Spinal Epidural Hematoma

• Presents as sudden onset paraplegia, often in young patients without trauma 2
• MRI is essential for early diagnosis and urgent surgical decompression is critical to prevent permanent neurological deficits 2
• This is a rare but reversible cause if treated emergently 2

Aortic Pathology with Spinal Cord Ischemia

• Thoracoabdominal aortic surgery or dissection can cause paraplegia through spinal cord ischemia 3
• Cerebrospinal fluid drainage reduces paraplegia risk in thoracoabdominal aortic repair and should continue up to 72 hours post-operatively to prevent delayed onset 3
• Re-attachment of intercostal arteries between T8-L1 and permissive hypothermia (34°C) are protective measures 3
• Motor evoked potentials (MEPs) are more sensitive than somatosensory evoked potentials (SSEPs) for detecting spinal cord ischemia during aortic procedures, with 29% vs 7% detection rates respectively 3

Acute Spinal Subdural Hematoma

• Can present with sudden severe back pain followed by rapid paraplegia 4
• Conservative management with bed rest may be appropriate in select cases with sacral sparing and early motor recovery within 24 hours, as spontaneous resolution can occur 4
• Serial MRI imaging can demonstrate rapid resolution of cord compression within 2-4 days in spontaneous recovery cases 4

Infectious/Inflammatory Causes

Schistosomiasis (Neuroschistosomiasis)

• Should always be considered as a cause of gradual onset paraplegia in patients with travel to endemic areas in Africa 3
• Myelitis from S. mansoni or S. haematobium causes inflammatory lesions resulting in spinal cord infarction or mass effect 3
• Treatment consists of praziquantel 40 mg/kg twice daily for 5 days plus dexamethasone 4 mg four times daily, reducing over 2-6 weeks 3
• Serology, stool, and urine microscopy are often negative; MRI shows cord enlargement with contrast enhancement 3
• Acute Katayama syndrome with neurological symptoms should be treated with corticosteroids alone initially to avoid neurological complications from dying parasites 3

Eosinophilic Meningitis

• Angiostrongylus cantonensis can cause severe headache, meningism, and cranial nerve palsies with marked peripheral eosinophilia 3
• Treatment is prednisolone 60 mg daily for 14 days plus albendazole 15 mg/kg/day for 14 days 3

Structural/Mechanical Causes

Cervical Disc Herniation

• Non-traumatic acute paraplegia from cervical disc herniation is rare but can occur 5
• MRI is crucial for management of patients with acute neck pain and cervical canal stenosis 5
• Surgical treatment should not be delayed to avoid permanent neurologic deficits; anterior decompression with vertebrectomy is recommended 5
• Cord lesions detected on MRI may indicate incomplete surgical outcomes 5

Spinal Angiolipoma with Hemorrhage

• Rare epidural tumors that can present with acute paraplegia from spontaneous bleeding 6
• Emergency laminectomy is required for mass effect on spinal cord 6

Critical Diagnostic Approach

When evaluating sudden paraplegia, immediately obtain:

• Complete neurological examination documenting motor function, sensory level, reflexes, and presence/absence of sacral sparing 1
• Urgent MRI of entire spine to identify compressive lesions, hematomas, or cord signal abnormalities 1, 2, 5
• Travel history to endemic areas for parasitic infections 3
• History of cancer, anticoagulation, or recent procedures 1, 2

Common Pitfalls to Avoid

• Do not delay dexamethasone administration while awaiting imaging in suspected malignant cord compression 1
• Do not mistake brief seizure-like activity or myoclonic movements for seizure disorder when evaluating collapsed athletes—presume cardiac arrest 3
• Do not assume negative serology excludes schistosomiasis in endemic area travelers with compatible clinical picture; consider empiric treatment trial 3
• Do not perform only SSEP monitoring during aortic procedures—MEPs are significantly more sensitive for detecting anterior spinal cord ischemia 3
• Recognize that CSF eosinophilia is present in <50% of neuroschistosomiasis cases 3

Time-Critical Treatment Windows

• Malignant cord compression: Neurologic deficits present <48 hours predict better surgical outcomes 1
• Spinal epidural hematoma: Emergency decompression is essential 2
• Aortic-related paraplegia: Intraoperative MEP changes require immediate intervention (reimplantation of segmental arteries, hemodynamic optimization) 3
• Slower development of motor deficits (>14 days) predicts better functional outcomes than rapid progression (<14 days) 1