Case Report III

( Saturday / April 12th 2014)

Extradural Spine Tumor
Presentant : dr. Marfri Andy
Supervisor : dr. Hj. Yuliarni Syafrita, Sp.S (K)
Moderator : dr. Hendra Permana, Sp.S
Opponents : dr. Mella Berti Adriyani
dr. Daril AL Rasyid

Case Report
A 59 years old female patient was transferred from Internal
Department on March 18th 2014 with ;
Chief complaint : weakness of the lower limbs
Present ilness history :
 Weakness of the lower limbs since 8 moths ago. The weakness started
with tingling on the right limb, followed by weakness a few weeks later.
The weakness progressively worsen and followed with the same pattern
on the lefy limb a month later. Since then, the patient cannot stand or
walk by her self and became fully dependent in daily activity. In the last
2 months, the patient started to feel back pain. The pain constant in
one location (above 2 fingers above umbilicus), unrelated to activity,
radiate to other parts of body, aggravated by cough, sneeze and other
movements. In the last 2 weeks, the patient also had difficulities in
urinate.

Past medical hostory :
 No history of trauma
 No history of infections
 No history neoplasm (breast, lung or cervical cancer).

Family history :no history of neoplasms
Social history :
 A housewife
 Doesn’t smoke
 Fully dependent in daily activity

General Examinations General appearance : moderately ill Level of conciousness : alert Blood pressure Heart rate Respiratory rate Temperature : 120/70 mm/Hg : 76 x/min : 24 x/min : 37o .

no murmur Abdomen : no signs of abdomnial distension. normal bowel sounds Back : ulcer decubitus at the right (grade 3-4) .Eye : anemic congjungtiva. vesicular. HR 88 x/min. palpable apex beat at the left of 5th intercostal space medial to the mid clavicular line. no carotid bruit Lungs : symmetrical chest wall. normal percussion. liver and spleen within normal. no ronchi or weezing Heart : no visible apex beat. no gallop. no arryhtmia. no icteric Lymph nodes : no enlargement Neck : JVP 5-2 cm H2O. timpanic percussion. normal fremitus.

Eutrofi Eutonus. no kernig sign Cranial nerves : within normal Motor system : Extremities Upper Lower Involunter movement Right Left 555 555 Eutonus.Glasgow coma scale : E4 M6 V5 (15) Meningeal signs : no ruchal rigidity. Diseus Atrpfi Hipotonus. Dissus atrofi - - . Eutrofi 000 000 Hipotonus. no brudizinkis.

.

Physiological reflexes : Reflexes Right Left Biceps ++ ++ Triceps ++ ++ Knee pee reflex + + Achiles Pee reflex + + Right Left Hoffman Tromner - - Babinski - - Oppenheim - - Gordon - - Chaddock - - Schaefer - - Pathological reflexes : Reflexes .

).). Conclusion: within normal . ST depression ( .).ECG : sinus rhythm. ST elevation ( . T inverted ( . SV1+RV5 <35mm.

000/mm3  GDS : 179 mg/dL  Natrium : 133 mmol/L  Kalium : 3.4 %  WBCs : 10.4 mg/dL  Protein total : 4.3 g/dL .3 g/dL  Ht : 23.300/mm3  Eritrosit : 2.0 mmol/L  Clorida : 105 mmol/L  Ureu : 14 mg/dL  Kreatinin : 0.8 /mm3  Platelets: 506.9 g/dL  Albumin : 2.Laboratory findings  Hb : 7.

Urinalysis : Protein :(+) Glukosa :(-) Leukosit : 200-250 Eritrosit : 1-2 Silinder :(-) Kristal :(-) Epitel :(+) Bilirubin :(-) Urobilinogen : ( + ) .

neutrofilia shift to the right Trombosit : increased . target cells ( + ) Leukosit : normal.Peripher Blood Smear : Eritrosit : anisositosis normokrom. hipokrom ( + ).

Diagnosis Clinical diagnosis : Paraplegia (spinal shock phase) Topical diagnosis : Spinal cord – 8th thoracal vertebrae Etiology of diagnosis : Spinal cord tumor Secondary diagnosis :  Ulcer decubitus  Hypochromic micositic anemia .

