Clinical meeting case of spondolysis (1).pptx

case of cervical spondylsis.

1. DEPARTMETAL CLINICAL MEETING HOD – DR SAMAR CHATTERJEE MODERATOR –DR. OSVK SUBRAMANYAM PRESENTER- DR KOPPINEEDI LAKSHMI PRASANTHI DATE – 11/03/2025

2. PRELIMINARY DATA: NAME: B MANEMMA AGE:62 GENDER:FEMALE RELIGION:HINDU OCCUPATION:HOUSEWIFE MARITAL STATUS:MARRIED ADDRESS:KONDURG DATE OF CASE TAKING:27-03-2024 CASE RECORD NO:392431

3. CHIEF COMPLAINTS : Lower backache since 5 years Pain in the nape of neck since 3 years

4. HISTORY OF PRESENTING COMPLAINTS Patient was apparently healthy 5 years back, since 5 years the complaints of dragging type of pain in lower back which is aggravated by bending , exertion, ameliorated by lying down. Negative history : no radiation of pain. Pricking type of pain in nape of neck radiating to shoulder with tingling, which is aggravated by exertion, motion. Complaints of giddiness since 1 year which is aggravated by sitting in raising position. Hearing difficulty B/L since 2 year with no discharge.

5. Onset - gradual Progression - gradual Duration: 5 years Location : lower back and neck

6. LSMC LOCATION SENSATION MODALITIES CONCOMITANTS Musculoskeletal system Lower back Onset : gradual Duration : 5 years Dragging type of pain < bending , exertion > Lying down Musculoskeletal system Neck (cervical region) Onset gradual duration: 3 years Pricking type of pain tingling <flexion, severe exertion.

7. PAST HISTORY Medical history :nothing specific Surgical history: hysterectomy for uterine fibroids 12 years ago Treatment history : used allopathic medication for the same complaint

8. FAMILY HISTORY FATHER :Passed away MOTHER : Passed away

9. PERSONAL HISTORY Appetite - Decreased 2 times/day. Thirst - 3-4 lit/day Desires - Sweets Aversion - Nothing specific Bowels - stool hard, constipated once in 3 days Bladder - Clear no burning Perspiration - profuse on face, scalp, cold Sleep - Disturbed Dreams - of ghost, husband Thermal reaction - Chilly

10. LIFE SPACE INVESTIGATION: Patient was born and bought up in lower middle-class family, father is a farmer. From childhood she is working in fields. Married at the age of 17 years Husband left home 10 years back for some work and did not come back they searched for him in nearby places, now also she believes that her husband will come back she prays to god and talks to god while praying when he will come back Some astrologer in the village said that he will come back by end of her life she believes that. At present stays with son but son and daughter in law does not care her, she does all the household work like cooking, bringing water alone. Daughter in law does not care her when she scolds, she does not eat food for 2 to 3 days drinks toddy and sleeps she always feels that if her husband was there this situation would have not come to her, she misses the support and courage given by her husband.

11. She always thinks that who will take care if she falls ill and thinks of suicide but believes husband will come back and death should come naturally by gods wish and she also thinks that if she will commit suicide his son will be blamed and she does not want him to be blamed. Son and daughter in law asked them to move away from home but she asked them how she will survive, she misses husband the affection and support given by husband and now she saves money for herself now whatever she is getting from fields and also from pension. She saved all money and purchased gold ear rings for herself. Patient was continuously talking about something or other matter. She gave money to his son but son is not giving back and not taking care of her, she owns a land son wants that land but now she is refusing to give. Sleep disturbed due to thoughts and grief and dreams of ghosts, husband. She believes in god mainly god related to snake and talks with the god, she feels that she will pray to god that is why snake will not harm her. Was weeping while explaining about husband and lack of care by the son.

12. SITUATION REACTION INTERPRETATION 1)Husband missing Believes husband will come back and praying and talking to god Optimistic/ religious mania 2)Son and daughter in law not caring Thoughts on how she will stay in her old age Neglected feeling, despair of life. Hatred 3)son and daughter in law not caring Son asking her to go away from home Does all her work alone, saves money for future. Independent personality, inconsolable 4) Continuously talking Irrelevant talking loquacity

13. GENERAL PHYSICAL EXAMINATION: No signs of pallor , icterus , cyanosis, clubbing and lymphadenopathy Weight - 45 kgs Height - 5 ‘7 BP - 110/70mmhg Pulse - 69 bpm Nails - not brittle

14. SYSTEMIC EXAMINATION RESPIRATORY SYSTEM: Normal vesicular breathing. CARDIOVASCULAR SYSTEM: S1 ,S2 HEARD , No murmurs no abnormality detected. ABDOMEN – Soft & Tender. MUSCULOSKELETAL SYSTEM: Spinal examination: Tenderness at cervical region. C3, C4.spurlings test positive Tenderness at lumbar region L3, L4.

