CASE REPORT

MYELOPATHY

Wahyu Permaya Lisa. S

1708435968

Supervised by :
dr. Yossi Maryanti, Sp.S, M.Biomed

Clinical Clerkship of Neurology Department

Faculty of Medicine University of Riau
Arifin Achmad General Hospital
 Patients’ Identity
• Name : Ms. S
• Age : 20 years old
• Sex : Female
• Address : Pekanbaru
• Admission to Hospital : February, 28th 2019
• Date of Examination : February, 28th 2019
• Medical Record : 005355xx
• Occupation : Not Worked
1. History
Chief Complaint
Weakness on both arm and leg that
more severe since 10 days before
admitted to the hospital.

”
History of Present Illness
(Auto & Alloanamnesis)

• 10 days before admitted to the hospital, the patient has

complained the weakness of arm and leg. Weakness began
numbness on both of the leg and occur gradually. Previously the
patient couldn’t moved her legs and always walked slowly by
dragged her legs. But now, the patient couldn’t be lifted and moved
both of the leg and just had a bed rest

• The patient also has complained on her arm, the arm felt heavy but
the patient could to lifted her arm and hold the object previously.
But, in this time she felt difficult to hold the object example to hold
the pen. The patient felt her arm doesn’t has a power to do it.
History of Present Illness
(Auto & Alloanamnesis)

• The patient has complained in controlling her urination. She felt not
satified after miksi. But, she could know if she want to miksi. There
is no complaint of controlling her defecation. Fever was denied,
weight loss denied, prolonged cough denied, and history of trauma
was denied.

• 1 months before admitted to the hospital, patients complained pain

in his neck and radiating to her shoulder and arm intermittently.
Pain felt when woke up in the morning and will decrease with a
rest, it occured suddenly without any previous trauma histories
before.
History of Present Illness
(Auto & Alloanamnesis)

• 8 years before admitted to the hospital, its the first time the patient
has complained difficult to walked because of weakness on both
legs. Although difficult to walked, patient still moved the legs. The
patient could take care of herself and do some activity in her
house.

• The patient also has a complained in her arm. Firstly she felt
tingled in her arm, but she still do daily activity. Because of the
complained she go to a physioteraphy and do the exercise for 5
yeras. But the complained couldn’t decrease. After that, the patient
decided to stopped the physioteraphy.
 History of Past Illness

• Cough produced phlegm (-)

• Bump on the back (-)
• Weight loss and appetite (-)
• A history of 6 months medication (-)
• Hypertension (-), Diabetes mellitus (-)
• A history of Cancer (-)
• History of backbone surgery (-)
History of Family
• A history of TB (-)
• A history of Cancer (-)
 Resume

Ms. SE, 20 years old admitted to the hospital on February, 28th 2019 with chief
complained the weakness of arm and leg that more severe since 10 days before
admission. Because of that the patient couldn’t be lifted and moved both of the leg and
arm, couldn’t do anything and just had a bed rest. The patient also complained pain in
the neck when woke up, and the pain radiating to her shoulder and arm intermittently
since about 1 months before admission. Previously the patient had a phisioteraphy
since 8 years ago.
2. PHYSICAL EXAMINATIONS
PHYSICAL EXAMINATION
Generalized Condition
• Blood Presure : 100/80 mmHg
• Heart Rate : 82 bpm
• Respiratory rate : 20 tpm
• Temperature : 36,3°C
• Weight : 40 kg
• Height : 150 cm
General Status

Neurological status

• Consciousness : Composmentis
• GCS : 15 (E4V5M6)
• Cognitive Function : Normal
• Neck Stiffness : Negative
Cranial Nerves
• N. I (Olfactorius)

Right Left Interpretation

Sense of Smell Normal Normal Normal

• N.II (Opticus)

Right Left Interpretation

Visual Acuity
Visual Fields Normal Normal Normal
Colour Recognition
• N.III (Oculomotorius)

Right Left
Ptosis (-) (-)
Pupil
Shape Round Round
Size Φ3mm Φ3mm
Extraocular movement Normal Normal
Pupillary reaction to light
Direct + +
Indirect + +
• N. IV (Trochlearis)

Right Left Interpretation

Extraocular
Normal Normal Normal
movement

• N. V (Trigeminal)

Right Left Interpretation

Motoric Normal Normal

Normal
Sensory Normal Normal

Corneal reflex (+) (+) Normal

• N. VI (Abduscens)

Right Left Interpretation

Extraocular
Normal Normal
movement
Normal
Strabismus (-) (-)
Deviation (-) (-)
• N. VII (Facialis)

Right Left Interpretation

Tic (-) (-)
Motoric
 Frowning Normal Normal

 Raised eye brow Normal Normal

 Closed eyes Normal Normal Normal
 Corners of the
Normal Normal
mouth
 Nasolabial fold Normal Normal
(-) (-)
Chvostek sign

