29.1. Spastic paralysis
Deformities of the limbs caused by spastic paralysis may depend on changes in the brain or spinal cord.
Cerebral palsies
Etiology
The causes resulting in cerebral palsy may include:
- congenital - defects of intrauterine brain development in case of mother's diseases (pregnancy toxicosis, syphilis, tuberculosis, mechanical and psychological trauma, radiation sickness, etc.);
- birth - mother's contracted pelvis, forceps delivery, placental abruption with the development of fetal brain hypoxia, birth asphyxia;
- postpartum - brain injury in the first days and months of life, meningitis, encephalitis, premature birth.
Disorders may affect not only the cerebral cortex but also the downstream central nervous system parts with damage to the central motor pathways. 56% of patients with cerebral spastic paralysis suffer from mental retardation.
Clinical forms of spastic pathology
Monoparesis is characterized by a lesion of only one limb. Monoparesis of the upper limb is characterized by flexion-pronation of the forearm, palm flexion of the fingers and hands. Monoparesis of the lower limb is characterized by flexion in the knee joints and plantar flexion of the foot.
Hemiparesis is characterized by a lesion of one half of the body. The lower limb, as a rule, lags behind in growth, is significantly adducted and rotated internally, movements in the joints are significantly limited due to spastic muscle contracture. Spastic hemiplegia usually occurs after encephalitis and in case the extrapyramidal pathways are affected, accompanied by the development of athetosis (constant chaotic movements of the fingers, decreasing with dorsiflexion of the limbs).
Paraparesis (paraplegia) is characterized by lesions of both lower extremities and is most often observed in Little disease. The legs are adducted, flexed in the genicular and coxofemoral joints with internal rotation, the feet are in the plantar flexion position (the patient walks on their toes).
Quadriparesis (quadriplegia) - all four limbs are affected. Deformities of the lower extremities are the same as in paraparesis but more prominent (up to scissor legs). The upper extremities are flexed and pronated. Patients are confined to stretchers, and as a result, the spine loses its physiological curvature, the head is bent back.
Classification and Diagnosis
Mild, moderate, and severe pathologies are distinguished.
Mild pathology. It is difficult to diagnose pathology immediately at birth, and only when the child begins to walk belatedly (by 2-3 years), some stiffness in the gait is observed. Internal hip rotation, muscle tension may be revealed during leg separation. Some patients walk on their toes. However, they are able to walk on their own, fully serve themselves, and in case of preserved intelligence, they successfully study and master a profession.
Moderate pathology. All symptoms are more pronounced. Sometimes, patients are not able to walk without assistance or crutches, dress and undress on their own. Strabismus, mental deficiency, slow syllabic speech are observed. The lesion of the upper extremities is characterized by a typical position: shoulder adduction, sharp pronation and flexion of the forearm, palmar flexion of the hand, adduction of the fingers.
Severe pathology. Patients are confined to bed, unable to attend to themselves. Marked mental disorders (up to anoesia), speech, visual and other disturbances are observed.
Diagnosis of moderate and severe spastic paralysis is not difficult, just one glance at the patient is enough for diagnosis statement. The lower limbs are rigid, rotated inwards, flexed in the genicular and coxofemoral joints, the legs "decussate" during ambulation due to the sharp hip adduction, and the lower legs are thrown outwards. The genicular joints "rub" one against the other, the trunk is tilted forward. Coordination of movements is disrupted, involuntary movements are noted. The balance between inhibition and excitation is disrupted with the predominance of excitation elements. With age, spastic paralysis may slightly decrease but only until 14-15 years, after that the process stabilizes.
Conservative treatment
Newborns with cerebral pathology should be in a special room in semi-darkness and silence to limit the influence of external stimuli. In the first days, dehydration therapy, B vitamins, antibiotics, bendazole (Dibazole♠) are prescribed, with a mental deficiency - Cerebrolysin♠. It is very important to consistently conduct physical therapy, which in the first days and weeks pursues the goal of proper distribution of muscle tone, correction of impaired limb and neck installation. To counteract the thigh adductor muscles, soft pads are placed between the legs; to prevent flexion contractures, the child is placed on the stomach with a sandbag applied on the pelvic area. Physiotherapy procedures (water, thermal, mud applications, paraffin, pulse current, diathermy, etc.) are widely used.
Treatment should be carried out comprehensively and consistently including medication, orthopedic, surgical and physiobalneotherapeutic methods.
Surgical treatment
Surgical correction of spastic limb contractures is advisable at the early stages (from the age of 2-3 years) and includes surgeries on nerves, muscles, tendons, bones, and joints.
Surgeries on peripheral nerves
Surgeries on peripheral nerves are most often performed with deformities of the lower extremities.
Resection of the obstructor nerve with the obligatory transection of its anterior and posterior branches is performed with extra- or intra-pelvic (with more pronounced spastic contracture) approach. Extra-pelvic resection is combined with myotenotomy of the thigh adductor muscles. With pronounced contractures after surgery, the hips are fixed in the abduction position with an external fixator (plaster cast or orthosis).