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CPC1 Degenerative Spine Disease 201

CPC 1:
Degenerative Spine

Disease

GRAND MENTOR :
ZAMYN ZUKI BIN

DATO DR HAJI
TAN SRI DATO
HAJI MOHD

ZUKI
MENTOR

: MR. LIM SZE WEI

PREPARED BY

: DR. NEERMALADEVI PARAMASIVAM

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Figure 1: Photo with my mentor Mr Lim Sze Wei


CONTENTS

N0

TITLE

PAGE

ACKNOWLEDGEMENT

INTRODUCTION

CASE STUDY
CLINICAL HISTORY & EXAMINATION
INVESTIGATIONS

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MANAGEMENT
PROGRESS
4

DISCUSSION

CONCLUSION

REFERENCES

ACKNOWLEDGEMENT
First of all, I would like to take this opportunity to express my gratitude and
sincere thanks to my grand mentor Dato Dr. Haji Zamyn Zuki for being a wonderful
Grand Mentor and a constant pillar of encouragement and for the never ending
support and guidance. He is a great teacher and good inspiration to us throughout my
2 months Ortholife training in this department so far. All his dedication and effort had
pushed me to strive further and unravel my own potential.

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Secondly, I would like to give my special thanks to my mentor MrLim for his
patience, guidance and support towards me in this housemanship training .His
priceless experience and knowledge that he shared are very useful for me to continue
my journey in Ortholife training as well as a doctor. Last but not least ,to all medical
officers and my colleagues. Thanks for the assistance and encouragement throughout
the orthopaedic housemanship training.

INTRODUCTION
Spinal stenosis is a condition characterized by a progressive narrowing of the
spinal canal, the vertical tube formed by the vertebrae that houses the 31 nerves of the
spinal cord.
The symptoms of congenital spinal stenosis depend on which portions of the
nerves are being compressedSpinal stenosis is often results from aging, but it can also

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be a congenital disorder. With congenital spinal stenosis, the patient is born with a
narrow spinal canal due to abnormally formed parts of the spine. This condition is
most common in patients with a short stature.
Generally, narrowing in the upper, or cervical, section of the spine produces
pain and/or numbness in the shoulders, torso, hands, or arms. Narrowing in the
buttocks, thighs, or feet lower, or lumbar, region of the spine produces similar
symptoms in the calves. Congenital spinal tends to worsen progressively with age.
Many people born with the condition may develop symptoms as early as the age of
15. It is a puzzling condition that can neither be predicted nor prevented. It does not
distinguish by sex, race, or ethnicity. Nor is it associated with any particular
occupation or any particular body type.
An accurate diagnosis is essential, and can typically be made with the help of
imaging equipment such as MRIs, X-rays or CT scans. For those suffering from
congenital spinal stenosis, surgery can offer relief. A decompressive laminectomy, an
operation that widens the spinal canal, is most frequently used to treat congenital
spinal stenosis.

CASE STUDY
CHIEF COMPLAINT :
The subject of my study is a 59 years old Indian woman with co- morbids of
dyslipidemia, hypertension, schizophrenia since 2001 and history of endometrial with
hysterectomy done followed by radiotherapy. She presented to ED HSB on 8/10/15
with complaints of generalised weakness over upper and lower limbs since 2 weeks

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prior to admission. Besides, she unable to pass urine for 3 days and unable to pass
motion for 1 week prior to admission.
HISTORY OF PRESENTING ILLNESS :
She started to have generalised weakness over upper and lower limbs since 2
weeks ago which upper limbs were more severe compared to lower limbs.
Subsequently unable to pass urine for 3 days and unable to pass motion for 1 week
prior to admission.
There was an incidence of fall at home on 29/9/15 (presented to HSB at post
trauma day 11) She claimed feeling of giddiness, and knees gave way due to
weakness , subsequently fell backwards her on buttocks. After the fall, she was
unable to ambulate, but still able to kick the wall till neighbour hears her and came
over within two hours. Otherwise, there was no loss of consciousness, no cervical
pain, no vomiting of ENT bleeds. She was then brought to Hospital Teluk Intan via
ambulance. The generalised body weakness started since few hours after fall, upper
limbs are more severe than lower limbs. The weakness were associated with bilateral
upper limb and lower limb numbness from the level of upper abdomen. At that point,
she still able to pass urine and motion.
Subsequently she was admitted for 11 days in Hospital Teluk intan, claims that
after 3 days, she was already ambulating, but then fell again multiple times in
hospital due to weakness of bilateral lower limbs. In fact, this is not the first
admission to Hospital Teluk Intan. There was a recent admission in Hosp Teluk
Intan on 27/9/15, with history of fall at home associated with giddiness, feelings of
lethargy and history of hand cramps for 1 week duration.
Computed Tomography of brain was done on 28/9/15 to rule out any brainstem
injury and resulted as normal with no intracranial haemorrhage. She was reviewed by
psychiatry in view of suspecting the antipsychotic medication causing her nystagmus
prior to fall but claimed unlikely the causes. Cervical-thoraco X ray at Hospital teluk
intan showed eroded left pedicle at T5 changes while cervical X ray had inadequate
view with no obvious pathology. Hence, she was referred to orthopaedic department
in Hospital Selayang for cervical myelopathy above C4. Hospital Selayang
discharged her with Tab Gabapentin and planned for MRI as outpatient.
Unfortunately prior the TCA of MRI, she presented to this Hospital Sg Buloh on
8/10/15 as she could not pass urine for 2days and not pass motions for 7days ago. The
symptoms associated with minimal abdominal discomfort. claims fell again due to
lower limbs weakness in front of the hospital when came out from taxi.
Allergic history :
Nil

