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RB: A Case of Te traparesis. Block Y. Tagomata . Talan . Tayag . Tolibas . Toledo. Uy . Wi. Yu. Zaldivar . Zamora. General Data. RB 25/M From Camarines Norte Roman Catholic Married, with 1 child R handed. Chief Complaint. Inability to walk. History of Present Illness.
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RB: A Case of Tetraparesis Block Y. Tagomata. Talan. Tayag. Tolibas. Toledo. Uy. Wi. Yu. Zaldivar. Zamora.
General Data RB • 25/M • From CamarinesNorte • Roman Catholic • Married, with 1 child • R handed
Chief Complaint Inability to walk
History of Present Illness 10 mos PTA, (+) intermittent pain on R medial arm, described as “parangbinabanatangugat”, NPS 10/10, occurring 3x/wk, aggravated by exertion (e.g. reaching out or lifting an object) relieved by an unrecalled analgesic 0/10 (-) numbness, (-) tingling, (-) skin lesions, (-) hx of trauma 2 wks after, development of similar symptoms on L armand both scapular areas, no consult was done
History of Present Illness 9 mos PTA, (+) weakness of R LE, (-) pain, (-) numbness, (-) tingling, (+) sensation of abdominal tightness, (+) dyspnea (-) hx of trauma consult was done at BHC, given vitamins and analgesic
History of Present Illness A few days later, (+) weakness of R LE, admitted to LH; CXR, holoab UTZ, cranial CT scan and labs done were allegedly normal discharged and prescribed with unrecalled meds but stopped due to allergy (rashes on both thighs)
History of Present Illness 8 mos PTA, inability to walk/stand; assisted on ADLs (+) urinary/bowel incontinence (+) bedsore (approximately 1 cm, sacral) (-) fever
History of Present Illness 5 mos PTA, consult was done at V. Luna A> t/c Decompression sickness P> recompression x 10 session However, pt opted to discontinue after the third session due to fear of dyspnea inside the vessel
History of Present Illness (+) consult at PGH OPD Ortho A> Pott’s disease P> workup and follow-upx 2 mos
History of Present Illness 3 mos PTA, admitted at Spine Unit, started on anti-TB meds co-managed by Rehab 1 mo PTA, s/p anterior decompression, debridement, fusion(C6-T2) with fibular strut graft (7/18/12) Day of admission, admitted at Rehab Ward for further therapy
Review of Systems (present) • (-) Cough, colds, fever • (-) headache, blurring of vision, dizziness • (-) chest pain, difficulty of breathing • (-) changes in appetite • (-) heat or cold intolerance, irritability • (-) muscle or joint pain • (-) penile pain, discomfort, erectile dysfunction
Past Medical History (-) HPN, DM, BA, CA, previous hosp (-) PTB/Primary Complex (?) drug allergy
Family Medical History (+) HPN, father (+) BA, 5 siblings (+) DM, uncle (-) PTB
Personal and Social History (-) smoking, alcohol intake, illicit drug use Breadwinner of the family Works as fisherman(diver) Married, with 1 daughter Finished 2ndyr HS
Functional History Previously independent on ADL Previously works as a fisherman (diving, swimming)
Environmental History Lives in a 1-storey concrete house Safe from falls
Current Physical Exam General: awake, NICRD BP 110/60 HR 90 RR 18 T afebrile HEENT: AS, pink PC, (-) CLAD/NVE (+) surgical scar on L neck to anterior chest Chest/Lungs: DHS, (-) murmur/thrills/heaves ECE, clear BS (-) rales/wheeze/rhonchi Abdomen: Flat, normoactive BS, (-) masses/tenderness Skin/Extremities: FEP, pink NB, (-) edema/cyanosis/jaundice (+) sacral ulcer, healed
Current Physical Exam Motor: (R) (L) (R) (L) C5 5/5 5/5 L2 5/5 5/5 C6 5/5 5/5 L3 5/5 5/5 C7 5/5 5/5 L4 4/5 5/5 C8 5/5 5/5 L5 4/5 5/5 T1 5/5 5/5 S1 3/5 5/5 (Score 97) Sensory: ASIA Sensory: pin prick light touch (R) (L) (R) (L) C5-L3 2/2 2/2 2/2 2/2 L3 1/2 1/2 1/2 1/2 L4 1/2 2/2 1/2 2/2 L5-S4 S5 2/2 2/2 2/2 2/2
Physical Examination on Admission General Survey: Awake, coherent, not in cardiorespiratory distress Vital signs: BP 100/70 HR 87 RR 20 T afebrile HEENT: Anicteric sclerae, pink palpebral conjunctivae, no cervical lymph nodes, no tonsillopharyngeal congestion
