CLINICAL CASE #1

CAUDA EQUINA INJURY

DEMOGRAPHIC DATA
Gender: Male
Age: 26
Marital Status: Common-law marriage
Dominance: Right-handed
Education Level: 8th grade of high school
Occupation: He used to work in several jobs such as
bricklayer where he suffer the accident, at the present
he doesnt work, but he says he wants to work again
but in more quiet jobs.
Social Security: Colmedicas

DEMOGRAPICH DATA
Hes from Jamund
He lives in Robles,
Valle.
Rural land
Single storey house,
but situated in a
small hill
He lives with his
significant other
and her mother.

TIMELINE OF THE PATIENTS INJURY

HISTORY
April 13th 2015 A building wall fell down above him
while he was working and caused him an L1 burst
fracture with spinal cord injury causing a cauda equina
syndrome and asymmetric flaccid paraparesis.
April 25th 2015 Vertebral osteotomy by anterior via
with osseous graft and osteosynthesis.
July 2015 Electromyography which showed severe
axonal injury from L2 to S1 bilateral roots without signs
of reinnervation.
November 2015 Orthopedic spine orders him another
radiography.

SPINAL
CORD

AREA OF
INJURY

VERTEBRAL
BODY

L1 BURST
FRACTURE
WITH
RETROPULSION
OF BONE
FRAGMENTS
INTO THE SPINAL
COMPRESSION
OF
CANAL
THE
SPINALCORD AT
THE
LEVEL OF THE
CAUDA
INJURYEQUINA

SPINOUS
PROCESS

LEVEL
OF L1
INJURY

INTERVERTEBRAL
DICS

DURA
SPINAL NERVES AND
LUMBO-SACRAL
PLEXUS

BLADDER
BOWEL
DYSFUNCTION DYSFUNCTION

Image taken from http://www.nucleuscatalog.com/l1-compression-burst-fracture-with-spinal-cord-injury/view-item?ItemID=366

CURRENT CONDITION
He arrives to the consult in a weelchair
He doesnt feel pain anymore.
Bladder/Bowel control and sensibility preserved.
Perform physical therapies that helps him to improve his
balance and lumbar control.
Hes not dependent.
2 months ago he started to use an orthopedic walker at
his home.
Topic appointment: Authorization to use the walker.

PHYSICAL EVALUATION
Bilateral foot drop syndrome
He has an optimal balance
He can stand on tip and heels with help
Hip strength 4 Knee extensors 3 Right foot dorsiflexion 3
Left foot dorsiflexion 2- WITH RECUVATUM
Plantarflexion 4

CONCLUSION
Custom made AFO with fixed ankle at 90
To control the dorsiflexion of the left foot and prevent the
recurvatum.

Image taken from: http://protesica.com.co/portfolio-item/ferula-tipo-afo-o-antiequ