Paraplegia a textbook case

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A typical presentation of a not so rare condition.

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Paraplegia a textbook case

  1. 1. PARAPLEGIAA TEXTBOOK CASE Chair:- Prof. Dr. Baby Paul Presenter: Dr.Shybin Usman
  2. 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. 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. 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. 5. SNIPPETS No significant medical past history. H/o haemorrhoidectomy 7 years ago. Occasional alcoholic. Non smoker.
  6. 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. 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. 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. 9. PRIMA FACIEACUTE TRANSVERSE MYELOPATHY with SPINAL SHOCK
  10. 10. SUSPECTS Pott’s spine Spinal extradural tumour with bleed Transverse myelitis Epidural abscess IVDP
  11. 11. M SP RI INE
  12. 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. 13. FINAL DIAGNOSISSPINAL EPIDURAL ABSCESS
  14. 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. 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. 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. 17. SPINAL EPIDURAL ABSCESS AN OVERVIEW
  18. 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. 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. 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. 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. 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. 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. 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. 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. 26. IMAGING MODALITY OF CHOICEMRI + Gadolinium (best) Less invasive Delineates lesion best Diff b/w infection & tumours
  27. 27. DIFFERENTIALS Meningitis Transverse myelitis Spinal tumour Spinal hematoma Osteomyelitis of vertebrae Diskitis IVDP Degenerative joint disease Demyelinating illness Sepsis
  28. 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. 29. MONITORING Neurological status (esp. antibiotic only)-  Deterioration – Extension/incomplete evacuation Signs of sepsis Repeat imaging (esp. antibiotic only)
  30. 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. 31. COMPLICATIONS Irreversible paralysis Bladder dysfunction Decubiti Supine hypertension Recurrent sepsis
  32. 32. THANK YOU

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