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History Taking Format for Paraparesis
1. Patient Details
Name, Age, Sex, Occupation, Address
2. Presenting Complaint
Weakness of both lower limbs (paraparesis)
Duration and progression
3. History of Presenting Illness
Clarification:
What does the patient mean by weakness? (Loss of strength, heaviness, stiffness, difficulty walking, or coordination problems)2
Onset:
Progression:
Distribution:
Is it equal in both legs? Proximal, distal, or both?
Any involvement of upper limbs or trunk?
Associated symptoms:
Stiffness or spasticity in legs
Numbness, tingling, or sensory loss (ask about level of sensory change)2345
Pain in back or legs
Bladder or bowel disturbances (urgency, retention, incontinence)2345
Sexual dysfunction
Muscle cramps or spasms
Gait disturbances, balance issues, or falls
Visual symptoms, hearing loss, cognitive changes (suggests complicated HSP or other CNS involvement)45
Preceding events:
Recent trauma, infection (fever, sore throat, diarrhea), vaccination, surgery, or exposure to toxins2
Previous episodes:
Effect on daily activities:
Difficulty walking, standing, climbing stairs, or self-care
4. Past Medical History
Previous neurological illness (stroke, myelitis, multiple sclerosis, GBS)
Chronic illnesses (diabetes, hypertension, vitamin B12 deficiency)
Previous spinal trauma or surgery
5. Drug History
Recent or current medications (especially those affecting the nervous system)
Any recent changes or use of alternative therapies
Exposure to toxins (lead, drugs)
6. Family History
7. Personal and Social History
Smoking, alcohol, substance use
Diet (especially B12 intake)
Occupational exposures (toxins, heavy metals)
Recent travel (risk for infections)
8. Systemic Enquiry
Fever, weight loss, night sweats (suggests infection or malignancy)
Visual, hearing, speech, or cognitive symptoms
Symptoms of connective tissue disease (rash, joint pain)
Case History 1
Personal Details:
Mr. Rohan Desai, 35-year-old male, office worker
Presenting Complaint:
Progressive weakness in both legs for 6 weeks
History of Presenting Illness:
Mr. Desai reports gradual onset of stiffness and weakness in both legs over the past 6 weeks. Initially, he noticed difficulty climbing stairs and rising from a chair. The weakness has progressively worsened, now affecting his ability to walk without support. He describes his legs as "heavy" and "stiff," particularly in the mornings.
Associated Symptoms:
Mild numbness below the waist (no sharp sensory level)
Urinary urgency and occasional incontinence for 2 weeks
No back pain, trauma, or fever
No upper limb weakness, visual changes, or speech difficulties
Precipitating Factors:
No recent infections, vaccinations, or travel
No history of heavy lifting or spinal injury
Previous Episodes:
No similar complaints in the past
Past Medical History:
No chronic illnesses (diabetes, hypertension, thyroid disorders)
No prior surgeries or hospitalizations
Drug History:
No regular medications
No history of steroid use or immunosuppressants
Family History:
Father and paternal uncle had similar leg weakness in their 40s (undiagnosed but attributed to "hereditary nerve weakness")
Personal/Social History:
Vegetarian diet for 15 years
Non-smoker, occasional alcohol use
Sedentary lifestyle
Socioeconomic History:
Middle-class, lives with family in an urban area
Access to healthcare
Systemic Enquiry:
No weight loss, night sweats, or fatigue
No joint pain or skin rashes
Case Summary
A 35-year-old male with a family history of similar symptoms presents with progressive spastic paraparesis (stiffness and weakness in both legs), urinary urgency, and numbness below the waist. No back pain, trauma, or systemic symptoms.
Differential Diagnosis
Hereditary Spastic Paraplegia (HSP)
Most likely: Insidious onset, family history, and progressive spasticity without sensory deficits.
Compressive Myelopathy (e.g., spinal tumor, disc herniation)
Requires imaging (MRI spine) to rule out structural causes.
Multiple Sclerosis (MS)
Possible with spinal cord involvement, but absence of optic neuritis or relapsing-remitting history makes it less likely.
Vitamin B12 Deficiency Myelopathy
Suspect due to vegetarian diet; subacute combined degeneration can cause paraparesis with sensory and bladder symptoms.
Transverse Myelitis
Less likely without preceding infection or rapid progression.
Amyotrophic Lateral Sclerosis (ALS)
Rare at this age; typically involves upper and lower motor neurons with fasciculations.
Spinal Cord Infarction
Sudden onset is typical, but gradual progression in this case makes it un
Case History
Personal Details:
Mr. Ramesh Kumar, 42-year-old male, farmer
Presenting Complaint:
Progressive weakness in both lower limbs for 3 months
Inability to walk for 1 week
History of Presenting Illness:
Mr. Ramesh Kumar was apparently well 3 months ago when he began experiencing dull, aching pain in his mid-back, which was persistent and gradually worsening. About 2 months ago, he noticed tingling and numbness below his umbilicus, followed by increasing heaviness and stiffness in both legs. Over the next several weeks, he developed progressive weakness in both lower limbs, initially having difficulty climbing stairs and rising from a squatting position. The weakness worsened, and for the past week, he has been unable to walk without support.
