Transcript SGD: SPINE

SGD: SPINE
A Cautionary Tale
BLOCK 5
GENERAL DATA
ALANGILAN, Ronalyn
21/F
Nursing Student
Right-handed
Sta. Ana Manila
DOA: October 1, 2009
HISTORY of PRESENT ILLNESS
2 months PTA
(+) nape pain, VAS 4-5/10
(+) fatigue; (+) easy fatigability
(-) sensory deficits
(-) bowel and bladder incontinence
(+) Consult with private MD  unrecalled
meds, no relief
HISTORY of PRESENT ILLNESS
2 weeks PTA
(+) bilateral LE weakness, left first then right
(+) difficulty in ambulation - community
ambulator
(-) sensory deficits
(-) bowel and bladder incontinence
(+) Consult with albularyo  no relief
HISTORY of PRESENT ILLNESS
1 week PTA
(+) bilateral LE numbness
(+) constipation
(+) urinary retention
(+) difficulty in ambulation - home ambulator with
help
HISTORY of PRESENT ILLNESS
1 day PTA
(+) consult at PGH ED
foley catheter inserted; for OPD ff-up
HISTORY of PRESENT ILLNESS
On day of admission
(+) consult at PGH ED; laboratories and
imaging done  admitted at spine unit-Pay.
ROS: (-) weight loss, (-) cough and colds,
(+) intermittent fever lysed with paracetamol,
(+) slight DOB; (+) malaise, (+) easy fatigability,
(+) dysuria, (+) urinary retention, (-) night
sweats (+) constipation, (-) Hx of trauma
PAST MEDICAL HISTORY
(+) PTB exposure – school
No previous hospitalizations
No food or drug allergies
FAMILY MEDICAL HISTORY
(-) PTB
(+) HTN – father
(-) DM, BA, CA, goiter, liver disease, kidney
disease, heart disease
PERSONAL SOCIAL PROFILE
No vices
2nd year nursing student with ward and local
health center exposure
1 non-promiscuous sexual partner
Lives at home with mother and sibling in a 2storey building; father works abroad as a
seaman
PE on ADMISSION
Stretcher-borne, awake, coherent, NICRD
BP 110/70 HR 76 RR 20 Temp afebrile
AS, PC, (-) CLAD, (-) NVE, (-) ANM
ECE, CBS, (-) r/w
AP, DHS, NRRR, (-) murmur
Soft, flabby, nontender abdomen, NABS
PNB, FEP, GCR, (-) cyanosis, (-) edema
GCS 15, oriented to 3 spheres, CNs intact
NE on ADMISSION
UPPER LIMB MOTOR FUNCTION
C5
C6
C7
C8
T1
R
5
5
5
5
5
L
5
5
5
5
5
Elbow flexors
Wrist extensors
Elbow extensors
Finger flexors
Finger abductors
NE on ADMISSION
LOWER LIMB MOTOR FUNCTION
L2
L3
L4
L5
S1
S4-S5
R
L
0
0
Hip flexors
0
0
Knee extensors
0
0
Ankle dorsiflexors
0
0
Long toe extensors
0
0
Ankle plantar flexors
(-) bowel incontinence
NE on ADMISSION
SENSORY FUNCTION: Light Touch
C2-T5
T6-L2
L3
L4
S4-S5
R
2
1
0
0
0
L
2
1
1
0
0
0
Absent
1
Impaired
2
Normal
NE on ADMISSION
SENSORY FUNCTION: Vibration
(+) vibration, UE
(+) decreased, R ASIS
(-) L ASIS
(-) bilateral patella
NE on ADMISSION
REFLEXES
R
Biceps
2+
Triceps
2+
Brachioradialis 2+
Patellar
3+
Ankle
4+
L
2+
2+
2+
4+
4+
(+) babinski, B
(+) clonus, B
LABS on ADMISSION
CBC: Hgb 114, Hct 0.349, WBC 8.8, Plt Ct 287, Neut%
0.890, Lymph 0.101%, Mono% 0.007, Eos% 0.000,
Baso% 0.002
AFB SMEAR x 3: No acid fast bacilli seen
URINALYSIS: yellow, turbid, SG 1.030, pH 6.5, RBC
3/hpf ↑, WBC 7/hpf ↑, Bacteria 8,536/hpf ↑, few
epithelial cells, no casts
LABS on ADMISSION
PT: 13 / 12.9 / 0.91 / INR 1.24
aPTT: 36.9 / 33.1
ECG: Sinus rhythm, normal axis
BLOOD CHEM: BUN 3.53, Crea 43, Na 141, K 3.9
URINE GS/CS: 100,000 colonies of E. coli
IMAGING
T1
T2
T3
T4
SUMMARY OF THE CASE
• 21/F Nursing Student with a chief complaint of neck
pain and history of PTB exposure
– 2-week history of progressive sensory deficit with deficit
starting T6 level
– 1-week history of progressive motor deficit with deficit
starting L2 level
– Associated with fever, malaise, easy fatigability, & urinary
and bowel changes; (-) weight loss, (-) anorexia
