Acta Neurochir
DOI 10.1007/s00701-009-0238-0
NEUROSURGICAL CONCEPTS
Paraparesis or incomplete paraplegia? How should we call it?
Alécio Cristino Evangelista Santos Barcelos &
Fabrizio Borges Scardino & Gustavo Cartaxo Patriota &
José Marcus Rotta & Ricardo Vieira Botelho
Received: 6 May 2008 / Accepted: 17 September 2008
# Springer-Verlag 2009
Abstract
Introduction The neurological examination terminologies
and definitions of the status of spinal cord injured (SCI)
patients are of great importance to establish scales and
provide standard nomenclatures. There is a disagreement
between the classical neurological terminology and the
definitions of complete and incomplete paraplegia that have
been proposed in traumatic spinal cord injured patients.
Objective To discuss the adequacy and the impact of the
terms incomplete paraplegia and paraparesis in current
literature.
Materials and methods A review of the origin of the terms,
definitions and nomenclatures applied by the most widespread assessment scales in traumatic SCI published in peer
review papers was performed, searching the scales cited on
the references of the latest American Spinal Injury
Association classification (2002; available in http://www.
asia-spinalinjury.org/) up to the first classification, described by Frankel et al. [14].
Results The term “incomplete paraplegia” has been used to
define clinical situations classically described as “paraparesis”.
Conclusion The terms “complete” and “incomplete” are
adequately used to characterize the completeness of spinal
cord lesion but inadequately used when associated to the
term “plegia” as a qualifier. Therefore, patients with any
preservation of motor strength below the injury level
should be described as paraparetic and not as incomplete
paraplegic.
A. C. Evangelista Santos Barcelos : F. B. Scardino :
G. C. Patriota : J. M. Rotta : R. V. Botelho (*)
Department of Neurosurgery, Spine Surgery Section,
Hospital do Servidor Público Estadual de São Paulo,
R. Haberbeck Brandão 68, 122–Indianópolis,
04027-040 São Paulo, Brazil
e-mail: [email protected]
Keywords Paraparesis . Incomplete paraplegia .
Spinal cord injury . Terminology . Classification . Scales
Introduction
The standardisation of neurological examination scales in
patients with spinal cord injury (SCI) is of great importance
in the initial assessment and follow-up of these patients and
helps to group them according to the extent of neurological
damage. There are several assessment methods such as the
Frankel scale, Lucas and Ducker Neurotrauma motor index,
Yale scale, “National Acute Spinal Cord Injury Study”
(NASCIS) scale and the Standards of the Neurological
examination of the “American Spinal Injury Association”
(ASIA) [5–7, 12, 14, 15, 21].
Fundamental issues have to be considered in the
assessment of a neurological scale. First, in relation to
neurological examination, the terms have to be in accordance to classical nomenclature. Second, the corresponding
severity groups should correlate to outcome.
The terms incomplete paraplegia and incomplete
tetraplegia have been used in clinical situations in which
there is some preservation of motor and/or sensory
function below the neurological level in SCI patients
[28, 29].
Neurosurgeons have to deal with spinal cord injury on a
day to day basis. The use of a standard nomenclature is of
fundamental importance in the follow-up documentation of
neurosurgical procedures and communication among the
scientific community.
The latest review of The International Standards for
Neurological Classification of Spinal Cord Injury published
in 2002 kept the definition of paraplegia as the impairment
or loss of motor and/or sensory function in the thoracic,
A.C. Evangelista Santos Barcelos et al.
lumbar or sacral segments of the spinal cord secondary to
damage of neural elements within the spinal canal. This
definition is in contrast to the classical terminology used in
neurological literature [10, 11, 13]. The rationale for our
study was to perform a critical review of the literature
pertinent to neurological examination nomenclature in SCI
patients to discuss the adequacy and the impact of the terms
incomplete paraplegia and paraparesis.
Materials and methods
A review of the origin of the terms, definitions and
nomenclatures applied by the most widespread assessment
scales in traumatic SCI published in peer review papers was
performed, searching the scales cited on the references of
the latest American Spinal Injury Association classification
(2002) up to the first classification, described by Frankel in
1969 [14].
A second search was made on the meaning of the terms
paraplegia and paraparesis according to classical neurological examination textbooks.
Finally, a comparison was made, searching the frequency
of appearance of papers in the literature using the
descriptors “incomplete paraplegia” and “paraparesis”,
from the years 1994 to 2008 and limited by “Tag Terms”:
Title (PubMED).