Management IVFD Aminofusin L600 : Triofusin = 1 : 2 = 8 hours/kolf High calories and protein diet Folley catheter Medication given :  Ceftriaxon 1 x 2 gr (IV)  KSR 2 x 600 mg (PO)  PRC transfusion  Plasbumin 20% : 100 cc .

hematocrit. SGPT  Tumor marker (AFP. white blood counts and trombosit Radiology :  Chest X-Ray  Thoracic MRI .Next Investigation Laboratory :  SGOT. CEA) Post transfusion laboratory examination : Haemoglobin.

RR : 21 x/min. T : 36. BP 120/70 mm/Hg. moderately ill. tumor markers  Chest X-Ray .Follow Up : 2nd day Subjectives : weakness of the lower limbs Objectives :  General : alert.8  Neurological examinations :  Cranial nerves : within normal  Motor system : no improvement  Sensory system : bilateral hipestesia at imaginary line 8 th Thoracal  Autonom system : follet cath attached  Physiological reflexes : no improvement  Pathological reflexes : ( . SGOT. SGPT. HR rate : 82 x/min./ -) Assesment :Paraplegia (shock spinal) Plans :  Laboratory : electrolyte.

Chest X-Ray : CTR < 55 %. no mass and infiltrate. Conclusion : within normal .

RR : 21 x/min./ -) Assesment :Paraplegia (shock spinal) Plans : Thoracal Spine X-Ray . HR rate : 82 x/min.Follow Up : 3rd day Subjectives : weakness of the lower limbs Objectives :  General : alert. moderately ill. T : 36.8  Neurological examinations :  Cranial nerves : within normal  Motor system : no improvement  Sensory system : bilateral hipestesia at imaginary line 8th Thoracal  Autonom system : follet cath attached  Physiological reflexes : no improvement  Pathological reflexes : ( . BP 110/70 mm/Hg.

2 mmol/L Kalsium : 7.0 mmol/L Clorida: 105 mmol/L SGOT : 16 u/l SGPT : 8 u/l Tumor markers AFP : 0.64 .Laboratory finding Natrium : 133 mmol/L Kalium : 3.85 CEA : 1.

8  Neurological examinations :  Cranial nerves : within normal  Motor system : no improvement  Sensory system : bilateral hipestesia at imaginary line 8 th Thoracal  Autonom system : follet cath attached  Physiological reflexes : no improvement  Pathological reflexes : ( . HR rate : 82 x/min. moderately ill./ -) Assesment :Paraplegia (shock spinal) . BP 120/70 mm/Hg.Follow Up : 4th day Subjectives : weakness of the lower limbs Objectives :  General : alert. T : 36. RR : 21 x/min.

posterior angulation at 8th thoracic vertebrae. destruction of 8th thoracal vertebrae corpus and pedicle Conlusion : Destruction of 8th thoracic vertebrae pedicle.Thoracal X-Ray : alignment. Advised for thoracic MRI .

8  Neurological examinations :  Cranial nerves : within normal  Motor system : no improvement  Sensory system : bilateral hipestesia at imaginary line 8th Thoracal  Autonom system : follet cath attached  Physiological reflexes : no improvement  Pathological reflexes : ( ./ -) Assesment :Paraplegia (shock spinal) Plans :Thoracic Vertebrae CT . BP 120/70 mm/Hg. HR rate : 82 x/min.Follow Up : 7th day Subjectives : weakness of the lower limbs Objectives :  General : alert. moderately ill. RR : 21 x/min. T : 36.

8th and 9th posterior thoracic corpus. extends to intervertebral foramen with infiltration to the 8th costal .Thoracic Vertebrae CT : destruction of 7th.

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RR : 21 x/min. HR rate : 82 x/min./ -) Assesment :Paraplegia (shock spinal) Plans : abdominal USG . T : 36.Follow Up : 14th day Subjectives : weakness of the lower limbs Objectives :  General : alert. BP 120/70 mm/Hg.8  Neurological examinations :  Cranial nerves : within normal  Motor system : no improvement  Sensory system : bilateral hipestesia at imaginary line 8th Thoracal  Autonom system : follet cath attached  Physiological reflexes : no improvement  Pathological reflexes : ( . moderately ill.

Abdominal USG : hepatomegaly. Conclusion : Hepatomegaly The patient ask for discharge Care planning decision. pankreas and kidney within normal. choices and risks was given (informed) . spleen.

 Tingling on the right limb  Progressively worsen weakness.Discussion Diagnosis A 57 years old female with no history of trauma. constant. strated on the right limb followed with the the left side  Back pain . infections and neoplasm The history of present ilness . unrelated to activity. aggravated by cough. dull. radiate to other parts of body. sneeze and other movements  Bladder disfunction : difficulities in urinate  Physical examination revealed shock spinal .

