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Paraparesis

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Abstract

Paraparesis is a very common presentation in small animal veterinary practice and can be caused by orthopaedic, muscle, neuromuscular junction, nerve and spinal cord dysfunction. This chapter looks at clinical signs, lesion localization, pathophysiology, neurodiagnostic investigation, differential diagnosis, degenerative diseases, anomalous diseases, metabolic diseases, neoplastic diseases, nutritional diseases, inflammatory diseases, idiopathic diseases, traumatic diseases, toxic diseases, vascular diseases.

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Figures

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16.2 Schiff–Sherrington posture. Note the increased extensor muscle tone in the thoracic limbs and paralysis in the pelvic limbs. The absence of nociception is the most important prognostic indicator.
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16.4 Lesion localization for paraparesis. Spinal cord segments T3–L3 and L4–S3, and the lumbosacral plexus are highlighted. Illustration created by Allison L. Wright, MS, CMI, Athens, Georgia, USA.
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16.5 Lateral myelogram of the cranial lumbar spine showing extradural compression secondary to discospondylitis.
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16.8 Transverse section of the thoracic spinal cord from a dog with degenerative myelopathy. Note the neuronal fibre loss, which is most prominent in the dorsal portion of the lateral funiculi (arrowed). (Luxol fast blue stain; original magnification X20) (Courtesy of Dr G Johnson)
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16.9 Sagittal T2-weighted MR image of the lumbar spine of a 3-year-old Beagle. Note the hyperintensity in the spinal cord dorsal to the L4–L5 intervertebral disc space, reflecting spinal cord oedema caused by a high velocity disc extrusion. Note the dorsal displacement of the nucleus pulposus (arrowed). Transverse T2-weighted MR image at the level of the L4–L5 spinal cord segment showing a hyperintensity associated with oedema of the spinal cord.
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16.10 Lateral radiograph of the thoracolumbar spine showing opacity of the T11–T12, T12–T13 and L1–L2 intervertebral disc spaces. Note the narrowed intervertebral foramen and opacity in the spinal canal at the L1–L2 disc space (arrowed), which should raise suspicion for intervertebral disc herniation.
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16.11 Lateral myelogram showing extradural compression on the ventral aspect of the spinal cord at the T13–L1 intervertebral disc interspace. This is suggestive of intervertebral disc extrusion.
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16.12 Transverse CT image of a lateral disc extrusion at the T12–T13 intervertebral disc interspace (arrowed).
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16.13 Sagittal T2-weighted MR image of the thoracolumbar spine in a paraplegic 3-year-old Dachshund. Note the loss of hyperintensity (arrowed) in the L1–L2 intervertebral disc space, signifying degeneration of the nucleus pulposus. There is also a hypointense mass in the spinal canal at the level of the L1–L2 disc space, causing spinal cord compression and attenuation of the dorsal and ventral subarachnoid space. Transverse T2-weighted MR image at the level of the L1–L2 intervertebral disc space. Note the hypointense mass (arrowed) compressing the spinal cord. A right-sided hemilaminectomy revealed extruded nucleus pulposus.
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16.14 Sagittal T2-weighted MR image of the thoracolumbar spine of a 5-year-old Dachshund with loss of nociception. Note the loss of the dorsal subarachnoid space extending from the T11–T12 to the L5–L6 disc interspaces (arrowed). A hyperintensity in the spinal cord is visible extending from the T11–T12 to the L3–L4 interspaces. The extensive hyperintensity may be indicative of oedema, inflammation, malacia, haemorrhage and necrosis. Surgical decompression and durotomy revealed extensive myelomalacia.
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16.16 Lateral radiograph of the lumbar spine showing spondylosis at the L1–L2, L2–L3, L3–L4 and L5–L6 intervertebral disc spaces.
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16.17 Lateral radiograph at the level of the thoracolumbar junction showing osseous proliferation of the T13–L1 articular processes. Lateral myelogram at the level of the thoracolumbar junction showing dorsal and ventral extradural compression cause by the osseous proliferation. Histopathology confirmed osteochrondroma of the articular processes. (Courtesy of Dr D P O’Brien)
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16.19 Transverse section of the spinal cord from a dog with syringomyelia (arrowed) and hydromyelia (arrowhead). (H&E stain; original magnification X40) (Courtesy of Dr GE Lees)
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16.20 Lateral myelogram showing syringo(hydro)myelia in the lumbar spinal cord region. (Courtesy of Dr GE Lees)
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16.21 T2-weighted MR images of the thoracic spine of a 3-year-old male German Shepherd Dog with a dermoid sinus, spina bifida, meningocele and spinal dysraphism at T5–T6. Sagittal view. There is widening of the vertebral canal with dorsal displacement of the spinal cord, which appears to be pulled against the roof of T5–T6. The dura is displaced dorsally and protrudes between the abnormal dorsal spinous processes of T5 (due to spina bifida) and continues as a thin hypointense column to the surface of the skin. Transverse view. The displacement of the dura is also evident on this view. Note there is a depression in the surface of the skin where the dura makes contact (arrowed).