Physical Examination on Admission Chest/Respiratory: Equal chest expansion, clear breath sounds, no thoracic spine deformity Cardiovascular:Adynamic precordium, normal rate regular rhythm, distinct S1 & S2, no murmurs Gastrointestinal: Flat abdomen, normoactive bowel sounds, no tenderness Genitourinary: (+) weak sphincteric tone, (+) BCR
Physical Examination on Admission Extremities: Full and equal pulses, no edema, (+) multiple pressure ulcers - sacral area, grade 2 with undermining (+) well healing pressure ulcer on right posterior auricular area, right shoulder (+) grade 1 ulcer on heel, bilateral; medial knee, bilateral; lateral malleolus, bilateral
Physical Examination on Admission ASIA Motor
Physical Examination on Admission Light Touch ASIA Sensory Pin Prick
Physical Examination on Admission Tone: (+) grade 1 – 1+ spasticity on both lower extremities DTRs: hyporeflexia on both lower extremities, (+) flexor spasm on both lower extremities (+) clonus (-) Babinski (-) Hoffman’s
Laboratory Tests • ESR and CRP: elevated • Sputum AFB x 3: all negative • All else normal
Differential Diagnoses for Tetraparesis • Trauma • Tumors • Infection • Inflammatory • Vascular • Vertebral Disease • Others
Impression Tetraplegia secondary to multiple compression deformity secondary to Pott’s disease (Asia D) NL: C6, AL: C6-T2, ML: C7, SL: C7 Neurogenic bowel and bladder Nephrolithiasis, right Sacral decubitus ulcer, grade 2
Course in the Wards • Upon Ward admission: - noted (+) flexor spasm 1-3x/hr upon movement • able to tolerate sitting > 1 hr. during OT • fair sitting balance unsupported but cannot be totally challenged • still dependent in transition with sitting and transfer from bed • able to eat his dinner, can sit with brace on, independent with setup
Course in the Wards Underwent PT exercises during the 1st month: • Practiced transitions from supine to sitting sit to stand • Table tilt at 30o increasing by 15o • Standing with || bars with PKS on (B) knees, increasing in duration and number of reps || bars with one PKS || bars without PKS • Ambulating using walker with PKSusing BAC with 4 pt gait3 pt gait(B) Axillary crutches
Course in the Wards • 8/27 – ASIA MMT: (R) (L) (R) (L) C5 5/5 5/5 L2 2/5 2/5 C6 5/5 5/5 L3 2/5 2/5 C7 4/5 4/5 L4 3/5 3/5 C8 3/5 3/5 L5 3/5 3/5 T1 3/5 3/5 S1 3/5 4/5 - ASIA Sensory: pin prick light touch (R) (L) (R) (L) C2-C7 2/2 2/2 2/2 2/2 C8 2/2 1/2 2/2 1/2 T1-L2 2/2 2/2 2/2 2/2 L3-S4 S5 1/2 1/2 1/2 1/2 DTR: hyporeflexia on (B) LE (+) flexor spasm (B) LE pathologic reflexes: (+) clonus (-) Babinski (-) Hoffman
Course in the Wards • 9/18 – (R) (L) (R) (L) C5 5/5 5/5 L2 4/5 4/5 C6 5/5 5/5 L3 4/5 4/5 C7 4/5 4/5 L4 4/5 4/5 C8 4/5 4/5 L5 3/5 4/5 T1 4/5 4/5 S1 4/5 4/5 (Score 8375) - ASIA Sensory: maintained at Score of 97
Course in the Wards Underwent PT exercises during the 2nd month: • Started stepping exercises • Ambulating using BAC with 3 pt gait2 pt gaitBAC/3 pt. gait on level surface up/down stairs using BAC using quad cane Quad cane/3 pt. gait with ramp, stairs(B) axillary crutches Using Walker
Course in the Wards • 9/26 – Fall while ambulating in bathroom (+) pain (R) lateral aspect of foot • maintain MMT Score of 87 - ASIA Sensory: pin prick light touch (R) (L) (R) (L) C2-C7 2/2 2/2 2/2 2/2 C8 1/2 1/2 1/2 1/2 C9-L3 2/2 2/2 2/2 2/2 L4-S4 S5 1/2 1/2 1/2 1/2 A> Quadparesis and SCC secondary to Pott’s disease ASIA D, NLC7 MLC7 SL C8 AL: C6-T1, T4 T5 T8 Sacral decubitus ulcer Gr 2 Cystitis
Course in the Wards • 10/2 – increase in flexor spasm/ankle clonus ~ (R) LE (R) (L) (R) (L) C5 5/5 5/5 L2 4/5 5/5 C6 5/5 5/5 L3 4/5 4/5 C7 5/5 5/5 L4 5/5 5/5 C8 5/5 5/5 L5 4/5 4/5 T1 4/5 4/5 S1 3/5 5/5 (Score 9187) - ASIA Sensory: pin prick light touch (R) (L) (R) (L) C2-C7 2/2 2/2 2/2 2/2 C8 2/2 1/2 2/2 1/2 C9-L3 2/2 2/2 2/2 2/2 L4-L5 1/2 1/2 1/2 1/2 S1-S4 S5 2/2 2/2 2/2 2/2 (Score 10797)
