Clinical case presentation - spine

Dr. Guru PrasadDNB Orthopaedics

Case no .1

Dr. Guru prasad

Patient Details

• Name : G.Ashwin kumar• IP Number: 817• Age: 28 y• Gender: male• Residence : Hyderabad • Profession : salesman • DOA: 19/5/15• DOD: 25/5/15

Chief complaints :

low backache since 20 days

History of present illness

• Patient was apparently alright 9 months back, when he developed lower backache

• Which was insidious in onset,• Gradually progressive• Radiating to his right leg • Associated with tingling sensation.

• Pain was dragging in nature • Radiating from lower back to back of the thigh till the right foot• Pain increases with coughing and sneezing• Patient develops pain and tingling sensation or heaviness in

both lower limbs. More so in the right after walking a certain distance

• Pain becomes so severe that he has to take rest(sit) immediately for a few minutes

• Then the symptoms settle down temporarily and allow him to walk further the same distance

• Patient feels comfortable with Forward bending

No history of…

• Significant trauma• Constitutional symptoms (fever, loss of

weight)• Burning micturition• Other joint pains• Morning stiffness

• Not a known case of ...• Diabetes• Hypertension• Tuberculosis• Asthma • Epilepsy • Hypothyroidism

• Past history : no significant past history no h/o of any hospital admissions , previous medications

• Personal history : not significant bowel and bladder habits normal sleep disturbed appetite normal no h/o allergies Mixed diet Known alcoholic and a smoker• Family history : not significant

General examination

• Moderately built and nourished• No pallor /icterus

/cyanosis/clubbing/lymphadenopathy/edema• Pulse 86/min right radial• Blood pressure 110/80 mmHg right

upperlimb

Spine examination

• Inspection : no obvious deformity no swellings no scars or sinuses no paraspinal muscle spasm • Palpation : Tenderness over the L4- L5 and L5-S1 region Movements : extension was painful

Special Tests Name Left Right

Straight leg raising test (SLRT)

80 degrees 40 degrees

Lasegue test Negative positive

FABER test Negative Negative

Femoral stretch reflex Negative Negative

Neurological examination

• Higher mental function - NAD• Cranial nerves - NAD

Motor system

Muscle Left Right

Hip flexors (L1 /L2) 5/5 5/5

Quadriceps (L3) 5/5 5/5

Ankle dorsiflexors(L4) 5/5 5/5

Extensor hallusis longus(L5) 5/5 3/5

Ankle Plantar flexion(S1) 5/5 5/5

Nutrition : Bulk equal on both sides Tone : Normal on both sidesPower :

Sensory system

No neuro-deficit was observed in - Touch - Temperature - Pain

Reflexes Reflexes Left Right

Knee jerk (L4) Brisk Brisk

Ankle jerk (S1) Brisk Brisk

Plantar reflex (S1) Flexor (down going) Flexor (down going)

No bladder dysfunction (S2 S3 S4)

Hip examination

• No abnormality detected• Rotations were normal

Other systems

• Cardio vascular examination – NAD• Respiratory system – NAD• Per Abdomen – NAD

Differential diagnosis

Prolapsed intervertebral disc Lumbar canal stenosis Spondylolisthesis Tumors

Diagnostic tests

Sr. Investigation 19/5/151 Hb 15.3gm%2 TC 6900/cumm3 DC 60,34,03,03,004 Platelet 2.6 lakhs/cmm5 ESR 30mm6 CUE WNL7 RBS 93 mg%8 B.Urea 24mg%9 S.Creatinine 1.0mg%

10 BT 2.1011 CT 4.2012 Blood group B – Positive13 HIV Non Reactive14 HbsAg Non Reactive

15 S.Electrolytes

Na – WNLK – Cl -

16 TSH 1.52 microIU /ml

MRI

Diagnosis

• Prolapsed intervertebral disc L4 – L5 with lumbar canal stenosis

• Which correlates clinically with patient symptoms

Treatment plan

• Laminectomy with discectomy was done on 20 /5/15

Anaesthesia

• General anaesthesia• Prone position

Post operative X ray

Day - 1

• Patient got relief from the pain• Advised lumbo - sacral corset belt

Day - 2

• Patient was doing well• Drain removal was done • Patient was made to sit

Day - 3

• Patient was made to walk with walker support

Day – 4

• Patient discharged and called on 10th day for suture removal

• Physiotherapy started after 2 weeks

Case no 2

Dr. Guru prasad

Patient Details

• Name : P. Madhu babu• IP Number: 674• Age: 34 y• Gender: male• Residence : Hyderabad • Profession : businessman • DOA: 09/5/15• DOD: 14/5/15