– Normal pulmonary PE w/ (-) AFB smear; (-) cough
– UMN signs: hyperreflexia with babinski and clonus
– MRI showing compressive deformity of vertebra of T1-T2
level with soft tissue involvement
ASSESSMENT
Spinal Cord Compression, ASIA B, C7 last
normal level, compression deformity T1T2 level secondary to Pott’s disease
DISCUSSION:
POTT DISEASE
POTT DISEASE
“…a tuberculous osteomyelitis of the
spine that leads to compression of
vertebral bodies and a highly
characteristic kyphotic deformity at
the thoracic or upper lumbar level ”
POTT PARAPLEGIA
“…pus or caseous granulation tissue
may extrude from an infected
vertebra and gives rise to an epidural
compression of the cord ”
PATHOPHYSIOLOGY
• Result of activation of tuberculosis at a site
established by hematogenous spread.
• Infectious endarteritis causes bone necrosis
and collapse of a thoracic or upper lumbar
(less often cervical) vertebral body resulting
in a highly characteristic angulated kyphotic
deformity.
CLINICAL PRESENTATION
• Slight compression/mild symptoms
 pain in the back
 slight muscle weakness
 Tingling sensation
 other changes in sensation
 difficulty initiating and maintaining an erection (erectile
dysfunction, in men)
 Pain may radiate down a leg, sometimes to the foot
 exaggerated reflexes
 muscle spasms and increased sweating
CLINICAL PRESENTATION
• Substantial compression/severe symptoms
 block most nerve impulses
 severe muscle weakness, numbness
 paralysis and complete loss of sensation
 loss of bladder and bowel control
 A belt-like band of discomfort may be felt at the level of
spinal cord compression.
 Once compression begins to cause symptoms, damage
usually worsens from minimal to substantial unpredictably
but rapidly in a few hours to a few days.
DISCUSSION:
ASIA CLASSIFICATION
American Spinal Injury Association
(ASIA) Classification
• A - "complete" spinal cord injury
• no motor or sensory function is preserved in the sacral segments
S4-S5.
• B - "incomplete" spinal cord injury
• sensory but not motor function is preserved below the
neurological level and includes the sacral segments S4-S5.
• C - "incomplete" spinal cord injury
• motor function is preserved below the neurological level and more
than half of key muscles below the neurological level have a
muscle grade of less than 3, which indicates active movement with
full range of motion against gravity.
• D - "incomplete" spinal cord injury
• motor function is preserved below the neurological
level and at least half of the key muscles below the
neurological level have a muscle grade of 3 or more.
• E - "normal"
• it is possible to have spinal cord injury and neurological
deficits with completely normal motor and sensory
scores.
DISCUSSION:
CLINICAL SYNDROMES
Clinical Syndromes associated with
incomplete spinal cord injuries
• Central cord syndrome
– associated with greater loss of upper limb function
compared to lower limbs
• Brown-Séquard syndrome
– injury to one side with the spinal cord, causing weakness
and loss of proprioception on the side of the injury and
loss of pain and thermal sensation of the other side
• Anterior cord syndrome
– injury to the anterior part of the spinal cord, causing
weakness and loss of pain and thermal sensations below
the injury site but preservation of proprioception that is
usually carried in the posterior part of the spinal cord.
• Tabes Dorsalis
– injury to the posterior part of the spinal cord,
usually from infection diseases such as syphilis,
causing loss of touch and proprioceptive
sensation.