As the discussion below is directed to the suffix “plegia”
and “paresis” and does not refer to different spinal cord
segments, the terms paraplegia or paraparesis may also refer
to tetraplegia or tetraparesis, respectively.
Results
Standardised neurological examination scales in traumatic
SCI
In 1969, Frankel et al. presented a classification to closed
injury of the spine. This was the first neurological
examination scale to assess SCI patients. Complete lesions
were defined as total loss of motor and sensory functions
below the most caudal preserved spinal cord segment [14].
Stauffer reported that “if the patient has no perianal
sensation and no voluntary control over his sacral innervated muscles, toe flexors, or rectal sphincter, it is then
classified as being a complete lesion. If present, sacral
sparing means that the lesion is incomplete”. The period of
spinal shock is transient and is heralded by the return of the
bulbo-carvernosus reflex or anal wink. Stauffer suggested
that an apparently complete injury with no sacral sparing
should not therefore be considered as firmly complete until
the bulbocavernosus reflex returns” [26].
In 1978, Bracken et al. described the SCI severity scale
developed at the Yale University [7]. The Motor Severity
Scale differentiated quadriplegic, paraplegic, quadriparetic
and paraparetic patients. The author criticised the classification schemes that describe the extent of neurological
deficit with vague criteria such as significant, greater or
lesser, satisfactory or unsatisfactory and also the terms
discussed in the present article such as “complete” and
“incomplete”. Later, Bracken et al. presented a motor and
sensory examination scale in The National Acute Spinal
Cord Injury Study (NASCIS) I and II [5, 6]. The authors
presented a definition of complete and incomplete lesion.
At admission, complete lesions were defined as the level
below which there are no motor and sensory functions.
Incomplete lesions were characterised by residual motor
and/or sensory functions. Patients were also categorised
according to the degree of the paralysis.
In 1982, the American Spinal Cord Injury Association
(ASIA) presented in Chicago the “Standards for the
Neurological Classification of Spinal Injury Patients”,
which was published in 1984 [1]. The Frankel scale was
incorporated as the “ASIA impairment scale” to be the
functional abilities assessment tool. The ASIA assessment
tool underwent periodic reviews (1982, 1987, 1990, 1992,
1996, 2000, and 2002). SCI was divided into incomplete
and complete lesions which were further categorised into
five groups.
The international standards booklet for neurological and
functional classification of SCI defined that paraplegia
refers to the impairment or loss of motor and/or sensory
function in the thoracic, lumbar or sacral segments of the
spinal cord secondary to damage of neural elements within
the spinal canal. The use of the terms quadriparesis and
paraparesis was discouraged by Ditunno et al. as these
words described incomplete lesions imprecisely. Instead,
they suggested that the ASIA impairment scale provided a
more precise approach [12].
The origin of the confusion between the terms
Since ASIA defined paraplegia as loss or impairment of motor
and/or sensory function, it assumes that paraplegic patients
can have a complete or incomplete SCI. Incomplete lesions
are categorised as ASIA impairment scale B, C or D. In fact,
ASIA C and D, include paraparetic patients, defined by
ASIA as paraplegic patients that present an incomplete lesion.
The definition of paraplegia proposed by ASIA unites two
different neurological situations: paraparesis and paraplegia.
This simplification of the traditional nomenclature supported
the antagonist nomenclature of incomplete paraplegia that
had been used as a category of SCI [28].
In 1985, the Rancho Spinal Cord Injury Data Base was
established to enable a prospective collection of neurolog-
Paraparesis or incomplete paraplegia?
ical information on motor and sensory recovery and
functional outcome following SCI. Waters et al. published
a series of four reports relating to neurological recovery in
traumatic SCI patients classified as complete paraplegia,
complete tetraplegia, incomplete tetraplegia and incomplete
paraplegia [27–30]. In 1994, they replaced the term paraparesis by incomplete paraplegia and included those with
ASIA B, C and D as their incomplete paraplegic patients.
[28]. Later, in 1998, the term incomplete paraplegia was
used by Cohen et al. in an article entitled Test of the
International Standards for Neurological and Functional
Classification of Spinal Cord Injury [9].
