Poliomyelitis

By: Dr. Masoud Shayesteh Azar

Associate Professor, Orthopaedic Department,

Mazandaran University

Poliomyelitis

polio= gray matter

Myelitis= inflammation of the spinal cord

Poliomyelitis

First described by Michael Underwood in 1789

First outbreak described in U.S. in 1843

21,000 paralytic cases reported in the U. S. in 1952

Global eradication in near future

Poliomyelitis

Poliomyelitis, literally meaning “gray spinal

cord inflammation

It is a viral infection

There are three types of poliovirus and

many strains of each type

It is contagious: usually spread from person

to person.

Only harmful to humans

The Poliovirus

Virus localized in the anterior horn cells of the spinal cord and certain brain steam motor nuclei.

Poliovirus

Enterovirus (RNA)

Three serotypes: 1, 2, 3

Minimal heterotypic immunity between serotypes

Rapidly inactivated by heat, formaldehyde, chlorine, ultraviolet light

Poliomyelitis Pathogenesis

Entry into mouth

Replication in pharynx, GI tract, local lymphatics

Hematologic spread to lymphatics and central nervous system

Viral spread along nerve fibers

Destruction of motor neurons

Poliomyelitis Pathogenesis

The ant. Horn motor cells may be damaged

by viral multiplication or toxic byproducts of

the virus or indirectly by ischemia, edema,

and hemorrhage in the glial tissues.

Destruction of the spinal cord occurs focally

and within 3 days wallerian degeneration is

evident.

poliomyelitis

Most affects children under the age of 5

years in developing tropical countries.

Incubation period ranges from 6 to 20 days

What are the symptoms?

Acute stage: generally lasts 7 to 10 days.

Many include fever, pharyngitis, headache,

anorexia, nausea, and vomiting. Illness may

progress to aseptic meningitis and

menigoencephalitis in 1% to 4% of patients.

These patients develop a higher fever &

sever headache with stiffness of the neck

and back.

What are the symptoms?

Paralytic disease occurs 0.1% to 1% of those

who become infected with the polio virus.

Paralysis of the respiratory muscles or from

cardiac arrest if the neurons in the medulla

oblongata are destroyed.

Clinical course

Symptoms range :from mild malaise to

generalized encephalomyelitis with

widespread paralysis.

Hyperesthesia or paresthesia in the

extremities and muscular pain is common.

Muscles are tender even to gentle palpation.

Poliomyelitis

According to Sharrard, weakness is clinically

detectable only when more than 60% of the

nerve cells supplying the muscle have been

destroyed.

Paralysis occurs twice as often in the lower

extremity as in upper extremity.

Poliomyelitis

The most commonly affected muscles are the

Quadriceps, glutei, tibialis anterior, medial

hamstrings, and hip flexors.

Deltoid, triceps, and pectoralis major.

Poliomyelitis

Patients have some or full recovery from

paralysis, most clinical recovery occurs

during the 1 month and almost complete

within 6 months.

Limited recovery may occur for about 2

years.

Poliomyelitis

In cases with paralysis superficial reflexes

usually are absent first, and deep tendon

reflexes disappear when the muscle group

is paralyzed.

DDX.: Guillain-Barre syndrome, and other

forms of encephalomyelitis

Treatment in the acute stage

Bed rest, analgesics, hot packs, and

anatomical positioning of the limbs

gentle passive ROM exercises of all joints

Treatment in the acute stage

close monitoring of respiratory and

cardiovascular functioning is essential during

the acute stage of poliomyelitis along with

fever control and pain relievers for muscle

spasms.

Mechanical ventilation, respiratory therapy may

be needed depending of the severity of

patients.

Convalescent stage

From 2 days after the temperature return to

normal and continues for 2 years

Muscle power improves

Physical therapy is recommended for full

recovery.

Passive stretching exercises and wedging

casts can be used for mild to moderate

contractures.

Convalescent stage

Surgical release of tight fascia and muscle

aponeuroses and lengthening of tendons

may be necessary for contractures

persisting longer than 6 months.

Orthoses should be used until no further

recovery is anticipated.

Chronic stage

24 months after the active illness:

The goals of treatment include correcting any

significant muscle imbalance and

preventing or correcting soft tissue or bony

deformities.

Chronic stage

Static joint instability can be controlled by

Orthoses.

Dynamic joint instability result in a fixed

deformity that cannot be controlled by

Orthoses.

Chronic stage

Soft tissue surgery, such as tendon transfers,

should be done in young children before

the development of any fixed bony

changes.

Bony procedures for correcting a deformity

can be delayed until skeletal growth is near

completion.

Global eradication in near future

Prevention

Prevention

Prevention

Immunization of the young continues

Wild Poliovirus 1988

National Immunization Program

Centers for Disease Control and Prevention

Wild Poliovirus 2004

National Immunization Program

Centers for Disease Control and

Prevention

National Immunization Program

Centers for Disease Control and Prevention

National Immunization Program

Centers for Disease Control and Prevention

Study

We study 246 patient with polio in Sari

Male:156 cases (63/4%)

female: 90 cases (36/6%)

age :22 to 63 years old main age 46/3

One lower limb: 164 cases (66/6%)

Both lower limb: 62 cases (25/2 %)

Both lower limb together with upper limb 10

cases (4/1% )

Result:

From 246 patients ;108 used brace

56 patients needs brace but not used

187 operation has down for these patients

97 patients more than one operation has down

82 patients have mild symptoms and don’t need

To any operation or brace.

Result:

From 187 operation :

53 cases; ankle triple arthrodesis

81 cases; tendon transfer EHL to dorsum

foot

10 cases; other kind of tendon transfers

11 cases; ATL

8 cases; lower limb lengthening

Result:

2 cases; Ephypisodesis

1 case; ankle fusion

23 cases; toe deformity correction

53 cases; soft tissue release for knee and hip

flexion contracture

37 cases; osteotomy around knee

Result:

Very important point

No any new case in last 10 years

reported.