A case of Compressive Myelopathy

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A case of Compressive Myelopathy

  1. 1. Prof. S.Sundar unit Dr. Vikraman.G A CASE OF PARAPLEGIA
  2. 2. CHRONOLOGY 0F EVENTS <ul><li>1/3/2008-A 40 Year old male admitted in salem medical colege with c/o cough with mucoid expectoration,breathlessness,vomitting-2-3 months duration </li></ul><ul><li>H/o fever,low grade 10 days backnot associated with chills,evening rise of temperature, settled with treatment </li></ul><ul><li>h/o LOA/LOW </li></ul><ul><li>No h/o hemoptysis,chestpain,palpitation,PND,orthopnoea,bone pain,any focal neurological deficit,headache,syncope,bowel,bladder disturbance,seizures,abdominal pain,distension </li></ul><ul><li>No other specific complaints </li></ul><ul><li>PAST HISTORY- not a known DM/SHT/CAHD/CVA/SEIZURE/PT </li></ul><ul><li>PERSONAL HISTORY-SMOKER/ALCOHOLIC </li></ul>
  3. 3. Examination <ul><li>o/e Pt. conscious, oriented, afebrile,hydration fair GRADE 1 CLUBBING PALLORno CY/PE/LA/JVP/ICT </li></ul><ul><li>RS- trachea in midline, no TF, chest movements decreased in right side,BS diminished in whole of Right hemithorax,VF/VR decreased in right hemithorax </li></ul><ul><li>Other systems-WNL </li></ul>
  4. 4. INVESTIGATIONS <ul><li>RBS-137mg% </li></ul><ul><li>RFT-B.Urea-17mgs%,Sr.creat-0.9mgs%,Na+-142meq/l,k+-4.3meq/l </li></ul><ul><li>CHG-Hb%-8.6g%,TC-10,200cells/cumm,DC-P60,L38,E2,platelets-1.74mgs%,ESR-25/50 </li></ul><ul><li>MP/MF neg </li></ul><ul><li>Urine WNL </li></ul><ul><li>PLEURAL FLUID EXAMINATION-sugar-70mgs%,proteins-2.8g%,WBC’s 160cells/cu.mm,RBC’s plenty </li></ul><ul><li>Mantoux-reactive,10mm </li></ul>
  5. 5. <ul><li>CT thorax-massive right Hydrothorax,destroyed right lung with collapse,consolidation with minimal left pleural effusion </li></ul><ul><li>Sputum AFB-neg </li></ul><ul><li>Sputum C&S-no growth </li></ul>
  6. 6. <ul><li>Diagnosed as right effusion (tubercular origin) and started on ATT cat III and discharged </li></ul>
  7. 7. <ul><li>30/4/2008-pt re-admitted with added c/o -pain in back of chest,weakness of lower limbs-2 days </li></ul><ul><li>Positive sign- GRII clubbing,pallor, </li></ul><ul><li>RS-chest movements,dullness on percussion in right side,VF/VR,BS decreased in right side </li></ul><ul><li>CVS,PA- wnl </li></ul>
  8. 8. <ul><li>CNS HF-wnl </li></ul><ul><li>SPINOMOTOR </li></ul>RIGHT LEFT BULK N N TONE UL N N LL POWER UL 5/5 5/5 LL 4/5 4/5 DTR UL ++ ++ LL +++ +++ ABDOMINAL ABSENT ABSENT PLANTAR EXTENSOR EXTENSOR
  9. 9. <ul><li>CRANIAL NERVES/CEREBELLAR/EXTRAPYRMIDAL-WNL </li></ul><ul><li>SENSORY SYSTEM-DECREASED BELOW D6 </li></ul><ul><li>GIBBUS ,TENDERNESS D2,D3,D4 </li></ul>INVESTIGATION ESR-I5/40,HB%-9.5,HIV NONREACTIVE,ECG-WNL X RAY DORSAL SPINE-NO RADIOLOGICAL ABNORMALITY DETECTED IN SPINE
  10. 10. <ul><li>CT BRAIN-Evidence of moderately defined rounded minimally enhancing iso to hypodense lesion with surrounding white matter edema noted in right parieto occipital region and left temporal regions. No evidence of mass effect& midline shift. To consider the possibility of multiple granulomatous lesions involving right parieto occipital region & left temporal region. </li></ul><ul><li>Neuro opinion- multiple tuberculoma. Advice to continue ATT </li></ul>
  11. 11. DIAGNOSIS ANDMANAGEMENT <ul><li>TUBERCULOSIS/PLEURAL EFFUSION/MULTIPLE TUBERCULOMA/?POTT’S SPINE/PARAPARESIS </li></ul><ul><li>STARTED ON CAT I ATT/STEROIDS/NSAIDS/ </li></ul>
  12. 12. <ul><li>PT CONDITION DIDN’T IMPROVE. REFERRED TO DEPARTMENT OF MEDICINE STANLEY MEDICAL COLLEGE ON 15/6/2008 FOR FURTHER MANAGEMENT. </li></ul>