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Past medical history :
1/ Dyslipidemia on Tab simvastatin 20mg ON
2/ HPT on Tab Amlodipine 5mg OD and Tab Atenolol 100mg OD
3/ Schizophrenia on T risperidone since 2001 under HTI follow up
Past surgical history :
History of endometrial cancer which diagnosed in 2009 at Hospital Ipoh.
Hysterectomy was done followed by post op radiotherapy. Patient unsure of staging
of disease , but she is under yearly surveillance at oncology HKL. Last CT scan was
done 2 years ago and patient was told disease free.
Family history :
No family history of malignancy.
Medication History :
Tab Amlodipine 5mg OD
Tab Atenolol 100mg OD
Tab Cardiprin 100mg OD
Tab simvastatin 20mg ON
Tab Ca Lactate 300mg OD
Tab Folate 1/1 OD
Tab Risperidone 2mg OD
Tab Fluroxamine 50mg OD
Social History :
She is blessed with 1 child but was divorced previously. Her son is staying with her
ex-husband and does not keep in touch with her, She is staying in Teluk Intan alone.
She has a sister in Kuala Lumpur but unable to be main care taker.

PHYSICAL EXAMINATION :
Patient GCS full, warm peripheries, CRT < 2 secs, good pulse volume,
hemodynamically stable unsupported and saturating well under room air.

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On auscultation, lungs was clear bilaterally with good and equal air entry. S1 and S2
heard on heart auscultation with no murmurs detected. .Abdomen was soft, not tender
and not distended.
Neurological Examination.
On the neck and back, no deformity seen.
On palpation,
Neurological examination:
Power: 8/10/2015-28/10/15
Right
Left
C5 4
4
C6 4
4
C7 4
4
C8 3
3
T1 3
3
L2
L3
L4
L5
S1

4
4
4
4
4

4
4
4
4
4

There is impaired sensation (numbness) from upper abdomen downwards (T4 S1)
Muscle tone are hypotonia over bilateral upper limbs but appears normal over lower
limbs
Barbnski signs are equivocal bilaterally.
On per rectal examination, anal tone is lax, with impacted stool, deep and superficial
sensation intact. Bulbocarvenosus reflex present.

INVESTIGATIONS
1) Hematological
Preoperative result on
Full Blood Count (FBC)

WCC 11.62, HB 10, HCT 37.8, PLT 307

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Postoperative result on
Full Blood Count (FBC)
Renal Profile (RP)
Liver Function Test (LFT)
Coagulation Profile
Electrolytes

WCC 10 , HB 8.8, HCT 33.7, PLT 296


Urea 4, Na 138, K 4.3 , Creatinine 47.3
Total protein 72, Albumin 44, Total bilirubin 9,
ALT 44, AST 127, ALP 107
PT 12.6/ INR 1.15/ APTT 31.4
Calcium 2.13, Magnesium 0.76, Phosphate 1.75

2) Radiological
Xray thoracolumbar at Hospital Teluk Intan on /10/15

Magnetic Resonance Imaging (MRI) Whole Spine on done on 9/10/15 to rule out
cauda equine syndrome with spine metastatsis.
The findings are as below :

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Loss of cervical lordosis. Vertebral alignment is preserved.
Linear T2 hyperintensity is seen at C6, T6 and T7, associated with wedging of
the vertebral bodies, suggestive of compression fractures.
Modic type II (fatty) changes at the opposing end plates of T-10/11 and L-4/5.
Desiccation of the cervical discs with multilevel circumferential discs bulge
(From C3/4 to C7/T1).
The ligamentum flavum at these levels are also severely thickened and
ossified.
The above changes result in severe cervical canal narrowing and spinal cord
compression with cord oedema from C3 to C7 levels.
The narrowest AP diameter measures 6.5mm at C6 level.
Low signal intensities are observed at the spinal process of C6 and the erector
muscles, may represent calcification/ossification.
Narrowing of the C4/5, C5/6, C6/7 neural foraminae, more on the left side,
causing exiting nerve root impingement.
Spinal cord ends at L1 level. No compression of the cauda equina.
No abnormal spinal enhancement or paravertebral mass.
Impression: Severe cervical canal stenosis with cord compression from C3 to
C7 levels and cervical nerve roots impingement as described.