15. Diagnosis?

16. Provisional diagnosis Lumbar ( M47. 896) and cervical radiculopathy (  M54.12)

17. DIFFERENTIAL DIAGNOSIS?

18. DIFFERENTIAL DIAGNOSIS Cervical disc injury Sacroiliac joint dysfunction Ankylosing spondylitis

19. FINAL DIAGNOSIS : Cervical and lumbar spondylosis

20. Lumbar spondylosis:

21. Introduction to lumbar spondylosis This is a degenerative disorder of lumbar spine characterized clinically by an insidious onset of pain and stiffness and radiologically by osteophyte formation. CAUSE: Bad posture and chronic back strain is the commonest cause Other causes are Previous injury to spine; birth defects and old intervertebral disc prolapse.

22. PATHOLOGY Primarily, degeneration begins in the intervertebral joints. This is followed by reduction in the disc space and marginal osteophyte formation. Degenerative changes develop in the posterior facet joints. Osteophytes around the intervertebral foramen may encroach upon the nerve root canal, and thus interfere with the of the emerging nerve .

23. CLINICAL FEATURES Symptoms begin as low backache, initially worst during activity . A catch while getting up from A sitting position, which improves as one walks a few steps. Pain may radiate down the limb up to the calf (sciatica) because of irritation of one of the nerve root. There may be complaints of transient numbness and parasthesia in the dermatome of a nerve root, commonly on the lateral side of the leg or foot (l5,s1) respectively.

24. Examination The spinal movements are limited terminally but there is little muscle spasm. The straight leg raising test (SLRT) may be positive if the nerve root compression is present. Radiological findings: AP and lateral views of the lumbosacral spine should be done after preparing the bowel with a mild laxatives and gas adsorbent like charcoal tablets.

25. RADIOLOGICAL FINDINGS Reduction In Disk Space Osteophyte Formation Narrowing Of The Joint Space Subluxation Of One Vertebrae Over Another

26. There are many causes of backache. The most common ones is being back muscle, strain, ligament sprain and lumbar disk disease due to abnormal posture and ageing process. Ankylosing spondylitis Multiple myeloma Osteoporosis with stress fractures Extradural tumors Arthritis of hip joint

27. Condition Small Difference from Lumbar Spondylosis Lumbar Disc Herniation Acute sciatica , positive straight leg raise (SLR), disc bulge on MRI. Lumbar Radiculopathy Sharp nerve root pain , dermatomal sensory loss, muscle weakness. Facet Joint Arthropathy Localized pain worsened on extension & rotation , normal discs on imaging. Spondylolisthesis Forward slip of vertebra seen on X-ray, step deformity on palpation. Muscle Strain Acute pain after exertion, localized tenderness, no degenerative changes . Ankylosing Spondylitis Young males , morning stiffness, HLA-B27 positive , bamboo spine on X-ray. Spinal Tumor Constant pain, night pain, neurological signs, systemic symptoms.

28. Introduction to cervical spondylosis:

29. Cervical spondylosis: It is a degenerative condition of cervical spine found almost universally in persons over 50 years of age. It occurs early in persons pursuing ‘white collar jobs’ or those susceptible to neck strain because of keeping the neck constantly in one position, while reading, writing etc.

30. PATHOPHYSIOLOGY Intervertebral discs lose hydration and elasticity with age - leading to cracks and fissures. The surrounding ligaments also lose their elastic properties and develop traction spurs. The disk subsequently collapses as a result of biomechanical incompetence, causing the annulus to bulge outward. As the disk space narrows, the annulus bulges, and the facets override. This change, in turn, increases motion at that spinal segment and further hastens the damage to the disk. Annulus fissures and herniation may occur. Acute disk herniation may complicate chronic spondylotic changes.

31. Due to annulus bulges - the cross- sectional area of the canal is narrowed. This effect may be accentuated by hypertrophy of the facet joints (posteriorly) and of the ligamentum flavum, which becomes thick with age. Neck extension causes the ligaments to fold inward, reducing the anteroposterior (AP) diameter of the spinal canal .

