What is the recommended evaluation and acute management for a patient presenting with paraplegia?

Acute Management of Paraplegia

Immediately obtain urgent MRI of the entire spine to identify life-threatening compressive lesions, cord ischemia, or hemorrhage, and simultaneously initiate high-dose dexamethasone (96 mg IV daily) if malignant spinal cord compression is suspected—do not delay steroid administration while awaiting imaging. 1, 2

Initial Emergency Assessment

Perform a rapid but complete neurological examination documenting:

• Motor function in all lower extremity muscle groups using a standardized scale (0=no movement, 1=flicker, 2=able to bend knee, 3=unable to perform straight leg raise against gravity, 4=normal movement) 3, 2
• Sensory level to identify the exact spinal cord level involved 2
• Presence or absence of sacral sparing (perianal sensation, rectal tone, voluntary anal contraction)—this distinguishes complete from incomplete injury and has major prognostic implications 2
• Deep tendon reflexes—normal reflexes in acute complete paralysis should raise suspicion for functional/nonorganic paraplegia 4
• Bowel and bladder function—preserved function with otherwise complete paralysis suggests nonorganic etiology 4

Critical Time-Sensitive Interventions

For Suspected Malignant Cord Compression

Administer dexamethasone 96 mg IV immediately upon clinical suspicion—this improves ambulation rates from 63% to 81% at 3 months. 1, 2 Do not wait for imaging confirmation. 1, 2

• Obtain MRI of entire spine (sensitivity 0.44-0.93, specificity 0.90-0.98) 2
• Proceed to surgical decompression followed by radiation therapy if patient meets criteria: single level compression, neurologic deficits present <48 hours, age <65 years, or predicted survival ≥3 months 1, 2
• Surgery plus radiation is superior to radiation alone in these patients 1, 2

For Post-Aortic Surgery Paraplegia

Maintain cerebrospinal fluid (CSF) drainage for up to 72 hours postoperatively to prevent and treat delayed-onset paraplegia. 1, 2 This is a Class I recommendation for patients at high risk of spinal cord ischemic injury. 3

• Optimize spinal cord perfusion pressure by maintaining proximal aortic pressure and treating hypotension aggressively with fluids or vasopressors 3
• Hypotension is equally dangerous as hypertension in this setting—inadequate perfusion pressure causes irreversible spinal cord ischemia 3
• Two-thirds of patients with paraparesis will recover, and approximately half with paraplegia will recover to the point of walking again with aggressive management 3

Diagnostic Imaging Strategy

MRI of the entire spine is the diagnostic modality of choice for acute paraplegia. 1, 2 The imaging protocol depends on temporal onset:

Acute Onset (Hours to Days)

• MRI without contrast to identify compressive lesions, cord ischemia, hemorrhage, or epidural hematoma 1
• Anterior spinal artery syndrome presents with sudden motor paralysis and loss of pain/temperature sensation while preserving proprioception 1
• Epidural hematoma requires emergent surgical decompression 1

Subacute Onset (Days to Weeks)

• MRI with and without IV contrast to identify demyelinating disease, infections, or neoplastic processes 1
• Look for longitudinally extensive transverse myelitis (≥3 vertebral segments) suggesting neuromyelitis optica 1
• Consider tuberculosis (Pott disease) with vertebral destruction and epidural abscess 1

Chronic Onset (Weeks to Months)

• MRI with contrast to distinguish compressive from non-compressive etiologies 1
• Spondylotic myelopathy is the most common cause of extrinsic cord compression in chronic paraplegia 1, 5
• Intramedullary cord signal changes represent important prognostic factors for surgical outcomes 1, 5

Etiology-Specific Considerations

Vascular Causes

Aortic dissection causes acute paraplegia in 1-3% of thoracic dissection patients from spinal cord malperfusion. 1, 5 Risk factors for perioperative spinal cord injury include emergency surgery, dissection, extensive disease, prolonged aortic cross-clamp time (>60 minutes carries 20% risk), aortic rupture, and prior hypogastric artery exclusion. 3

Infectious Causes

In patients with travel to endemic areas in Africa, always consider schistosomiasis (S. mansoni and S. haematobium) as a cause of gradual onset paraplegia. 1, 2

• Do not rely on negative serology to exclude schistosomiasis—consider empiric treatment trial in endemic area travelers with compatible clinical picture 1, 2
• Treatment: praziquantel 40 mg/kg twice daily for 5 days plus dexamethasone 4 mg four times daily, tapering over 2-6 weeks 1, 2

Traumatic Causes

Spinal cord contusion or laceration from vertebral fracture-dislocation is the most common traumatic cause. 1 Patients with initial neurologic level at or below T9 have 38% chance of some lower extremity motor recovery, primarily in hip flexors and knee extensors. 6 Those with initial level at or below T12 have 20% chance of regaining sufficient strength to ambulate with orthoses and crutches. 6

Critical Diagnostic Pitfalls to Avoid

• Never delay dexamethasone while awaiting imaging in suspected malignant cord compression 1, 2
• Do not perform only somatosensory evoked potential (SSEP) monitoring during aortic procedures—motor evoked potentials (MEPs) are significantly more sensitive (29% vs 7%) for detecting anterior spinal cord ischemia 1, 2
• Do not exclude schistosomiasis based on negative serology alone in endemic area travelers 1, 2
• Beware of functional/nonorganic paraplegia in patients with normal bowel/bladder function, shifting sensory findings, and normal deep tendon reflexes early after injury 4
• Exercise extreme caution with spinal anesthesia in patients with known malignancy—vertebral metastases may already be present and the procedure could precipitate acute cord compression 7

Hemodynamic Management

Maintain strict blood pressure control in the acute phase:

• Hypertension can cause stent migration and bleeding from aortic suture lines 3
• Hypotension impairs spinal cord perfusion pressure and causes irreversible ischemia—treat immediately with fluids or vasopressors 3
• Any decrease in lower extremity function must be reported immediately as it represents potentially reversible early paralysis 3

Thromboembolism Prophylaxis

Combined mechanical and pharmacologic prophylaxis is recommended for patients with paraplegia from thoracolumbar spine injuries. 3 External pneumatic calf compression (EPCC) combined with antiplatelet agents reduces DVT rates more effectively than mechanical prophylaxis alone (25% vs 40%). 3 The consensus recommendation supports thromboprophylaxis despite limited evidence specific to thoracolumbar injuries. 3