Flavour Sense Normal Normal

• N. VIII (Acusticus)

Right Left Interpretation

Hearing sense Normal Normal Normal

• N. IX (Glossopharyngeus)
Right Left Interpretation
Pharyngeal arches Normal Normal
Flavour sense Normal Normal Normal
Gag Reflex (+) (+)
• N. X (Vagus)

Right Left Interpretation

Pharyngeal arches Normal Normal

Normal
Dysfonia (-) (-)

• N. XI (Accesorius)

Right Left Interpretation

Motoric Normal normal Normal
Trophy Eutrophy Eutrophy Normal
• N. XII (Hypoglossus)
Right Left Interpretation

Motor Normal Normal

Trophy Eutrophy Eutrophy

Normal
Tremor (-) (-)
Dysarthria (-) (-)
 Right Left Interpretation
Upper Extremity
Strength
Distal 2 2
Proximal 2 2
Tone Spastic Spastic
Trophy Atrophy Atrophy
Involuntary movements - -
Clonus + +
Tetraparese
Lower Extremity (UMN Type)
Strength
Distal 1 1
Proximal 1 1
Tone Spastic Spastic
Trophy Atrophy Atrophy
Involuntary movements - -
Clonus + +
Body
Trophy Eutrophy Eutrophy
Involuntary movements - - Normal
Abdominal Reflex + +
 Sensory
Right Left Interpretation

Touch ↓ on C1-2 ↓ on C1-2 Hypesthesia on

Pain ↓ on C1-2 ↓ on C1-2 high as C1-C2
Temperature Not identified Not identified dermatome
Propioseptive Negative Negative
Reflex
Right Left Interpretation
Physiologic
Biceps (+++) (+++)
Triceps (++) (++) Hyperreflexia
Knee (+++) (+++)
Ankle (++) (++)

Pathologic
Babinsky (+) (+)
Chaddock (+) (+)
HoffmanTromer (+) (+) Pathologic reflex (+)
Openheim (-) (-)
Schaefer (-) (-)
Gordon (-) (-)
 Coordination
Right Left Interpretation
Point to point Normal Normal Normal
movements
Walk heel to toe Not Tested Not Tested
Gait Not Tested Not Tested
Tandem Not Tested Not Tested Difficult to assess
Romberg Not Tested Not Tested

Autonom system
Laseque >70o Others Examination
Urination (-)
Kernig > 130 o Spruling test +
Defecation (+) Patrick -/- Head traction -
Kontrapatric -/- Valsalva test -
Valsava test -
Brudzinski -
EXAMINATION RESUME
• General status
Blood pressure 100/80 mmHg
Heart rate 82 bpm
Respiratory rate 20 x/minute
Temperature 36,3oC
• Neurologic examination

Cognitive function Normal

Neck stiffness Negative
Cranial nerves Normal
Motoric Tetraparese
Sensory Hypesthesia on high as C1-C2 dermatome to the lower
Coordination Difficult to interpretate
Autonom system Abnormal urination
Reflex Hyperreflexia (+), Pathologic Reflex (+)
Others Examination Normal
Clinical diagnosis :
- Tetraparese with UMN type
- Hypesthesia from C1-2 dermatome to lower
- Abnormal urination

Topical diagnosis : 1st- 2nd cervical spinal cord

segments

Etiologic diagnosis : Cervical Mielopathy ec

suspect spondylosis

Differential diagnosis: Susp. Spondilitis TB

 Blood routine

Blood chemistry

Electrolytes

MRI Thoracal spine

Management
• Maintanance : IVFD NaCl 0,9% 20 dpm

• Anti inflamation : Methylprednisolone 3 x 125 mg per IV

• Gastric Protector : Ranitidine 2 x 50 mg IV

• Neurotropic : Mecobalamin 3 x 500 mg

 Laboratory Findings

• Blood Chemistry

• Ureum : 26 mg/dL
• Blood Routine • Creatinin : 0,60 mg/dL
• AST : 15 U/L • Electrolyte
• Hb : 7,9 g /dl • ALT : 9 U/L
• Na : 142 mmol/L
• WBC : 5030 • K : 4,0 mmol/L
• Ht : 26,4 % • Cl : 101 mmol/L
• PLT : 386.000
MRI cervical spine non contrast and
with contrast (February, 26th 2019)
• Result :
• Stenosis of canalis spinalis on C1-2 with compression of spinal
cord because of suspect spondylosis.
• Suspect edema spinal cord on C1-2
 Final Diagnosis
Cervical myelopathy ec Spondylosis Cervical

34
”
 Follow up March, 1st 2019
Subjective
Weakness both on legs and arms, neck pain (+), fever (-), defecation (+).