32. As disk degeneration occurs, the uncinate process overrides and hypertrophies, compromising the ventrolateral portion of the foramen. Likewise, facet hypertrophy decreases the dorsolateral aspect of the foramen. This change contributes to the radiculopathy that is associated with cervical spondylosis. Marginal osteophytes begin to develop. Additional stresses, such as trauma or long- term heavy use, may exacerbate this process.

33. These osteophytes stabilize the vertebral bodies adjacent to the level of the degenerating disk and increase the weight- bearing surface of the vertebral endplates. The result is decreased effective force on each of these structures. Degeneration of the joint surfaces and ligaments decreases motion and can act as a limiting mechanism against further deterioration. Thickening and ossification of the posterior longitudinal ligament (OPLL) also decreases the diameter of the canal .

34. The blood supply of the spinal cord is an important anatomic factor in the pathophysiology. Radicular arteries in the dural sleeves tolerate compression and repetitive minor trauma poorly. The spinal cord and canal size also are factors. A congenitally narrow canal does not necessarily predispose a person to myelopathy, but symptomatic disease rarely develops in individuals with a canal that is larger than 13 mm .

35. Flexion of the cervical spine may lead to compression of the spinal cord against osteophytic bars while extension may lead to compression against the hypertrophied ligamentum flavum.

36. CLINICAL FEATURES Pain and stiffness . Intially intermittent but later persistant . Occipital headache may occur if the upper half of the cervical spine is affected. Radiating pain – patient present with pain radiating to shoulder or downwards on the outer aspect of the forearm and hand. There may be parathesia in the region of nerve root commonly over the base of thumb along the C-6 Nerve root. Muscle weakness is uncommon. Giddiness. – pt . May present with episode of giddiness because of vertebro -basilar syndrome.

37. EXAMINATION Loss of normal cervical lordosis and limitation in neck movement. Tenderness of lower cervical spine or para-vertebral region ( myalgia ) Upper limb – signs – Nerve root compression – usually C6 root involvement. Lower limbs must be examined for signs of early cord compression. ( positive Babinski reflex ).

38. Radiological Findings Narrowing of intervertebral disc space – C5-C6. Osteophytes at the vertebral margins, anteriorly and posteriorly. Narrowing of intervertebral foramen in cases presenting with radicular symptoms.

39. PHYSICAL EXAMINATION Spurling sign - Radicular pain is exacerbated by extension and lateral bending of the neck toward the side of the lesion, causing additional foraminal compromise. Lhermitte sign - This generalized electrical shock sensation is associated with neck extension. Hoffman sign - Reflex contraction of the thumb and index finger occurs in response to nipping of the middle finger. This sign is evidence of an upper motor neuron lesion.

40. Investigations Where there is no trauma, imaging should not be carried out for isolated cervical pain. MRI is the investigation of choice in those with radicular symptoms. X-rays offer limited benefit, except in excluding destructive lesions, and electrophysiological studies rarely add to clinical examination with MRI.  

41. X RAY CERVICAL SPINE LATERAL VIEW

42. DIFFERENTIAL DIAGNOSIS Congenital – Arnold- Chiari malformation, tethered cord, syringomyelia Acquired –trauma, herniated intervertebral disc, kyphosis, extramedullary haematopoiesis, epidural lipomatosis Neoplastic – spinal cord tumours, carcinomatous meningitis, paraneoplastic syndrome Vascular – haematoma, spinal cord infarction, spinal cord AVM, Autoimmune – multiple sclerosis, Devic syndrome Infectious – paraspinal abscess, osteitis/osteomyelitis, pyogenic discitis, AIDS- related myelopathy, tuberculosis, spinal meningitis, viral and syphilitic involvement Amytrophic lateral sclerosis

43. Condition Small Difference from Cervical Spondylosis Cervical Disc Herniation More acute radicular pain , positive Spurling test, MRI shows disc prolapse. Cervical Myelopathy Upper & lower limb weakness , gait disturbances, hyperreflexia, positive Hoffmann's sign. Cervical Strain/Sprain History of trauma/overuse , soft tissue tenderness , no bony changes on X-ray. Fibromyalgia Widespread musculoskeletal pain , fatigue, multiple tender points, normal imaging . Vertebral Fracture History of trauma/osteoporosis , sudden pain, fracture line on imaging. Tumor/Metastasis Persistent, severe night pain , weight loss, systemic signs, abnormal mass on imaging.

