Medicine- Spinal Cord System- Case discussion.pptx

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1. Clinical seminar Moderator: Dr.S.R.Chandra Retired professor NIMHANS

2. Name : XYZ Age : 60 years Address:Ganaganuru,Chamarajanagar Occupation: Jaggery factory worker Education:Illiterate Handedness: right handed Informant: patient himself and his wife

3. Chief complaints C/o low back pain since 1 month. C/o weakness of both lower limbs since 5 days C/o numbness of both lower limbs since 5 days C/o inability to pass urine since 5 days .

4. History of presenting illness Patient complaints of low back pain since 1 months, which was sudden in onset at around 3 am while he was sleeping ,which woke him from sleep which was sharp ,dragging type radiating along buttock back of thigh till foot on left side , due to pain patient couldn’t sleep whole night next day morning patient went to local doctor and he was given IM injection and tablets after which pain decreased but not completely relieved

5. Pain used to increase on standing , coughing and sneezing Pain used to be present continousoly Patient also used to get increased pain in legs on walking – pain used to be more on initial few steps and he used to bend forward while walking which use to relieve the pain No history of band like sensation

6. There was no associated weakness of lower limbs Pain used to relieve on taking oral medications After 7 days patient also started having pain radiating to right leg

7. 5 days back, while getting up after praying in temple near MM hills at around 8 am ,patient felt sudden severe band like pain in lower back and developed weakness of both lower limbs sudden and complete at onset, associated with numbness of both legs, he was carried by his relatives to his home on that day by 2pm There was no improvement in his weakness and he was confined to bed and was dependent on the caregivers for all the activities

8. There was associated numbness of both lower limbs and the patient was not able to feel any sensations below the umbilicus.

9. On the same day patient was not able to pass urine but could feel the fullness of bladder and there was no dribbling of urine . Next day morning patient was taken to local hospital where he was catheterized and approximately 1.5 to 2 litres of urine was drained and was referred to K R hospital for further management.

10. H/o not passing stools since 5 days No history of fever. No history of blurring of vision,double vision. No history of trauma. No history of headache ,loss of consciousness,seizures.

11. Course in the hospital There is no improvement in weakness or numbness of both lower limbs There is little relief in pain after giving injections

12. Past history 8 months back, patient developed difficulty in swallowing for solid foods insidious onset gradually progressive initially he used to take solid foods with difficulty but later he used to take only liquids,not associated with pain No h/o nasal regurgitation ,nasal tone of voice

13. For above symptoms he consulted a doctor and was evaluated and he was told to have a cancerous mass in the esophagus. He was treated with 4 cycles of chemotherapy and radiotherapy After which his above symptoms improved but not completely resolved.

14. There is history of weight loss over last 8 months

15. No H/o Diabetes mellitus, hypertension, tuberculosis

16. Family history Not significant

17. Personal history Diet: mixed Appetite: decreased Sleep: disturbed Bladder habits: disturbed Bowel habits: disturbed He drinks alcohol since 20 years, local 180ml/day. Last drink 5 months back He is a smoker since 2 0 years& he smokes 2 pack of beedis per year.

18. Summary An elderly Male with significant past history of CA esophagus presented with radicular back pain radiating to left lower limb 1 month back and weakness of both lower limbs associated with sensory ,bowel and bladder involvement

19. General physical examination A elderly male patient moderately built & poorly nourished conscious, co operative & well oriented to time, place & person. Length:160 cms Weight: couldn’t be checked Pallor :+ Lymph node: solitary lymphnode of size 1*1 cm in right supraclavicular region just lateral to insertion of clavicular head of sternocleidomastoid,mobile,non tender, hard in consistency and not fixed to surrounding tissue and skin

20. Grade 3 clubbing present. No icterus No cyanosis No edema

21. Head to toe examination Male pattern baldness Graying of hair Temporal hallowing Generalized wasting Bilateral immature cataract and arcus senilis Poor dental hygiene Nicotine staining of teeth White nails with increased longitudinal ridges Fine tremors of both hands on outstretched arms