It is important to point out that the first paper using the
term “incomplete paraplegia” was published in the British
Journal of Urology in March of 1956, before the paper of
Waters in 1994 [28], and was entitled, “Lesions of the
bladder in incomplete paraplegia” [4]. Furthermore, the first
use of the term “paraparesis” located using the electronic
search tool was in 1951 in an article entitled, “Cases of
spastic paraparesis treated by resection of the sympathetic
nerve; results after 16 years” published in the Acta
Chirurgica Patavina [8]. Nevertheless, Waters et al. were
the first to establish a correlation between incomplete
paraplegia and the ASIA scale.
The classical terminologies in neurologic examination
According to DeJong “paraplegia is the paralysis of the legs
or the lower parts of the body; tetraplegia is the paralysis of
all four extremities”. “Paralysis is the absence of strength
while paresis is the impairment of strength or weakness”
[11]. Peter Duss reports that “when the weakness is
incomplete it is called paresis rather than plegia. Thus, a
bilateral lesion in the upper cervical spinal cord can cause
quadriparesis or quadriplegia” [13]. DeJong states that the
complete transection of the spinal cord causes isolation of
the segments below the level of the lesion. In these cases
the paralysis and sensory loss are symmetric and total. In
incomplete transection the resulting signs and symptoms
will depend upon the pathways and cellular structures
involved [10]. Michaelis and Braakman defined “complete
lesion” similarly to DeJong′s “complete transection” and
also reported that it is essential to examine the S3, S4, S5
dermatomes, both around the anus and on the glans penis,
to exclude or confirm sacral sparing [22].
The frequency of usage of the terms “incomplete
paraplegia” versus “paraparesis”
On the 27th of April, 2008, a PubMED search, with the
descriptor “incomplete paraplegia” (using the limit “Default
Tag Title”) yielded eleven references. The same search
using the descriptor “paraparesis” yielded 905 papers.
Among the eleven papers using the former, two were not
in the English language, one being French [2] and the other
in Chinese [32]. Among the nine English papers, three were
published in rehabilitation journals [17–19], one in physiotherapist journal [25] and another in a urological periodical
[4]. The other four papers were published in the following
journals:- “Spinal Cord” [16], “Spinal Cord Med.”[3], “J
Neurotrauma” [31] and “Spine” [20].
Discussion
Early in 1969 Michaelis et al. published “the International
inquiry on neurological terminology and prognosis in
paraplegia and tetraplegia” to establish an international
agreement on neurological terminology. He stated that the
term incomplete lesion was vague and meant anything
between only sacral sparing, complete motor-paralysis but
substantial sensory sparing and incomplete motor and
sensory paralysis. However, the authors did not apply the
terms paraplegia and paraparesis. Instead, they used
“complete motor paralysis” and “incomplete motor paralysis” [23].
Classical neurological examination nomenclature defines
that paraplegia is the paralysis of the legs or the lower parts
of the body. Paralysis is the absence of strength while
paresis is the impairment of strength or weakness [11, 13].
The American Spinal Injury Association SCI assessment
tool is widely used in multi-centre studies. It is considered
as a level 2 recommendation and is the accepted “goldstandard” assessment tool for clinicians involved in the care
of SCI patients [24]. However, in relation to neurological
examination, the system has to be in accordance to classical
nomenclature.
The classical terms paraplegia and paraparesis were
joined in the ASIA definition of paraplegia. The term
incomplete paraplegia reinforced the concept that a
paraplegic patient can have an incomplete lesion. Another
equivocal was to include sensory function in the definition
of paraplegia which is in fact a descriptor of motor
strength [12].
Paraplegia is a well-established definition that occurs in
complete (ASIA A) or incomplete (ASIA B) spinal cord
lesions. These terms, complete and incomplete, are adequately used to characterise the completeness of spinal cord
lesions but inadequately used as a qualifier. The unique
incomplete SCI with paraplegia describes the patient with
ASIA B category.
The electronic search with “incomplete paraplegia”
revealed that the term is not frequently used. Although
Ditunno et al. have discouraged the use of “paraparesis”
describing it as imprecise, current literature has shown it is
in frequent use [12].
A.C. Evangelista Santos Barcelos et al.
The neurosurgeons and other clinicians involved in the
care of SCI patients should realise that the terms paraparesis
and incomplete paraplegia cannot be used interchangeably.
In fact, the latter should not be used at all because it carries
a contradiction. Neurological examination scales do not
substitute or redefine the classical nomenclature.
Conclusion
The term incomplete paraplegia is in disagreement with the
classical terms used to describe sensory and motor function
in SCI patients. The term paraplegia should only be applied
to describe complete loss of motor strength and not to the
impairment of motor function.
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