  13. 13. DEPARMENT OF MEDICINE,GSH <ul><li>Pt. a 40 year old on ATT cat I for multiple tuberculoma/?Pott’s spine admitted with C/o back pain 2 months,difficulty in using both lower limbs for the past 17 days. decreased sensation below coastal margin-17 days c/o bowel and bladder disturbance-4 days </li></ul><ul><li>c/o difficulty in using both lower limbs, insidious onset , slowly progressive,spastic and now complete inabilty to use both lower limbs </li></ul>
  14. 14. <ul><li>Constricting band like sensation at the level of Xiphi sternum decreased sensation below that level. </li></ul><ul><li>c/o breathlessness, right sided chest pain, cough </li></ul><ul><li>No other specific complaints </li></ul>
  15. 15. <ul><li>o/e pt. conscious , oriented , afebrile, hydration fair, pallor +, grade II clubbing, Dyspnoeic , tachypnoeic, accessory muscles of respiration active </li></ul><ul><li>Vitals- stable </li></ul><ul><li>CVS-WNL </li></ul><ul><li>RS- trachea in midline, diminished respiratory movements in right hemi thorax, chest expansion 2 cm only on left side, BBS in right side with VF/VR in right side dull on percussion </li></ul><ul><li>PA-WNL </li></ul>RIGHT
  16. 16. <ul><li>CNS HF-wnl </li></ul><ul><li>SPINOMOTOR </li></ul>RIGHT LEFT BULK N N TONE UL N N LL POWER UL 5/5 5/5 LL 0/5 0/5 DTR UL ++ ++ LL +++ +++ ABDOMINAL ABSENT ABSENT PLANTAR EXTENSOR EXTENSOR
  17. 17. <ul><li>CRANIAL NERVES/CEREBELLAR/EXTRAPYRMIDAL-WNL </li></ul><ul><li>SENSORY SYSTEM-DECREASED BELOW D6 </li></ul><ul><li>GIBBUS ,TENDERNESS D2,D3,D4 </li></ul><ul><li>BOWEL/BLADDER INCONTINENCE PRESENT, BLADDER SENSATION LOST </li></ul>
  18. 18. <ul><li>INVESTIGATIONS </li></ul><ul><li>RBS-87MG%,BLOOD UREA-20MG%,SR. CREAT-0.8MG%,SR.NA+-142MEQ/L,K+-4.1MEQ/L </li></ul><ul><li>CHG HB%-9.6MG%,ESR-20/45MM,PLT CT-1.4 L,WBC-10,400 CELLS/CU.MM, DC-P62L36E2 </li></ul><ul><li>CXR HOMOGENOUS OPACITY ON RIGHT SIDE </li></ul><ul><li>USG ABDOMEN- CONSOLIDATION RIGHT LUNG </li></ul><ul><li>ECG-WNL </li></ul><ul><li>LFT- WNL (SAP-67 IU/L) </li></ul>
  19. 25. <ul><li>MRI SPINE WITH SCREENING OF BRAIN-METASTASIS IN D3D4 CAUSING SIGNIFICANT CORD COMPRESSION, SMALL METASTASIS IN D8D9 </li></ul><ul><li>MULPIPLE LARGE METASTASIS BRAIN </li></ul><ul><li>MASS RIGHT LUNG(?SARCOME/?CARCINOMA) </li></ul>
  20. 26. <ul><li>ULTRASOUND GUIDED TRANSTHORACIC NEEDLE ASPIRATION- CLUSTERS OF SMALL ROUND CELLS WITH DARK STAINING NUCLEUS AND INCONSPICUOUS NUCLEOLI. FEW AREAS SHOW DYSCOHESIVE CELLS S/O SMALL CELL CARCINOMA. </li></ul>
  21. 27. DIAGNOSIS <ul><li>SMALL CELL CARCINOMA- STAGE IV </li></ul><ul><li>PARA PLEGIA DUE TO COMPRESSIVE MYELOPATHY D4 LEVEL EXTRADURALEXTRAMEDULARY-SENSORY LEVEL D6/MOTOR LEVEL D6 SECONDARIES SPINE AND SECONDARIES BRAIN </li></ul>
  22. 28. Small cell carcinoma <ul><li>The current classification of subtypes of small cell lung cancer are: </li></ul><ul><li>small cell carcinoma </li></ul><ul><li>mixed small cell/large cell carcinoma </li></ul><ul><li>combined small cell carcinoma (small cell lung cancer combined with neoplastic squamous and/or glandular components) </li></ul>
  23. 29. TREATMENT-LIMITED STAGE DISEASE <ul><li>Standard: </li></ul><ul><ul><li>1. Combination chemotherapy with one of the following regimens and chest irradiation (with or without PCI given to patients with complete responses): </li></ul></ul><ul><ul><ul><li>The following regimens produce similar survival outcomes: </li></ul></ul></ul><ul><ul><ul><ul><li>EC: etoposide + cisplatin + 4000-4500 cGy chest radiation therapy </li></ul></ul></ul></ul><ul><ul><ul><ul><li>ECV: etoposide + cisplatin + vincristine + 4500 cGy chest radiation </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>therapy </li></ul></ul></ul></ul></ul><ul><ul><li>2. Combination chemotherapy (with or without PCI in patients with complete responses), especially in patients with impaired pulmonary function or poor performance status. </li></ul></ul><ul><ul><li>3. Surgical resection followed by chemotherapy or chemotherapy plus chest radiation therapy (with or without PCI in patients with complete responses) for patients in highly selected cases. </li></ul></ul>
