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Paraplegia   a textbook case
Paraplegia   a textbook case
Paraplegia   a textbook case
Paraplegia   a textbook case
Paraplegia   a textbook case
Paraplegia   a textbook case
Paraplegia   a textbook case
Paraplegia   a textbook case
Paraplegia   a textbook case
Paraplegia   a textbook case
Paraplegia   a textbook case
Paraplegia   a textbook case
Paraplegia   a textbook case
Paraplegia   a textbook case
Paraplegia   a textbook case
Paraplegia   a textbook case
Paraplegia   a textbook case
Paraplegia   a textbook case
Paraplegia   a textbook case
Paraplegia   a textbook case
Paraplegia   a textbook case
Paraplegia   a textbook case
Paraplegia   a textbook case
Paraplegia   a textbook case
Paraplegia   a textbook case
Paraplegia   a textbook case
Paraplegia   a textbook case
Paraplegia   a textbook case
Paraplegia   a textbook case
Paraplegia   a textbook case
Paraplegia   a textbook case
Paraplegia   a textbook case
Paraplegia   a textbook case
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Paraplegia a textbook case

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A typical presentation of a not so rare condition.

A typical presentation of a not so rare condition.

Published in: Education, Health & Medicine
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  • 1. PARAPLEGIAA TEXTBOOK CASE Chair:- Prof. Dr. Baby Paul Presenter: Dr.Shybin Usman
  • 2. STRIKE ONE Mr. Gopakumar, 28 years from Neyyatinkara. Working in the BSF & posted in Bengal. Developed a nagging backache. Admitted in a local hospital near his base on 17/10/07. D/D on 20/10/07 as he was better.
  • 3. STRIKE TWO Backache was back by 23/10/07. Shooting pain radiating from back to umbilicus. Noticed gradually developing weakness of both lower limbs. Admitted from 23/10/07 to 31/10/07. Symptoms grew worse and he got on the next train home.
  • 4. STRIKE THREE Reached here on 3/11/07. Weakness of lower limbs was complete. Had lost all sensation in both lower limbs. In the final day of journey high grade fever set in. Backache was very severe with difficulty in lying on his back.
  • 5. SNIPPETS No significant medical past history. H/o haemorrhoidectomy 7 years ago. Occasional alcoholic. Non smoker.
  • 6. PRESENTING PICTURE Moderately built and nourished. Concious and oriented. Febrile. No PICCLE, conjunctival congestion. Chest – Clear. CVS – WNL. Abdomen – Bladder distended. Spine - Tenderness at D12 spine.
  • 7. NEUROLOGIC DEFICITS Grade 0 power both LL. Reflexes totally absent below the level of umbilicus. Sensations totally absent below the level of umbilicus. Bladder was distended. Rest of the nervous system examination was normal.
  • 8. INVESTIGATIONS Hb-11.4, TC-22700, N82 P15 E3, ESR-76. RBS-113. B.Urea- 62, S.Creat- 0.9 Na⁺- 139, K⁺-3.9 Bili- 1.4(T)/0.5(D), SGOT- 112, SGPT- 222, ALP-156 Prot- 6.0, S.Alb- 2.6 APTT- 31 sec, INR- 1.2
  • 9. PRIMA FACIEACUTE TRANSVERSE MYELOPATHY with SPINAL SHOCK
  • 10. SUSPECTS Pott’s spine Spinal extradural tumour with bleed Transverse myelitis Epidural abscess IVDP
  • 11. M SP RI INE
  • 12.  Diffuse posterior dorsal epidural abscess with spinal cord compression. Altered spinal cord signal intensity s/o edema. Multiple vertebral body (D12,L4,L5,S1) destruction with involvement of posterior elements & abscess formation. Extensive paravertebral & iliopsoas abscess formation.
  • 13. FINAL DIAGNOSISSPINAL EPIDURAL ABSCESS
  • 14. EPILOGUEPatient was handed over to the NS1 unit of the Dept.of Neurosurgery for further management on 6/11/07. He underwent posterior decompression with abscess evacuation on 13/11/07.