22. Multiple Hypopigmented macules over abdominal wall Knuckle pigmentation Onychorrhexis of toe nails Thickened sole with fissures Dry skin below the umbilicus

23. Pulse:110 bpm, regular rhythm, normal character, normal volume, no radio radial delay, no radiofemoral delay, no arterial wall thickening, all peripheral pulses felt. BP:1 2 8/76mmHg right upper limb, supine position. Respiratory Rate: 20 cpm , abdominothoracic Temperature: 37.0⁰ celsius (axilla)

24. Central Nervous System Higher mental functions: Appearance – normal Behaviour- normal Conscious, oriented to time, place, person Memory- intact Intelligence- normal Speech and language- normal Insight and judgment –normal Abstract thought –normal Calculation –normal No delusion or hallucination

25. Cranial nerves examination

26. Facial nerve Normal Normal Vestibulocochlear nerve Normal Normal Glossopharyngeal nerve, Vagus nerve Normal Normal Spinal accessory nerve Normal Normal Hypoglossal nerve Normal Normal

27. Motor System

28. Nutrition Muscle bulk Right Left Arm 22.5cms 22cms Forearm 19cms 19cms Thigh 36cms 36cms Leg 25cms 25cms

29. Tone Right Left Upper limb Normal Normal Lower limb Hypotonia Hypotonia

30. Power Power Right Left Shoulder Flexion 5/5 5/5 Extension 5/5 5/5 Adduction 5/5 5/5 Abduction 5/5 5/5 External rotation 5/5 5/5 Internal rotation 5/5 5/5 Elbow Flexion 5/5 5/5 Extension 5/5 5/5 Wrist Flexion 5/5 5/5 Extension 5/5 5/5 Ulnar deviation 5/5 5/5 Radial deviation 5/5 5/5

31. Power Right Left Hand grip Normal Normal Hip joint Flexion 0/5 0/5 Extension 0/5 0/5 Adduction 0/5 0/5 Abduction 0/5 0/5 External rotation 0/5 0/5 Internal rotation 0/5 0/5 Knee joint Flexion 0/5 0/5 Extension 0/5 0/5 Ankle joint Dorsiflexion 0/5 0/5 Plantarflexion 0/5 0/5

32. Subtalar joint Inversion 0/5 0/5 Eversion 0/5 0/5

33. Deep tendon reflexes Right Left Biceps jerk 2+ 2+ Triceps jerk 2+ 2+ Supinator jerk 2+ 2+ Knee jerk Absent Absent Ankle jerk Jaw jerk :absent Absent Absent

34. Superficial reflexes Right Left Corneal Present Present Conjunctival Present Present Abdominal - upper middle lower Present Present present Present present present Plantar Mute Mute Cremastic Anal reflex absent Absent Absent

35. Coordination Upper limbs: normal on both sides lower limbs: could not be done No cerebellar signs in upper limbs Gait Could not be assessed

36. Sensory system There is pansensory loss upto 1cm below the umbilicus anteriorly and T9 vertebra posteriorly

37. No signs of meningeal irritation Spinal tenderness present at the level of T 9 vertebra No localised swelling and deformities.

38. RS: trachea central Bilateral vesicular breath sounds heard normally. No added sounds CVS: Apex beat 6 th intercostal space 1cm lateral to MCL – normal character first and second heart sounds heard normally, no murmurs. Per abdomen: soft, no organomegaly Liver span—15cm No other mass palpable

39. Diagnosis Neurological deficits: UMN paraplegia with UMN bladder IN spinal shock Pansensory loss below T 9 vertebra Anatomical localisation: spinal cord level T 12 Segment Pathology: Compressive myelopathy at T 12 Segment of spinal cord, extradural extramedullary Etiology : ? metastasis – fracture of vertebra CARCINOMA ESOPHAGUS