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16.22 Kyphosis and multiple vertebral anomalies of the thoracic region of the spine. Block vertebral anomaly of the fourth and fifth lumbar vertebrae. (Courtesy of Dr M Walker)
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16.23 Transverse T2-weighted MR images of the thoracic spine showing a normal canal (left) and a stenotic canal (right). Note the deformation of the spinal cord as a result of dorsal compression.
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16.24 Lateral and transverse T2-weighted MR images of the thoracolumbar spine of a 5-year-old Shih Tzu with progressive paraparesis. The cyst is visible as a distension of the subarachnoid space dorsally (arrowed).
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16.25 Lateral myelograms. Extradural compression with ventral and dorsal compression of the contrast medium column. The diagnosis of an undifferentiated sarcoma was confirmed by surgery. Intramedullary compression over the T13 vertebral body is suggestive of an intramedullary neoplasm.
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16.26 Transverse CT image of T11 showing extensive osteolysis of the vertebral body. The diagnosis of an osteosarcoma was confirmed by histopathology.
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16.27 Transverse T2-weighted MR image of the thoracic spine of a neutered cross-breed bitch that presented with progressive paraparesis. Note the large mass extending from the vertebral body to occupy two-thirds of the vertebral canal (arrowed). The mass is causing severe spinal cord compression.
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16.28 Sagittal T2-weighted MR image of the thoracic spine of a 9-year-old cross-breed dog with a mass extending from the T7 spinous process and overlapping the spinal cord segment of T7. Note the hyperintensity in multiple vertebral bodies. The diagnosis was confirmed as multiple myeloma. (Courtesy of Dr FA Wininger)
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16.29 Sagittal and transverse T1-weighted MR images (post-contrast medium administration) of the thoracolumbar spine of a 3-year-old female neutered German Shepherd Dog with a 2-week history of progressive paraparesis, due to a nephroblastoma. The tumour is seen as a contrast-enhancing lesion compressing the parenchyma.
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16.30 Necropsy finding of an extradural mass in a cat, causing severe spinal cord compression. The mass was confirmed by histopathology to be a lymphosarcoma.
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16.31 Lateral myelogram of the thoracic spine showing an extensive epidural compressive lesion dorsally, which was confirmed as spinal empyema. (Courtesy of Dr CW Dewey)
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16.32 Transverse T1-weighted MR image of the lumbar spine of a cross-breed dog. The spinal cord is compressed by a lateralized mass of pus.
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16.33 Lateral radiograph showing extensive contiguous bony proliferation in the thoracolumbar spine of a 10-year-old Boxer. These findings are suggestive of DISH.
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16.34 Lateral radiograph of the thoracolumbar spine of a 5-year-old Golden Retriever with spinal displacement at T12 and T13 after being hit by car.
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16.35 Transverse CT image showing a complete vertebral body fracture of T13 and displacement of all three compartments (dorsal, middle and ventral). The spinal cord is arrowed.
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16.36 Sagittal T2-weighted MR image of the thoracolumbar spine showing displacement of the T12 and T13 vertebrae at the disc interspace (arrowed) and spinal cord compression. There is also disruption of the T12–T13 articular processes.
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16.37 Lateral radiograph showing the spinal stapling technique used to stabilize a T6–T7 spinal fracture in a cat.
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16.38 Lateral and ventrodorsal radiographs showing the use of PMMA and implants to stabilize a T12 fracture.
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16.39 Great Dane with an asymmetrical spinal cord lesion suggestive of FCE. Note the conscious proprioceptive deficit and atrophy of the biceps femoris muscle in the right pelvic limb.
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16.40 The spinal cord vascular supply showing the approximate regions of the parenchyma, which have differing arterial networks. Illustration created by Allison L. Wright, MS, CMI, Athens, Georgia, USA.
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16.41 Transverse T2-weighted MR image at the level of L2 in a 4-year-old Labrador Retriever with acute-onset right pelvic limb plegia and a diagnosis of presumptive FCE. Note the hyperintense grey and white matter lesion on the right-hand side of the spinal cord (arrowed).
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16.42 Transverse section of the dorsal funiculus of the sacral spinal cord. An artery is occluded by Alcian blue-positive material (arrowed), suggestive of a cartilaginous substance. Note the degeneration of the axons and myelin in the white matter of the spinal cord. (Courtesy of Dr BR Berridge)

Supplements

Degenerative myelopathy

Serial videos showing disease progression over time in a number of Boxers with ataxia, paraparesis, UMN paraplegia, LMN paraplegia and tetraparesis (with both UMN and LMN signs). (See page 302 in the Manual)

Fibrocartilaginous embolism

A 7-year-old Miniature Schnauzer presented with acute onset left pelvic limb plegia and signs of right pelvic limb paresis after running in the yard. Myelography and CSF analysis were within normal limits. The dog started to regain strength in the right pelvic limb and was ambulating without assistance 10 days after the incident. The left pelvic limb remained weaker. (See pages 325 and 326 in the Manual)

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