PARAPLEGIAA TEXTBOOK CASE Chair:- Prof. Dr. Baby Paul Presenter: Dr.Shybin Usman
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.
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.
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.
SNIPPETS No significant medical past history. H/o haemorrhoidectomy 7 years ago. Occasional alcoholic. Non smoker.
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.
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.
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.
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.
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.
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
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
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%)
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
IMAGING MODALITY OF CHOICEMRI + Gadolinium (best) Less invasive Delineates lesion best Diff b/w infection & tumours
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
MONITORING Neurological status (esp. antibiotic only)- Deterioration – Extension/incomplete evacuation Signs of sepsis Repeat imaging (esp. antibiotic only)
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.