• Conus medullaris syndrome
– injury to the tip of the spinal cord, located at L1
vertebra.
• Cauda equina syndrome
– injury to the spinal roots below the L1 vertebra.
DISCUSSION:
IMAGING & DIAGNOSIS
Radiologic Findings
• Lytic destruction of anterior portion of vertebral
body
• Increased anterior wedging
• Collapse of vertebral body
• Reactive sclerosis on a progressive lytic process
• Enlarged psoas shadow with or without
calcification
• Intervertebral disk spaces are decreased or
obliterated
• Fusiform paravertebral shadows suggest abscess
formation
Collapsed T9-11
and anterior
wedging
Day 0 – narrowed intervertebral disk
space, hazy vertebral body edges
Day 14 – collapse of vertebral bodies
• Vertebral collapse,
sever anterior
wedging
MRI
Bilateral
psoas
abscesses are
frequent
complication
in lumbar
involvement
Axial T2
demonstrate
marrow edema
at L2-L4. Right
paraspinal rim
enhancing fluid
is demonstrated
compatible with
a paraspinal
abscess.
DIAGNOSIS
• The diagnosis still depends on biopsy for culture
and pathologic examination of the affected tissue
because radiographs are not diagnostic.
• Imaging modalities such as CT or MRI however
help target the biopsy site.
• It is mentioned that MRI is the modality of
choice because it can discriminate between
abscess and granulation tissue and can delineate
soft tissue masses and identify the amount of
bone destruction.
DISCUSSION:
TREATMENT
TREATMENT: ANTI-KOCH’S
SITE
DURATION
RATING
Lymph node
Bone and joint
Pleural disease
Pericarditis
CNS
Disseminated
Genitourinary
Abdominal
6
6-9
6
6
9-12
6
6
6
Level 1
Level 1
Level 2
Level 2
Level 3
Level 2
Level 2
Level 1
TREATMENT: ADJUNCTIVE
SITE
CORTICOSTEROIDS
RATING
Lymph node
Bone and joint
Pleural disease
Pericarditis
CNS
Disseminated
Genitourinary
Abdominal
NOT RECOMMENDED
NOT RECOMMENDED
NOT RECOMMENDED
RECOMMENDED
STRONGLY REC.
NOT RECOMMENDED
NOT RECOMMENDED
NOT RECOMMENDED
Level 3
Level 3
Level 1
Level 2
Level 1
Level 3
Level 3
Level 3
TREATMENT: SURGERY
Surgery in addition to chemotherapy is indicated in the
following situations (Parthasarathy et al):
1. Those less than 25 years of age, in whom the initial
angle of kyphosis is more than 30°
2. Those who develop progressive kyphosis while on
ambulant chemotherapy
3. Children aged less than 10 years with destruction of
the vertebral bodies who have partial or no fusion
during the adolescent growth spurt
4. Those with compression of the spinal cord whose
neurological status deteriorates in spite of
chemotherapy
DISCUSSION:
ADDF
Anterior Decompression and Fusion
of the Spine
• A major surgery which utilizes a skin incision
over the front of the body to approach the
spine
• simple, requires less operative time, and
provides excellent exposure up to the level of
T2.
• There was no long-term morbidity attributed
to the approach and procedure (according to
study by MM. Prabhakar)
Indications
• Degenerative conditions causing compression of spinal
cord or spinal nerves, e.g. intervertebral disc prolapse,
posterior vertebral body osteophytes
• Instability of the spine
• Spine fracture
• Spinal tumour
• Spinal infection (usually tuberculous or bacterial)
• Spinal deformity
• Miscellaneous conditions causing spinal cord or spinal
nerve damage
Fig 1: Titanium plate and screw device
secured to the vertebral bodies
In the study.. Anterior Decompression
for Cervicothoracic Pathology: A
Study of 14 Patients MM Prabhakar,
MS1,2 and Tejas Thakker, MS2
The sternal-splitting approach from C4-T4
Method: left oblique incision along the
medial border of the
sternocleidomastoid muscle to the
sternal notch. The platysma was
incised, and the plane between the
carotid and tracheoesophageal
sheaths separated using the finger.