Course in the Wards • 10/8 – ambulate on level surface with ramp using quad cane. Not Stairs • increase in flexor spasm/ankle clonus ~ (R) LE (R) (L) (R) (L) C5 5/5 5/5 L2 5/5 5/5 C6 5/5 5/5 L3 5/5 5/5 C7 5/5 5/5 L4 4/5 5/5 C8 5/5 5/5 L5 4/5 5/5 T1 5/5 5/5 S1 3/5 5/5 (Score 9791) - ASIA Sensory: pin prick light touch (R) (L) (R) (L) C5-L3 2/2 2/2 2/2 2/2 L3 1/2 1/2 1/2 1/2 L4 1/2 2/2 1/2 2/2 L5-S4 S5 2/2 2/2 2/2 2/2
Course in the Wards • 10/21 – ambulate using walker • able to do vocational training • (+) flexor and bladder spasm on CMG • 10/24 – ambulate using walker • still with weakness of (R) plantar flexion • 10/27 – still with poor proprioception of (B) feet
Problem List • Medical s/p ADDT SCC sec to Pott’s Disease C7-T1 Neurogenic Bladder • Altered Body Function Tetraparesis Sensory impairment below C8 Grade I spasticity of bilateral LE Poor proprioception
Pott’s Disease • Secondary to an extraspinal source of infection. • Osteomyelitis + arthritis. • Anterior aspect of the vertebral body adjacent to the subchondralplate: usual site • Spreads to adjacent intervertebral disks. • Adults: spreads from the vertebral body. • Children: primary site (disk highly vascuarized)
Pott’s Disease • Vertebral collapse and kyphosis, narrowed spinal canal, cord compression • Kyphotic deformity: anterior spine collapse (thoracic > lumbar) • Cervical: minimal collapse • Healing: gradual fibrosis and granulomatous tuberculous tissue calcification • Paravertebral abscess formation is common (Lumbar-psoas fascial sheath; Thoracic-anterior chest wall, parasternal area)
Lesion The lesion could be: • Florid - invasive and destructive lesion • Non destructive • Encysted disease • Carries sicca • Hypertrophied • Periosteal lesion 2 Patterns • Classic:spondylodiscitis(SPD) • Atypical: spondylitis without disk involvement (SPwD); more common pattern of spinal TB
Anatomical • Paradiscal- destruction of adjacent end plates and diminution of disc space. • Appendeceal (Posterior) - involvement of pedicles, laminae, spinous process. • Central - Cystic or lytic, concertina collapse. • Anterior –longitudinal lig, Aneurysmal phenomenon • Synovitis in posterior facet
History • Presentation depends on: • Stage of disease • Site • Presence of complications such as neurologic deficits, abscesses, or sinus tracts • On diagnosis, already with the disease for 3-4 mos. • Back pain- earliest and most common symptom, can be spinal or radicular • Constitutional symptoms (fever and weight loss)
History • 50% with neurologic abnormalities (spinal cord compression with paraplegia, paresis, impaired sensation, nerve root pain, or caudaequinasyndrome) • If cervical, can present with pain and stiffness, dysphagia or stridor, torticollis, hoarseness, and neurologic deficits. • HIV positive > HIV negative patients
Pott’s on Imaging CT scan • Soft tissue findings: abscess with calcification is diagnostic of spinal TB • Pattern and severity: framentary, osteolytic, localized and sclerotic, and subperiosteal XRAY • Signs of infection with lytic lucencies in anterior portion of vertebrae • Disk space narrowing • Erosions of the endplate • Sclerosis resulting from chronic infection • Compression fracture • Continuous vertebral body collapse • Kyphosis; gibbous (severe kyphosis)
Complications of tuberculosis • Paraplegia • Cold abscess • Sinuses • Secondary infection • Amyloid disease • Fatality
Surgical indications • No sign of neurologic recovery after trial of 3-4 weeks therapy • Neurologic complication during treatment • Neurologic deficit becoming worse • Recurrence of neurologic complication • Prevertebral cervical abscesses, neurological signs, & difficulty in deglutition & respiration • Advanced cases: sphincter involvement, flaccid paralysis, severe flexor spasms