He also reports urinary urgency and occasional incontinence for the last 10 days. There is no history of trauma, fever, weight loss, or night sweats. He denies any upper limb weakness, visual disturbances, or difficulty with speech or swallowing.
He has no history of tuberculosis in the past, nor contact with known TB patients. No recent infections, trauma, or surgery.
Past Medical History:
No known diabetes, hypertension, or immunosuppressive conditions
No prior history of TB or chronic illness
Drug History:
Not on any regular medications
No history of steroid or immunosuppressive use
Family History:
No family history of tuberculosis or neurological disorders
Personal and Social History:
Lives in a rural area with limited access to healthcare
Low socioeconomic status
Non-smoker, non-alcoholic
Diet: Mixed, but reports recent loss of appetite
Systemic Enquiry:
No cough, hemoptysis, or respiratory symptoms
No chest pain or palpitations
No bowel incontinence, but occasional constipation
Case Summary
A 42-year-old male presents with a 3-month history of progressive mid-back pain, followed by tingling, numbness, and gradually worsening weakness and stiffness of both lower limbs, leading to inability to walk and urinary incontinence. There is no trauma, fever, or constitutional symptoms. No past or family history of TB.
Differential Diagnosis
Spinal Tuberculosis (Pott’s Disease) with Paraparesis
Compressive Myelopathy (Spinal Tumor or Metastasis)
Could present similarly but less likely without constitutional symptoms or a known malignancy.
Transverse Myelitis
Usually presents more acutely and often with preceding infection or autoimmune symptoms.
Degenerative Spine Disease with Cord Compression
More common in older age; progression may be slower and less likely to have systemic features.
Epidural Abscess (Pyogenic)
Usually more acute, with fever and systemic toxicity.
Multiple Sclerosis or Demyelinating Disease
Less likely with this pattern and age, but should be considered if imaging is inconclusive.
Supporting Details from Literature
Spinal TB is a common cause of paraparesis in endemic regions and often presents with chronic back pain, neurological deficits, and sometimes bladder involvement1458.
MRI is the investigation of choice, showing vertebral body destruction, disc involvement, and possible abscess formation148.
Early diagnosis and treatment (antitubercular therapy, sometimes surgery) are crucial to prevent permanent disability
Viva Questions and Answers on Paraparesis (with focus on TB spine)
1. What is paraparesis?
Paraparesis is partial weakness (incomplete paralysis) affecting both lower limbs17.
2. What is the difference between paraparesis and paraplegia?
Paraparesis is weakness of both lower limbs, while paraplegia is complete paralysis of both lower limbs57.
3. What are the most common causes of paraparesis in adults?
Compressive myelopathy (e.g., spinal tuberculosis, tumors, trauma)
Demyelinating diseases (e.g., multiple sclerosis)
Hereditary spastic paraplegia
4. What is Pott’s spine?
Pott’s spine is tuberculosis of the vertebral column, commonly affecting the thoracic and lumbar vertebrae, leading to destruction, deformity, and possible spinal cord compression.
5. How does spinal TB typically present?
Chronic back pain
Constitutional symptoms (may be absent)
Progressive paraparesis
Sensory loss below the level of lesion
Bladder/bowel disturbances
6. What are the risk factors for spinal tuberculosis?
Immunosuppression (HIV, diabetes)
Malnutrition
Previous TB infection or contact
Low socioeconomic status
7. What are the clinical features of compressive myelopathy?
Weakness and stiffness of lower limbs
Sensory loss below the lesion
Bladder and bowel dysfunction
Spasticity and exaggerated reflexes
8. How do you differentiate between upper motor neuron (UMN) and lower motor neuron (LMN) paraparesis?
UMN: Spasticity, hyperreflexia, Babinski sign
LMN: Flaccidity, hyporeflexia, muscle atrophy56.
9. What is the pathophysiology of paraparesis in spinal TB?
Destruction of vertebral bodies and intervertebral discs leads to collapse, deformity, and compression of the spinal cord or nerve roots.
10. What are the common sites of involvement in Pott’s spine?
Thoracic and lumbar vertebrae are most commonly affected.
11. What investigations would you order for suspected spinal TB?
MRI spine (gold standard for early detection)
X-ray spine
ESR, CRP
Tuberculin skin test, GeneXpert, AFB from biopsy
CBC, HIV screening2.
12. What are the differential diagnoses for paraparesis?
13. How do you confirm the diagnosis of spinal TB?
MRI findings, microbiological confirmation (AFB, GeneXpert), and histopathology from biopsy.
