Case presentation on cervical myeloradiculopathy

cervical myeloradiculopathy

1. Case Presentation On Cervical Myeloradiculopathy By M.Hemasree 16H61T0012 Pharm D 3 rd year

2. Definition : Cervical myeloradiculopathy is the dysfunction of the spinal cord (myelopathy) and nerve root (radiculopathy). Cervical myelopathy is loss of function in your upper and lower extremities because of compression of the spinal cord which involves your arms, hands, legs, bowel and bladder function. Cervical radiculopathy often called “pinched nerve” occurs when a nerve in your neck is compressed or irritated where it branches away from spinal cord. Pain radiates into shoulder, muscle weakness, numbness that travels down your arm and into your hand

3. Etiology The dysfunction is due to compression of spinal cord and nerve root. Compression can arise from: Facet osteophytes(overgrowth of bone) Disc herniation(slip disc) Ossification of posterior longitudinal ligaments(degenerative deposition of bone within ligaments). On rare occasion, the compression can be caused by tumors, infections, fractures of vertebrae

4. Pathogenesis

5. Signs and symptoms Heavyness in the legs or arms Inability to walk for long Difficulties in writing,buttoning or holding things Intermittent shooting pain to arms and legs. Urinary and bowel disturbances Losing your body consciousness Numbness or weakness in the corresponding muscles in your arm, forearm or hand

6. DIAGNOSIS Physical examination Cervical spine radiography to look for instability MRI scan to determine cause of compression X-Ray and CT scan TREATMENT Ice or heat applied to affected area Anti-inflammatory drugs, Muscle relaxants, narcotic painkillers Epidural steriod injections Physical therapy, occupational therapy, lifestyle changes surgery

7. SOAP ANALYSIS SUBJECTIVE DATA : A 58 years old male patient of 70kg was admitted in general ward on 24/11/2018 presented with complaints of increased urine output, B/L, UL and LL pain, tingling sensation, difficult in walking. History of past illness : K/C/O Hypertension , diabetes mellitus. Past surgery: S/P Lap appendectomy – 15 years back. C 4 – C 5 , C 5 – C 6 , PIVD Personal and family history : nothing contributory

8. Objective Data Vital signs Parameters Normal value Day 1 Day 2 Day 3 Blood pressure(mmHg) 130/90 130/70 140/80 120/80 Temperature(F) 98.6 98.6 98.6 98.6 Pulse rate( bpm ) 60-100 89 90 97 Respiratory rate( cpm ) 20 20 20 20

9. Lab investigations Test Normal range Results Haemoglobin 12-16 gms % 15.10 RBC count 3.8-5.8 million/ cumm 5.08 PCV 36-50% 45% Platelet count 1-4 lac cells/ cumm 2lacs/ cumm Total WBC count 4k-10k cells/ cumm 7,480cells/ cumm Neutrophils 40-70% 75.30% Lymphocytes 15-30% 18.40% Eosinophils 1-6% 2.20% Monocytes 2-10% 5% Basophills 0-1% 0% ESR 0-10mm 3.0mm PT 10-13 sec 12.1sec

10. Clinical pathology Test Normal range Result Colour Pale yellow Pale yellow Appearance Clear Clear Albumin Nil Nil Sugar Nil Nil Ketone Negative Negative Bile salts Absent Absent Bile pigments Negative Negative Uric acid crystals 0-1 Nil Bact cocci 0-29 Nil Bact bacilli 0-29 9 Mucus particles 0-60 3

11. Electrolytes X-Ray chest PA view:Normal 2D ECHO:Normal ECG:normal Test Normal range Result Sr.sodium 135-145mEq/L 136 Sr.potassium 3.5-4.5mEq/L 4 Sr.chloride 98-107mEq/L 100

12. MRI Cervical spine Technique : T1-T2 saggitals , T1 axials GRE axials , IR coronals Findings : Reduced disc height at c4-c5, c5-c6 levels Anterior osteophytes at c4-c5 levels noted Subtle hypertrophy causing posterior thecal sac indentation seen at C4-C5 levels Mild moderate annular disc bulge with ventral thecal sac compression and cord compression at C4-C5 levels s/o cord ischemia, myelomalacia changes Spinal cord narrowing at C3-C4 LEVELS, C4-C5 and C5-C6 levels

