Spastic paraplegia is a neurological syndrome that may be seen in numerous conditions that affect the spinal cord, primarily of vascular and inflammatory origin. The clinical presentation encompasses a variable degree of motor and sensory loss of the lower limbs, as well as bladder abnormalities and improper sphincter control. The diagnosis and the underlying cause can be revealed through a detailed neurological workup comprised of a lumbar puncture, imaging studies, and a thorough clinical examination.
Spastic paraplegia is roughly defined as the weakness of the lower limbs accompanied by neurological deficits of the sensory, motor, and autonomic nervous system  . Causes of spastic paraplegia are diverse. Ischemia of the spinal cord, from either damage or obstruction of the blood vessels supplying the lower portion of the spinal cord (the posterior and anterior spinal arteries), can arise from atherosclerosis, the formation of aneurysms, dissections, or trauma     . Conversely, hemorrhagic events (epidural, subdural, subarachnoid hemorrhage or hematomyelia) are important vascular disorders as well, whereas a number of inflammatory and infectious processes (spondylodiscitis, myelitis, abscesses in the epidural/subdural spaces, multiple sclerosis, etc.), but also genetic diseases (adrenoleukodystrophy) affecting the spinal cord might manifest with spastic paraplegia   . In addition, surgery should also be included as a possible etiology  . Apart from weakness and impaired motor and sensory activity of the lower limbs, loss of bladder and anal sphincter control, as well as gait disturbances, are hallmarks of spastic paraplegia  . Symptoms sometimes appear after minutes (in the case of vascular events), or days and even weeks after an infectious or inflammatory process is responsible for spinal cord damage (in which case fever frequently accompanies neurological signs) , while a transient clinical course is also described . Spastic paraplegia can be severely debilitating and result in a marked quality of life reduction, and some studies have implicated the psychological burden of this condition in many patients .
Because of the fact that numerous conditions comprise this neurological syndrome in its clinical presentation (but also because time is of the essence when it comes to neurological injury), it is necessary to conduct a rapid but comprehensive clinical, laboratory, and imaging workup. Firstly, physicians should a obtain a detailed patient history that reveals preexisting disorders or events (eg. trauma) and assesses the course and progression of symptoms, whereas a properly conducted neurological examination (evaluation of sensory and motor function) can be sufficient to recognize spastic paraplegia . As soon as clinical suspicion is raised, imaging studies of the thoracic and lumbar spine in the form of magnetic resonance imaging (MRI), particularly contrast-enhanced and diffusion-weighed imaging (DWI), must be employed  . A lumbar puncture is also a key component of the diagnostic workup in patients with spastic paraplegia, as it can provide clear indications whether an infectious or inflammatory process is active, by showing an increased cell count (pleocytosis) and predominance of neutrophils/lymphocytes, while the content of protein and glucose in the cerebrospinal fluid is equally important . If the diagnosis is still not conclusive, imaging studies should cover the endocranium and evoked potentials may be necessary, in order to exclude demyelinating diseases .