44. MANAGEMENT: Conservative treatment with analgesics and physiotherapy results in resolution of symptoms in the great majority of patients, but a few require surgery in the form of discectomy or radicular decompression. Isometric neck exercises. Minnerva body jacket.

45. Ankylosing spondylitis Ankylosing Spondylitis (AS) is a chronic, systemic, inflammatory autoimmune disease . Primarily affects axial skeleton , especially sacroiliac joints and spine . Leads to pain, stiffness, and spinal fusion .

46. Cause/Factor Details Genetic HLA-B27 positive in ~90% of cases. Gender Male predominance (3:1 ratio). Age Onset between 15-35 years . Family history Often familial . Etiology & Risk Factors

47. Clinical features Feature Description Back pain Chronic, inflammatory low back pain. Morning stiffness >30 min, improves with exercise. Reduced spinal mobility Loss of lumbar lordosis , thoracic kyphosis . Peripheral arthritis Asymmetrical , lower limb predominant. Enthesitis Tendon/ligament inflammation (e.g., Achilles). Extra-articular Uveitis , aortic regurgitation, lung fibrosis.

48. Diagnosis Investigation Finding X-ray (pelvis) Bilateral sacroiliitis . Spine X-ray Bamboo spine (advanced). HLA-B27 Positive in >90% (not diagnostic alone). ESR/CRP Elevated markers of inflammation. MRI Early inflammation detection.

49. HAHNEMANNIAN CLASSIFICATION OF DISEASE Dynamic –chronic- progressive –Reversible - Miasmatic disease

50. SUSCEPTIBILITY Onset :Gradual Nature and intensity: severe No of characteristic symptoms: More mental and characteristic particulars are expressed Pathology : Inflammation and degeneration Organ involved :spine Susceptibility : High

51. MIASMATIC ANALYSIS Stage and phase of disease: Gradual Type of structure and pathology included: spine and degeneration. Expression given on surface : pain stiffness Intensity of disease : severe Dominant miasm :Syphilitic

52. ANALYSIS OF SYMPTOMS ?

53. Common symptoms Uncommon symptoms Low back ache aggravated by bending , exertion, ameliorated by lying down. Religious mania Pain in the nape of neck aggravated by exertion Neglected feeling loquacity Inconsolable Head perspiration on scalp cold Sweets desire Alcoholic drinks desire Stool hard

54. Evaluation of symptoms : Religious mania –characteristic mental behaviour ( grade 1) Neglected feeling-characteristic mental emotion(grade 1) Loquacity- characteristic mental behaviour(grade 1) Inconsolable- characteristic mental emotion (grade 1) sweets desire- characteristic physical general( grade 2) Stool constipated( characteristic physical general grade 2)

55. TOTALITY OF SYMPTOMS : Religious mania Neglected feeling loquacity Inconsolable Head perspiration on scalp cold Sweets desire Alcoholic drinks desire Stool hard

56. Selection of repertory Synthesis repertory was selected as more mental generals are present in the case.

57. REPERTORIAL TOTALITY : MIND-Ailments from neglected being MIND-Delusions – God- communication with god; he is in MIND-Despair- religious despair of salvation MIND-Fear death of MIND- Inconsolable MIND- loquacity Head – perspiration of scalp, forehead, cold Stool –hard Generals food and drinks- sweets desire Generals food and drinks-alcoholic stimulants desire

58. RESULT OF REPERTORISATION

59. REPERTORIAL ANALYSIS: Veratrum album 20/10 Sulphur 19/10 Lyco 18/10

60. Prescription : Rx 06-03-2024 Bryonia 200 CP 6X BD 21 days

61. 27-03-2024 First follow up complaints decreased by 30 % Case defined Veratrum album 30 3 doses OD x 3 days S.L , WPT for 21 days. 10-04 -2024 Constipation decreased passing stool regularly Low back ache decreased by 60% Pain in nape of neck SQ RX :SL 3 DOSES OD X 3 DAYS

62. 4 TH Sept 2024 – Pain in B/L Knee joints with stiffness in legs. Tingling sensation in legs. Throbbing type of pain . Pain in lower back < motion, exposure to cold weather. Pain in cervical region radiated to B/L Upper limbs Hard stools. Feels forsaken. Weeping Weeps due to pain . Rx. Pulsatilla 200/3 DOSES. S.l 3-0-3, CP 6X for 21 days.

63. Thank you !!