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MANAGEMENT:
Preoperative, patient was having acute urinary retention, hence was put on CBD until
operation in ward
Surgical Operation
Patient underwent laminoplasty of C4, C5,C6 done by Mr Lim, Mr Thurai, assisted
by Dr Hafiz on 28/10/15 at 15:27H - 17:45H
Post op diagnosis:
Congenital Spinal Stenosis over C3-C6
Inta op finding:
Congenital Spinal Stenosis over C3-C6
Thick fibrous tissue overlying dural sheath
Laminoplasty Over C4-C6
Implant used:
Medtronic open door plate 10mmx3
Screws 2.6mmx7mmx6
2.6mmx5mmx5
3.0mmx5mmx1

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PROGRESS
Post-operatively, patient was admitted to ICU ( Intensive Care Unit ) overnight
to monitor closely. Initially, she was intubated, sedated and hemodynamically stable
unsupported. She was extubated well and was transferred to ward at post operative
day 1. In ward , she was hemodynamically stable unsupported. Pain score was well
tolerable post-operatively with the usage of patient controlled analgesia morphine
(PCAM) and subsequently wean off to oral anagelsia. She is put on Cervical Collar,
prop up 45 degrees and covered with IV cefuroxime 750mg TDS. Wound inspection
was done on day 3 postoperative on 1/11/2015. It was clean, no gapping, no pus
discharge. Drain was off on the same day as well. Total drain was minimal less than
50ml. Check X-ray whole spine reviewed by spine team and was acceptable.
Patient's neurological status was improved after operation. She started to
mobilized from lying to sitting position with assistance on day 3 postoperative. On
day 6 postoperative, patient was able to ambulate to chair with the help of
physiotherapy team.
Neurological examination post op day 6
Power :
C5
C6
C7
C8
T1

Right
5
5
4
5
3

Left
5
5
4
4
4

L2
L3
L4
L5
S1

4
5
5
5
5

5
5
5
5
5

Sensation: Best sensory at C6 level, proprioception intact


Per rectal: anal tone still lax, BCR present, deep and superficial anal sensation intact
She still required aid in daily activities and ambulating to chairs with helps.
She is able to sense full rectum but difficult to initiate full bowel opening and still on
CBD. She was referred to rehabilitation team, started with trial of catheter,
mobilization, strengthening exercises and respiratory exercise with triflow
spirometer. She started bowel opening with help of syrup lactulose 15ml BD and
suppository Dulcolax 20 mg every other day. At post-operative day 7, patients
wound had hemoserous discharges. Pus C&S taken on 3/11/15 grew pseudomonas
aeruginosa which is sensitive to amikacin and cefepime. Our team consulted
infectious disease on 5/11/15, in view of patient clinically well, septic markers not
raised, hence was planned to off antibiotics and observe wound. She is put on acetic
acid and bactigrass dressing daily in ward. At post-operative day 13, patient was

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discharged to Hospital Teluk Intan in view logistic problem. Upon discharge, patient
able to ambulate using walking frame with 1 person minimal assist. She was also able
to performed functional activities like feed herself, brush teeth and self hygiene,
however still need assistance for dressing. Wound inspection was donenoted clean
and dry. Patient was on bladder diary and bowel reflexes regime. Her neurological
power bilateral upper and lower limbs are 5 except C7-T1 are 4.
She comes for TCA orthopaedic clinics as outpatient 3/12/15 (1 month postoperative), she is able to ambulate with walking frame. Patient claims there is
minimal pain over the neck with pain score 2/10 minimal and able to sleep well.
Otherwise, she is able to control bowel and bladder habit and eating well. She
compliants to cervical collar.
Neurological examination during clinics TCA
Power :
Right
Left
C5
5
5
C6
5
5
C7
4
4
C8
4
4
T1
4
4
L2
L3
L4
L5
S1

5
5
5
5
5

5
5
5
5
5

Hence she is discharge with TCA after 2 months with LMS cream, planned for
continuous physiotherapy at teluk intan and keep the soft collar.

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Figure A: Xray Cervical after laminoplasty of C4, C5,C6 ( at 8/10/15)


Post op x ray cervical (at 30/10/15)

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Post op x ray cervical (at 11/2/15)

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MRI done on 15/10/15 pre operative

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Cervical x ray done at ortho clnics follow up 3/12/15

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DISCUSSION
1/ HISTORY