14. What is the treatment of spinal tuberculosis?
Anti-tubercular therapy (ATT) for at least 12 months
Surgical decompression if there is severe neurological deficit, spinal instability, or abscess formation
15. What are the indications for surgery in spinal TB?
Progressive neurological deficit
Spinal instability
Large abscess not responding to medical therapy
Severe deformity
16. How do you monitor the response to treatment in paraparesis?
Clinical improvement in power, sensation, and bladder function
Repeat MRI if needed
Regular neurological exams1.
17. What complications can arise from untreated spinal TB?
Permanent paralysis
Severe spinal deformity (kyphosis)
Chronic pain
Secondary infections
18. What is the prognosis for paraparesis due to spinal TB?
With early diagnosis and treatment, prognosis is good. Delayed treatment can result in permanent neurological deficits.
19. How is hereditary spastic paraparesis different from compressive myelopathy?
Hereditary spastic paraparesis is slowly progressive, often familial, with pure motor involvement and minimal sensory or bladder symptoms1.
20. What supportive therapies are important in paraparesis management?
Physiotherapy and rehabilitation
Bladder and bowel care
Nutritional support
Prevention of pressure sores and contractures1.
21. What are the main non-tuberculous infectious causes of paraparesis?
Other than TB, paraparesis can result from pyogenic (bacterial) spinal infections, fungal infections, and syphilitic involvement of the spinal cord1.
22. How can spinal tumors cause paraparesis?
Spinal tumors (primary or metastatic) can compress the spinal cord or cauda equina, leading to progressive weakness, sensory changes, and sphincter disturbances.
23. What is transverse myelitis and how does it present?
Transverse myelitis is an acute inflammatory disorder of the spinal cord, often presenting with rapid onset paraparesis, sensory level, and bladder/bowel dysfunction.
24. What is the role of trauma in causing paraparesis?
Spinal trauma (fracture, dislocation, or hematoma) can cause acute or subacute paraparesis due to direct cord injury or compression.
25. How does multiple sclerosis (MS) cause paraparesis?
MS causes demyelination in the spinal cord and brain, leading to relapsing or progressive paraparesis, often with sensory and visual symptoms.
26. Can vascular causes lead to paraparesis?
Yes, spinal cord infarction (due to anterior spinal artery thrombosis or embolism) can cause sudden-onset paraparesis, often with pain and loss of sphincter control56.
27. What is hereditary spastic paraplegia?
It is a group of inherited disorders characterized by slowly progressive spastic weakness of the lower limbs, often with minimal sensory or bladder involvement.
28. How can vitamin B12 deficiency lead to paraparesis?
Vitamin B12 deficiency causes subacute combined degeneration of the spinal cord, resulting in progressive paraparesis with sensory ataxia and bladder symptoms.
29. What is syringomyelia and how does it present?
Syringomyelia is a cystic cavity in the spinal cord, often presenting with dissociated sensory loss and progressive paraparesis.
30. How do epidural abscesses cause paraparesis?
Epidural abscesses compress the spinal cord acutely or subacutely, causing pain, fever, and rapidly progressive paraparesis.
31. Can syphilis cause paraparesis?
Yes, neurosyphilis (tabes dorsalis or meningovascular syphilis) can cause chronic progressive paraparesis with sensory and sphincter involvement1.
32. What is the impact of spinal anesthesia or intrathecal medications on paraparesis?
Complications from spinal anesthesia or intrathecal drug administration can cause direct cord injury or infection, leading to paraparesis1.
33. How do autoimmune diseases cause paraparesis?
Autoimmune conditions (like SLE, sarcoidosis) can cause myelitis, resulting in acute or subacute paraparesis.
34. What is the significance of non-osseous spinal tuberculosis?
Non-osseous spinal TB may cause paraparesis via intradural or intramedullary tuberculomas, granulomas, or arachnoiditis, even without bone involvement15.
35. How does HIV infection predispose to paraparesis?
HIV increases susceptibility to opportunistic infections (CMV, HSV, fungal, TB), neoplasms, and HIV-associated myelopathy, all of which can cause paraparesis5.
36. Can metabolic or toxic causes result in paraparesis?
Yes, toxins (lead, arsenic), severe hypokalemia, or metabolic myelopathies can cause acute or subacute paraparesis.
37. What is the role of congenital malformations in paraparesis?
Congenital conditions like tethered cord syndrome or spina bifida can cause chronic paraparesis, often noticed in childhood.
38. How does Guillain-Barré syndrome (GBS) present in relation to paraparesis?
GBS typically causes ascending symmetrical weakness, which may initially present as paraparesis before progressing to quadriparesis.
39. What are the clinical features that help distinguish compressive from non-compressive causes of paraparesis?
Compressive causes often present with back pain, a clear sensory level, and rapid progression, while non-compressive causes may have more diffuse or gradual symptoms.
40. Why is MRI the investigation of choice in evaluating paraparesis?
MRI provides detailed images of the spinal cord, vertebrae, and surrounding tissues, helping to identify compressive lesions, inflammation, infection, demyelination, or vascular events.