Further tests and radiological examination that was taken :  Elevated Alkali Phospatase  SGOT and SGPT were normal  Tumor markers : AFP and CEA were normal  The chest X-ray : normal  Thoracal vertebrae X-ray : destruction of thoracal vertebrae pedicle (thoracal VIII)  Thoracic vertebrae CT : destruction of posterior thoracal vertebrae pedicles across Th VII.pankreas. spleen . VIII. and kidney within normal . IX with infiltration to the 8th costal (Suggestive extradural spinal cord tumor)  USG Abdomen : hepatomegaly.

What is more likely to be considered as differential diagnosis from the tumor is multiple myeloma.The ethiology of the tumor remain unkonwn since there’s no suggestive values or clues (except elevated alkali phospatse) from the laboratory and radiology examinations. the breakdown of bone that leads release of calcium into blood  Renal failure . due to protein secreted by the malignant cells  Anemia . CRAB :  Calcium elevation . (bone scanning need to be done). tumor infiltration and inhibited red blood production  Bone pain (70 %) . activated osteoclast that resorb bone .

Thank You .

 Located within a bony canal created by the vertebral column  Tumors can arise in any of these spaces and are grouped according to location. The spinal cord :  Surrounded by though fibrous covering called the dura. a guide for patients and cares. 2002 . Spinal tumors : • Extradural • Intradural Extramedullar • Intradural Intramedullar Source : Brain and Spine Fondation .

a guide for patients and cares. 2002 . sneeze and spinal movements Intradural Extramedullar :  Chronic progressive radicular pain  Pain noted especially at night  Myelopathic symptoms as tumor grows Intradural Intramedullar :  Interruption of crossing fibers leading to sensory deficit  Followed by long tract signs  Subsequent weakness and wasting of muscles in extremities Source : Brain and Spine Fondation .Spinal Tumor Extradural :  Well defined root pain  Pain aggravetd by cough.

worsen when lting down and may radiate to other parts of body Gait disturbance Decreased pain and temperature sensation Paralysis/paresis Scoliosis or other spinal deformity Erectile dysfunction and or loss of bowel/bladder control Taken from American Cancer Society. Atlanta. Brain and Spinal Cord Tumors in Adults. unrelated to activity.General Symptoms of Spinal Cord Tumors Back Pain that progressively worsen. 2010. .

Metastasis Tumor Common primary sites : • Breast : 21 % • Lung : 14 % • Prostate : 7. Atlanta. Brain and Spinal Cord Tumors in Adults.5 % • Renal :5% • GI :5% • Thyroid : 2. 2010. .5 % Level of metastases • Thoracolumbar • Lumbosacral • Cervical : : 70 % : 20 % : 10 % Taken from American Cancer Society.

spineuniverse.com .Bone Tumors Source : www.

History : Age : high level of suspicion Details of the pain : insidious acute. GU and skin Any age specicic screening tests by GP Socail history : smoking. non mechanical. trauma. unrelenting. worse at night. 2010. alcohol. GI. Brain and Spinal Cord Tumors in Adults. radiculopathy. change in features if chronique Personal history on cancer Constitutional symptoms Review of the systems : thyroid. chest. exposure to carcinogen Family history of malignancy Taken from American Cancer Society. Atlanta. breast. .

Henry Lee and Patrick Boland Oncologist 2011 . oblique • Bone scan : screening • CT : bony architecture • MRI + gadolinium : gold standard Options of treatment : • Orthotic • Steroids • Radiotherapy • Chemotherapy • Hormonal therapy • Surgery • Combination Source : The Diagnosis and Treatment of Metastatic Spinal Tumor Mark H. ESR.Laboratory : • CBC. lateral. thyroid. liverfunction tests. Bilsky. Bence-Jones proteins • Special : PSA. Jeffrey Raizer. Creatinine • Ca. serum and urine protein. CEA Radiological evaluation : • X-ray of spine : AP.459-469 . electrophoresis.4. Alk phos • Urinalysis : routine. Eric Lis. CRP. PO4. BUN.

459-469 . Eric Lis. Bilsky.4. Jeffrey Raizer.Surgical Intervention Principles of surgical treatment : • Estbalish diagnosis • Decompression • Realignment • Stabilization Source : The Diagnosis and Treatment of Metastatic Spinal Tumor Mark H. Henry Lee and Patrick Boland Oncologist 2011 .