  • 15. INNARDSHistopathology report:- Section shows fragments of a lesion composed of numerous granulomas composed of epitheloid cells, multinucleated giant cells of Langhans type & inflammatory cells composed of mainly lymphocytes & also neutrophils. Areas show extensive caseation necrosis. The inflammatory infiltrate seems to invade the adjacent adipose tissue. Caseating granulomatous inflammatory lesion consistent with Tuberculosis.
  • 16. FOOTNOTE Patient was put on daily regimen of ATT.He bettered during the rest of his hospital stay.He was discharged on 21/11/07 with grade 1+ power in both LL.
  • 17. SPINAL EPIDURAL ABSCESS AN OVERVIEW
  • 18. Remains a challenging problem that often eludes diagnosis and receives suboptimal treatment.Vague symptomatology & non-specific clinical findings in the early stages can make diagnosis difficult.
  • 19. AETIOLOGY Predisposing factors:- • Underlying disease (DM, alcoholism, HIV, etc) • Spinal abnormality/intervention (Joint degeneration, Sx) • Source of infection- local/systemic Mode of spread:- • Hematogenous- 50% cases • Contiguous- 33% cases • Rest- unknown• Abscess can spread locally or via bloodstream
  • 20. ORGANISMS Staph. aureus- 67% MRSA on the increase S.epidermidis (invasive procedure) E.coli (UTI) P.aeruginosa (iv drug abuse) Rare- Actinomycetes, Nocardia, Mycobacteria, Fungi.
  • 21. COURSE OF DISEASE STAGE I- Pain @ affected spine(s) STAGE II- Nerve root pain from involved area STAGE III- Motor weakness, sensory deficit, bowel & bladder dysfunction. STAGE IV- Paralysis
  • 22. CLINICAL FEATURES CLASSIC TRIAD (infrequently seen):- • Back pain- 75% pts • Fever- 50% pts • Neurologic deficit- 33% pts (pattern depends on site) Duration & progression of symptoms vary widely Source of infection may be identifiable
  • 23. SITES More in infection-prone fat & larger epidural spaces Posterior > Anterior Thoracolumbar > Cervical Usually span 3-4 vertebrae Can involve the whole spine- Panspinal infection
  • 24. DIAGNOSIS Clinical features + clinical findings + lab data + investigation + high degree of suspicion Lab data (not specific):- • Leukocytosis- 66% • CRP & ESR increased- almost 100% • Bacterimia- 60% • CSF (mostly)- Protein ↑, Glucose N Leukocytosis (neutro+lympho) Gram stain- neg Culture- CSF +ve 25% (= Blood +ve 100%)
  • 25. INVESTIGATIONS LP to be avoided:-  Not much helpful  Meningitis  Subdural infection  Neurologic deterioration if below complete block X-ray spine-  Narrowed disc space  Bone lysis CT myelography- 90% specific, but unadvisable
  • 26. IMAGING MODALITY OF CHOICEMRI + Gadolinium (best) Less invasive Delineates lesion best Diff b/w infection & tumours
  • 27. DIFFERENTIALS Meningitis Transverse myelitis Spinal tumour Spinal hematoma Osteomyelitis of vertebrae Diskitis IVDP Degenerative joint disease Demyelinating illness Sepsis
  • 28. TREATMENT Surgical- Decompression laminectomy and debridement. (Rate of progress of symptoms cannot be predicted. Sx as early as possible) Appropriate systemic antibiotics (min 6 weeks)  Emperical- Vancomycin + 3rd /4th gen Cephalosporin MSSA- Cefazolin/Naficillin
  • 29. MONITORING Neurological status (esp. antibiotic only)-  Deterioration – Extension/incomplete evacuation Signs of sepsis Repeat imaging (esp. antibiotic only)
  • 30. PROGNOSIS Best predictor of post-op final neurologic outcome is pre-op neurologic status. Paralysis of <24-36 hrs= better prognosis. Recovery can continue till about 1 year.
  • 31. COMPLICATIONS Irreversible paralysis Bladder dysfunction Decubiti Supine hypertension Recurrent sepsis
  • 32. THANK YOU

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