13. ASSESSMENT Based on the subjective and objective data the patient was diagnosed with “CERVICAL MYELORADICULOPATHY”.

14. PLAN Medication chart Drug Generic name Dose ROA Freq D-1 D-2 D-3 D-4 D-5 Tab Gabiver NT gabapentin+ Nortryptyline 1tab PO HS + + + + + Tab transnerv Methylcobalmin + pregabalin 1tab PO OD + + + + + Tab MET-XL metoprolol 25mg PO OD + + + + + Inj Supacef cefuroxime 1.5g IV BID + + + + + Inj Pan pantoprazole 40mg IV OD + + + + + Inj Perfalgan paracetamol 1g IV TID + + + + + Inj zofer ondansetron 4mg IV TID + + + + +

15. Drug MOA Uses Side effects Tab Gabiver NT Gabapentin crosses BBB and enhances GABA release by binding to lipophilic molecule. Nortryptiline acts by inhibiting uptake of noradrenaline and 5-HT resulting in increased conc of neurotransmitters in synaptic cleft Epilepsy, relieve numbness, tingling sensations Weakness, stomach pain Tab Transnerv It act as a cofactor for enzyme methionine synthase and vit B12 Neuropathic pain, numbess Nausea, dizziness, diarrhea Tab MET-XL It blocks beta 1 adrenergic receptors in heart muscle cells, slows heart rate, BP and relaxes blood vessels To treat high blood pressure Chest pain and discomfort, tiredness, depression

16. Drug MOA Uses Side effects Inj Supacef It works by inhibiting the bacterial cell wall Bacterial infections, UTI, pharyngitis Diarrhea, nausea, headache Inj PAN Inhibits final step in gastric acid production by covalently binding to ATPase k+/H+ ions Antacid Headache, altered sense of taste, rhinorrhea Inj Perfalgan Increase pain threshold by inhibiting COX enzymes Pain killer anf anti-pyretic Allergic rxn , SOB, nausea, rashes Inj Zofer Blocks serotonin receptors CTZ decreases communication to vomiting center Nausea and vomitting Headache, painfull urination

17. Goals of treatment To provide symptomatic relief. To relive pain and help to maintain usual activites To prevent permanent injury to spinal cord and nerves. Problems identified Drug-drug interactions Nortryptyline+ondansetron (major) Have increase risk of serotonin syndrom include symptons like confusion, hallucination. Management: Discontinue serotonin agents and supportive therapy given

18. Cefuroxime + pantoprazole PAN decrease stomach acid leading to decrease absorption of cefuroxime Management: Avoid PPI,H2 receptor blockers or an alternative antibiotic is given Metoprolol + Nortryptyline They both have additive effects in lowering your bp hence may lead to headache, dizziness Management : close monitoring of hypotension and caution is advised

19. Drug – Food interactions Metoprolol + Food ( Moderate) Bioavailability metprolol enhance by food Management : Patient must be instructed to take metprolol at same time each day with or immediately after meals Pregabalin / Gabapentin + Alcohol Alcohol may potential CNS active agents causing CNS depression or impaired judgement Management: Avoid consumption of Alcohol or limit the use

20. PATIENT COUNSCELLING About the disease Patient must be expalin about diesease condition ( Cervical myeloradiculopathy ) that there are chances of loss of funcntion in upper and lower extremities because of compression of spinal cord or nerve that arise from spinal cord

21. LIFE STYLE MODIFICATIONS Perform neck stretching exercises Ice or heat applied to the effected area Stop looking on your phone or computer for long periods of time Moderate strength building exercises to be done K eep finding the best pillow and try to sleep in your back Maintain good posture and carry weight evenly

22. DIET Food to be taken: Eat calcium rich food which include cheese, milk, yogurt, and vegitables like spinach Omega-3- fatty acid found in fish, flax seeds, walnuts, lower inflammatary chemicals in the body Megnesium found in fruits, nuts, beans, soya and whole grains Food to be avoid: High fat products like butter, cream and meat Refined and processed foods Fewer intake of acidic foods like citrus fruits and coffee as they interfere during healing process

23. PRECAUTIONS Follow the medications as per the prescription Do not miss the dose Do not double the dose, If missed If any serious side effect / ADR’s are seen report, to the physician immediately

24. References https:// www.columbiaasia.com/malaysia/health-articles/cervical-myeloradiculopathy https://www.drugs.com / https:// emedicine.medscape.com/article/94118-overview

25. Thank you t