The anterior aspect of the low
cervical spine was exposed after
retracting the tracheoesophageal
sheath laterally. The strap muscles
were detached at their origins. The
lateral margin of dissection extended
to the longus colli muscle on either
side. Using metal markers, a
radiograph was taken to confirm the
target level. Using this low cervical
approach, exposure to the T2-T3
level obtained.
Sequential Surgical Procedure
Retractors placed to protect the soft
tissues of the neck
intervertebral discs are removed at
the level(s) to be decompressed
If multiple levels are to be
decompressed, surgeon may remove
the vertebral bodies between the
evacuated disc spaces --'corpectomy'.
Sequential Surgical Procedure
Bone and disc are removed down to
the level of the posterior longitudinal
ligament (PLL), which overlies the dura
directly.
After the spinal cord and nerve roots
have been decompressed at the
appropriate levels, the portions
removed must be reconstructed.
“Interbody grafts” - inserting bone
grafts within each disc space to have a
living bridge of bone between the
previously distinct vertebrae
“a
spine fusion “
Sequential Surgical Procedure
(1) patient's own bone (autograft) piece
of bone will be harvested from the ilium,
fibula or a rib
(2) banked human cadaver bone
(allograft), or
(3) synthetic scaffold into which bone
graft may be inserted (metal or carbon
fiber cages)
Sequential Surgical Procedure
Or… internal fixation with a
titanium plate and screw
device, secured to the
remaining vertebral bodies at
the margins of the corpectomy
—for further stability,
promoting adequate
fusion. preventing
dislodgement of bone graft
Sequential Surgical Procedure
Recovery—1-4 days in hospital
**Failure of bone graft healing is
among the principal reasons for
repeat surgery in these cases
(A) Radiograph showing tuberculosis of C7
with prevertebral abscess. (B) Eighteen-month
postoperative (C7 corpectomy and fusion)
radiograph showing solid bony fusion from C6
to T1
(A) Tuberculosis of T2 with
epidural abscess. (B)
Postoperative view after
anterior curettage with
fusion and posterior Hartshill
fixation. (C) Postoperative
clinical picture
Source: Anterior Decompression for Cervicothoracic Pathology: A Study of 14 Patients MM Prabhakar, MS1,2 and Tejas Thakker, MS2
Accepted January 2006.
Tuberculosis of T2 with abscess (A)
and picture (B and C) showing
postoperative CT scan illustrating
the position of the iliac crest graft
in the decompressed space.
Source: Anterior Decompression for Cervicothoracic Pathology: A Study of 14 Patients MM Prabhakar, MS1,2 and Tejas Thakker, MS2
Accepted January 2006.
Risk Factors in Bone Graft Failure
increasing numbers
of levels to be fused
smoking or other
sources of nicotine
non-compliance with
activity restriction
and/or brace wear
poor bone quality
(osteoporosis)
certain medications
(e.g. predisone, antiinflammatories,
chemotherapy)
malnutrition, etc.
POST-OP FINDINGS
POST-OP PE
Stretcher-borne, awake, coherent, NICRD
BP 100/60 HR 72 RR 20 Temp afebrile
AS, PC, (-) CLAD, (-) NVE, (-) ANM
ECE, CBS, (-) r/w
AP, DHS, NRRR, (-) murmur
Soft, flabby, nontender abdomen, NABS
PNB, FEP, GCR, (-) cyanosis, (-) edema
GCS 15, oriented to 3 spheres, CNs intact
POST-OP NE
LOWER LIMB MOTOR FUNCTION
L2
L3
L4
L5
S1
S4-S5
R
L
2
2
Hip flexors
2
2
Knee extensors
2
2
Ankle dorsiflexors
2
2
Long toe extensors
2
2
Ankle plantar flexors
(+) anal wink, good sphincter tone
POST-OP NE
SENSORY FUNCTION: Light Touch
C2-T5
T6-L2
L3
L4
S4-S5
R
2
2
2
2
2
L
2
2
2
2
2
0
Absent
1
Impaired
2
Normal
POST-OP NE
REFLEXES
R
Biceps
2+
Triceps
2+
Brachioradialis 2+
Patellar
2+
Ankle
2+
L
2+
2+
2+
2+
2+
(-) babinski
(-) clonus
THANK YOU!