Objective
Composmentis Motoric : Tetraparese
BP : 110/80 mmHg 2 2
HR : 80 bpm
1 1
RR : 20 tpm
T : 38.°C Sensory : Hypesthesia on C-2 dermatome to lower
Cognitive Function : Normal Coordination : NT
Neck Stiffness : Negative Autonomy : Micturition (+) with cateter, defecation (+)
Cranial Nerves : Normal Reflex : Hyperreflexia (+), Pathologic reflexes (+)
Assessment
Cervical myelopathy ec susp. Spondylosis cervical

Plan
IVFD RL 20 dpm
Metilprednisolon 3x125 mg IV
Mecobalamin 3x500 mg IV
Ketorolac 2x30 mg IV
Ranitidin 2x125 mg IV
MST 3x10 mg
Dulcolax sup
Plan: MRI Thoracal
Consul to surgeon  BNO 3 position and consul to interna  IVFD Ciprofloxacin 2x400 mg, IVFD
Metronidazol 3x500 mg, omeprazole 2x40 mg IV
3. Theory
 CERVICAL SPONDYLOTIC
MYELOPATHY (CSM)

41
”
 Definition Cervical spondylotic myelopathy
Cervical spondylotic myelopathy is the most serious consequence of cervical
intervertebral disk degeneration, especially when it is associated with a narrow
cervical vertebral canal.
Epidemiology
Cervical spondylosis myelopathy can be identified in the majority of people older
than 40 years. But sometimes it can identified in the patient younger than 40 years. In
Asia especially Taiwan has a data overall incidence of CSM-related hospitalization was
4.04 per 100,000 person-years. Specifically, males and older persons had a higher
incidence rate of CSM.
Classification
 Clinical
Manifestation
 Pysical
Diagnosis
Examination

Anamesis Radiograph
 Managment
Conservative treatments for CSM often :
1. Neck immobilization
2. Pharmacologic treatments
3. Lifestyle modifications
4. Surgical intervention.
 Definition Cervical Root Syndrome
Cervical root syndrome or Cervical radiculopathy is a dysfunction of a
nerve root of the cervical spine. The seventh (60%) and sixth (25%)
cervical nerve roots are the most commonly affected. In the younger
population, cervical radiculopathy is a result of a disc herniation or an
acute injury causing foraminal impingement of an exiting nerve. Disc
herniation accounts for 20-25% of the cases of cervical radiculopathy.
 Clinical Manifestation
Cervical radiculopathy produce some characteristic manifestation such as:
pain and sensory deficit in the corresponding dermatome; greater
impairment of pain sensation than of the other sensory modalities; reduced
strength in segment-indicating muscles and rarely muscle atrophy; reflex
deficits corresponding to the damaged roots; absense of autonomic deficits
in the limbs
 Provocative
Test

Pysical
Diagnosis
Examination

Anamesis Radiograph
4. DISCUSSION

”
BASIC CLINICAL DIAGNOSE

Anamnesis
Weakness on both arm and legs Numbness and Tingling Can’t urinate

Physical examination
Tetraparese, hyperreflexia, pathologic reflex
Hypesthesia on C-2 to the lower
(+)

Tetraparese UMN Type, Hypesthesia on C-2 dermatome,

autonomic dysfunction
BASIC TOPIC DIAGNOSE

Anamnesis
Weakness on both arm and leg

Physical examination
Tetraparese Hypesthesia on C-2 to the lower

2nd cervical spinal cord segments

BASIC ETIOLOGICAL DIAGNOSE

Anamnesis
Weakness on both arm and legs
Neck pain radiating Autonomic dysfunction
gradually

Physical examination
Tetraparese Hypesthesia on C-2 to the lower

Susp. Spondylotic Cervcial

BASIC DIFFERENTIAL DIAGNOSE

Anamnesis
Numbness on both arm and
Weakness on both legs Fever
legs

Physical examination
Tetraparese Hypesthesia on C-2 to the lower

Susp. Spondylitis TB
BASIC WORK UP
Laboratory
 to know the risk factors whether
the infection exis and knowing the
general condition of the patient for
therapeutic purpose
Thoracal MRI
 to find the etiologic for this
case at apinal cord area or
vertebrae.
 Basic Final Diagnosis

Physical
• Weakness on both arm and legs examinations • Normal of leucocyte
• Numbness • MRI : There is stenosis
• Neck pain • Tetrapareses UMN type
canalis spinalis on C1-2
• Hypesthesia on C-2 dermatome to the
lower with compression of
spinal cord because of
suspect spondylosis.

Workup
Anamnesis
exam
Basic of Treatments

The aim of
Metilprednisolon The aim of The aim of Ranitidine
The aim of IVFD NaCl 0,9% 3x125 mg Mecobalamin 3x500 3 x 50 mg
 to maintain the euvolemic
condition  to provide relief for mg  as a gastric
inflamed areas of the  as a neurotropic protector
body.
Thank You