1 / 80

RB: A Case of Te traparesis

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.

airell
Download Presentation

RB: A Case of Te traparesis

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. RB: A Case of Tetraparesis Block Y. Tagomata. Talan. Tayag. Tolibas. Toledo. Uy. Wi. Yu. Zaldivar. Zamora.

  2. General Data RB • 25/M • From CamarinesNorte • Roman Catholic • Married, with 1 child • R handed

  3. Chief Complaint Inability to walk

  4. 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

  5. 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

  6. 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)

  7. History of Present Illness 8 mos PTA, inability to walk/stand; assisted on ADLs (+) urinary/bowel incontinence (+) bedsore (approximately 1 cm, sacral) (-) fever

  8. 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

  9. History of Present Illness (+) consult at PGH OPD Ortho A> Pott’s disease P> workup and follow-upx 2 mos

  10. 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

  11. 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

  12. Past Medical History (-) HPN, DM, BA, CA, previous hosp (-) PTB/Primary Complex (?) drug allergy

  13. Family Medical History (+) HPN, father (+) BA, 5 siblings (+) DM, uncle (-) PTB

  14. 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

  15. Functional History Previously independent on ADL Previously works as a fisherman (diving, swimming)

  16. Environmental History Lives in a 1-storey concrete house Safe from falls

  17. 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

  18. 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

  19. P.E. on Admission & Course

  20. 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

  21. 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

  22. 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

  23. Physical Examination on Admission ASIA Motor

  24. Physical Examination on Admission Light Touch ASIA Sensory Pin Prick

  25. 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

  26. Laboratory Tests • ESR and CRP: elevated • Sputum AFB x 3: all negative • All else normal

  27. Imaging

  28. Differential Diagnoses for Tetraparesis • Trauma • Tumors • Infection • Inflammatory • Vascular • Vertebral Disease • Others

  29. Radiographic differentiation

  30. 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

  31. 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

  32. 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 PKSusing BAC with 4 pt gait3 pt gait(B) Axillary crutches

  33. 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

  34. 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 8375) - ASIA Sensory: maintained at Score of 97

  35. Course in the Wards Underwent PT exercises during the 2nd month: • Started stepping exercises • Ambulating using BAC with 3 pt gait2 pt gaitBAC/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

  36. 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

  37. 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 9187) - 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 10797)

  38. 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 9791) - 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

  39. 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

  40. 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

  41. 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)

  42. 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)

  43. 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

  44. Regional Distribution

  45. 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

  46. 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)

  47. 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

  48. 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)

  49. Complications of tuberculosis • Paraplegia • Cold abscess • Sinuses • Secondary infection • Amyloid disease • Fatality

  50. 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

More Related