IX.

DIAGNOSTICS

Examination: CT SCAN OF THE CERVICAL SPINE

Date: Sept. 27, 2018

FINDINGS:

The 3rd vertebral body is no longer seen likely from severe compression fracture. There are lucencies in
the right side of the posterior element (lamina intact including the spinous process) while the left side is
preserved. Frosive changes are visualized at the anteroinferior margins of C2 vertebral body and right
posterosuperior margin of the C4 vertebra body. There is also presumably disruption at the C2-C3 disc
with C2 being displaced/retropulsed into the central canal. The narrowest portion is about 0.67 cm
(posteroinferior margin C2 and posterior spinal line). Note soft tissue attenuation material (presumably
hematoma) at the anterior aspect of the canal at C4 with apparent tiny osseous fragments and or
calcifications resulting in some apparent cord compression. Thicker density is also noted in the
prevertebral space at C2, C3, and C4, levels likely also from a blood. Facet joints appear preserved, C1
vertebreal body is within normal though mild widening is present at the lower aspect of the C1 and
odontoid process.

IMPRESSION:

 POST-TRAUMATIC INJURIES IN THE UPPER CERVICAL SPINE WITH FRACTURES,

DISPLACEMENT, HEMATOMAS AND RESULTANT CORD COMPRESSION AS DESCRIBED
ABOVE IN DETAIL.

Examination: MRI OF THE CERVICAL SPINE

Procedure date: Oct. 14, 2018
Report date: Oct. 14, 2018

FINDINGS:

Sagittal T2W and STIR, sagittal and coronal T1W and axial GRE images of the cervical spine show
cystic destruction of the C2-C3 disc, and lytic erosions in the lower C2 and upper C3 endplates with
bone marrow edema in the rest of these vertebral bodies. There is mild anterior wedging of the base of
the odontoid, grade 3 retrolisthesis of C2 over C3, mild gibbus and levoscoliosis. These are associated
with a ventral epidural soft tissue mass which extends from C2 TO C4 level , and pre-and paravertebral
soft tissue masses which extend from C1 and C3 levels, bordered by prevertebral and retropharyngeal
space edema.
The retrolisthesis and ventral epidural soft tissue component cause spinal canal stenosis with spinal
cord compression, but no definite myelopathy.
The bilateral C2-C3 neuroforamina are also narrowed, with presumed encasement of the bilateral
exiting C3 nerve roots.
The rest of the cervical spinal cord, including the cervicomedullary junction, is intact.
The other neuroforamina are not narrowed.
 The ligamentum flavum and posterior longitudinal ligament are not hypertrophic.
The rest of the intervertebral disc, vertebral bodies, pedicles, laminae, transverse and spinous
processes, uncovertebral and facet joints, and craniocervical junction are remarkable.

Incidental note of retropharyngeal and bilateral cervical lymphadenopathies.

IMPRESSION:

 Consider TB spondylodiscitis, C2-C3 level, with mild anterior wedging of the base of the
odontoid, grade 3 retrolisthesis of C2 over C3, mild gibbus and levoscoliosis, and prevertebral
and ventral epidural abscesses.
- Correlation with pertinent laboratory parameters suggested.
 Spinal canal stenosis at C2-C3 level due to the retrolisthesis and ventral epidural abscess .
with spinal cord compression but no definite myelopathy.
 Bilateral C2-C3 neuroforaminal stenoses , also due to the abscesses, with presumed bilateral
exiting C3 nerve root encasement.
 Cervical lymphadenopathies.

Examination: HEMATOLOGY
Date received: Oct. 20, 2018 11:01
Date reported: Oct. 20, 2018 12:04
Date printed: Oct. 20, 2018 12:05

COMPONENT RESULT REFERENCE INTERPRETATION

RANGE

RBC 5.19 4.0-6.0x10^12L Normal

Hemoglobin Mass L 130 Male: 140-180 Abnormal

g/L Low in hemoglobin Mass of a patient with
Pott’s disease suggests anemia or
dehydration.

( Black and Hawks; 2005)

Hematocrit 0.40 0.37-0.57 Normal

Leucocyte Count 9.00 4.8-10.8x10^9/L Normal

DIFFERENTIAL COUNT
- Segmenters 0.49 0.40-0.74
 - Lymphocytes 0.35 0.19-0.48 Normal
- Monocytes 0.09 0.03-0.09
- Eosinophils 0.06 0.00-0.07
- Basophils 0.01 0.00-0.02

RETICULOCYTES
Platelet count 380 150-450x10^9/L Normal

CRP
CRP Quantitative 0.05 <0.6 mg/dl Normal

INDICES
- MCV 78 82-92 fl Normal
- MCH 25 28-32 pg
- MCHC 32 32-38 %

Abnormal
ESR H 46 0-10mm/hr
In patient with Pott’s disease, an
inflammation activity in body’s system
causes the Red blood cells to clump.
Since these clumps are denser than
individual cells, they settle to the bottom
(tubes) more quickly. Hence, elevated
erythrocyte sedimentation rate (ESR) is
noticed.

( Mayo Clinic;2017 )

Clotting time ( Lee and 8’00” 5-15 mins. Normal

white )

Bleeding time ( Ivy’s 1’30” 1-7 mins. Normal

method)
COAGULATION
STUDIES
- Prothrombin time 13.00 11-15 seconds
- PT% Activity 97.6
- PT INR 1.02 < 1.1 seconds Normal
- Activated PTT 34.9 22-45 seconds

Examination: URINALYSIS
Date: Oct. 21, 2018
 TEST RESULT NORMAL VALUES INTERPRETATION

PHYSICAL
CHARACTERISTICS:
- Color Yellow Yellow
- Transparency Clear Clear Normal
- pH 6 4.8-7.8
- Specific Gravity 1.020 1.015-1.025

CHEMICAL TEST:

- Glucose Negative Negative Normal

- Protein Negative Negative

MICROSCOPIC
FINDINGS:
CELLS:
- RBC 0-2/ hpf 0-11/hpf Normal
- PUS Cells 0-2/hpf 0-12/hpf
- Bacteria Few Few
- Mucus Threads Light Light

Examination: CHEST/CERVICAL
Date of examination : Nov. 7, 2018
Date of interpretation: Nov. 9, 2018
Date of Release: Nov. 12, 2018

CERVICAL SPINE
 Lytic areas of rarefraction are seen at C2 and C2 and C3 vertebral bodies with widening of the
retropharyngeal space at the same region.
 Consider Pott’s disease.
 MRI correlate is recommended.


CHEST X-RAY
 Both lungs are clear.
 Heart is normal in size and configuration.
 Aorta is unremarkable.
 Both costophrenic sulci and hemi diaphragms are intact.
 Visualized osseous structures are unremarkable.

IMPRESSION:
NORMAL CHEST X-RAY
References:

- Black and Hawks;2005, Medical Surgical Nursing vol.1 7 th edition. Page 269.
- Mayo clinic staff; 2017: Retrieved from: https://www.mayoclinic.org/tests-procedures/sed-
rate/about/pac-20384797. Retrieved last Nov. 18, 2018.