Chief complaints

• low backache since 15 days

History of present illness

• Patient was apparently alright 2 years back, when he developed lower backache,

• Pain was dragging in nature • Radiating from lower back to back of the thigh

till the left foot• Increased with sitting , rising from a seat,

standing and walking a few metres which led to restriction of his activities

• Pain was also more while lying on his back• Patient was comfortable lying prone

No history of…

• Significant trauma• Constitutional symptoms (fever, loss of

weight)• Burning micturition• Other joint pains• Morning stiffness• Tingling and numbness

• Not a known case of ...• Diabetes• Hypertension• Tuberculosis• Asthma • Epilepsy • Hypothyroidism

• Past history : no significant past history no h/o of any hospital admissions , previous medications• Personal history : not significant bowel and bladder habits normal sleep disturbed appetite normal no h/o allergies Mixed diet Non alcoholic non smoker• Family history : not significant

General examination

• Moderately built and nourished• No pallor /icterus

/cyanosis/clubbing/lymphadenopathy/edema• Pulse : 84/min • Blood pressure : 130/70 mmHg

Spine examination

• Inspection : lumbar spine curvature convexity towards right no swellings no scars or sinuses paraspinal muscle spasm • Palpation : Tenderness over the L4- L5 and L5-S1 region Paraspinal muscle spasm

Special Tests Name Right Left

Straight leg raising test (SLRT)

50 degrees 30 degrees

Lasegue test Negative positive

FABER test Negative Negative

Femoral stretch reflex Negative Negative

Neurological examination

• Higher mental function - NAD• Cranial nerves - NAD

Motor system

Muscle Right Left

Hip flexors (L1 /L2) 5/5 5/5

Quadriceps (L3) 5/5 5/5

Ankle dorsiflexors(L4) 5/5 5/5

Extensor hallusis longus(L5) 5/5 3/5

Ankle Plantar flexion(S1) 5/5 5/5

Nutrition : Bulk equal on both sides Tone : Normal on both sidesPower :

Sensory system

No neuro-deficit was observed in - Touch - Temperature - Pain

Reflexes Reflexes Right Left

Knee jerk (L4) Brisk Brisk

Ankle jerk (S1) Brisk Brisk

Plantar reflex (S1) Flexor (down going) Flexor (down going)

No bladder dysfunction (S2 S3 S4)

Hip examination

• No abnormality detected• Rotations were normal

Other systems

• Cardio vascular examination – NAD• Respiratory system – NAD• Per Abdomen – NAD

Differential diagnosis

prolapsed intervertebral disc spondylolisthesis Lumbar canal stenosis spondyloarthropathy Tumours

Diagnostic tests

Sr. Investigation 9/5/151 Hb 17.8gm%2 TC 9500/cumm3 DC 68,26,03,03,004 Platelet 2.8 lakhs/cmm5 ESR 20mm6 CUE WNL7 RBS 99 mg%8 B.Urea 22mg%9 S.Creatinine 0.8mg%

10 BT 2.1511 CT 4.1012 Blood group O Positive13 HIV Non Reactive14 HbsAg Non Reactive

15 S.Electrolytes

Na – WNLK – Cl -

16 TSH 3.07 microIU /ml

X ray

MRI

Diagnosis

• Prolapsed intervertebral disc L4 - L5 more so in the left side

• Which correlates clinically with patient symptoms

Treatment plan

• Laminotomy with micro-discectomy at L4-L5 level was done on 10 /5/15

Anaesthesia

• General anaesthesia• Prone position

Post operative x ray

Day - 1

• Patient got immediate relief from the pain• Advised lumbo - sacral corset belt

Day - 2

• Patient was doing well• Drain removal was done • Patient was made to sit

Day - 3

• Patient was made to walk with walker support With lumbo sacral corset belt

Day – 4

• Patient discharged and called on 10th day for suture removal

• Thank you…!