  24. 30. TREATMENT-EXTENSIVE STAGE DISEASE <ul><li>Standard: </li></ul><ul><ul><li>1. Combination chemotherapy with one of the following regimens with or without PCI given to patients with complete responses: </li></ul></ul><ul><ul><ul><li>The following regimens produce similar survival outcomes: </li></ul></ul></ul><ul><ul><ul><ul><li>CAV: cyclophosphamide + doxorubicin + vincristine CAE: cyclophosphamide + doxorubicin + etoposide EP or EC: etoposide + cisplatin or carboplatin ICE: ifosfamide + carboplatin + etoposide </li></ul></ul></ul></ul><ul><ul><ul><li>Other regimens appear to produce similar survival outcomes but have been studied less extensively or are in less common use, including: </li></ul></ul></ul><ul><ul><ul><ul><li>cyclophosphamide + methotrexate + lomustine cyclophosphamide + methotrexate + lomustine + vincristine cyclophosphamide + doxorubicin + etoposide + vincristine CEV: cyclophosphamide + etoposide + vincristine single-agent etoposide </li></ul></ul></ul></ul><ul><ul><li>2. Radiation therapy to sites of metastatic disease unlikely to be </li></ul></ul><ul><ul><ul><li>immediately palliated by chemotherapy, especially brain, epidural, and bone metastases. </li></ul></ul></ul>
  25. 31. SPINAL CORD COMPRESSION AND CANCER <ul><li>Oncological emergency </li></ul><ul><li>Occurs in 5-10% of patientswith cancer </li></ul><ul><li>Lung cancer is the most common cancer </li></ul><ul><li>Lung,breast and prostrate are the main offenders </li></ul><ul><li>Lymphomas,melanoma,renal cell carcinoma and genito urianary cancers are few others </li></ul>
  26. 32. <ul><li>Thoracic spine (commonest-70%) </li></ul><ul><li>Lumbosacral(20%) </li></ul><ul><li>Cervical spine (10%) </li></ul><ul><li>The most common initial symptom is localized back pain </li></ul><ul><li>Patient with cancer developing back pain should be evaluated as quickly as possible. </li></ul><ul><li>Early treatment-better prognosis </li></ul><ul><li>Upto 75%patients who are ambulatory remain ambulatory. But only 5-10% of patients with paraplegia recover walking capacity. </li></ul>
  27. 33. Radiological findings <ul><li>Erosion of pedicles(the winking owl sign) is the earliest finding </li></ul><ul><li>Others include increased inter pedicular distance,vertebral destruction,lytic or sclerotic lesions, scaolloped vertebral bodies and vertebral body collapse.(though not specific) </li></ul><ul><li>Normal appearance on plain films does not exclude the diagnosis of cancer </li></ul>
  28. 34. Paraplegia with unknown primary <ul><li>Simple work up </li></ul><ul><li>Chest radiography </li></ul><ul><li>Mammography </li></ul><ul><li>PSA </li></ul><ul><li>Abdominal CT </li></ul>
  29. 36. MANAGEMENT <ul><li>Radiation plus glucocorticoids is the initial treatment of choice </li></ul><ul><li>Indications for surgical intervention </li></ul><ul><li>Unknown aetiology </li></ul><ul><li>Failure of radiation therapy </li></ul><ul><li>Radioresistant tumours(melanoma,renal cell carcinoma) </li></ul><ul><li>Pathological fracture dislocation </li></ul><ul><li>Rapidly evolving neurological symptoms </li></ul>
  30. 37. <ul><li>At present laminectomy is used only for tissue diagnosis </li></ul><ul><li>As most cases involve anterior or anterolateral extradural disease, resection of anterior vertebral body with the tumour followed by spinal stabilisation has better results. </li></ul>
  31. 38. <ul><li>Chemotherapy is used for chemosensitive tumours with prior radiation and not fit for surgery. </li></ul><ul><li>Prostrate cancer patients can be given hormonal therapy if not given earlier in addition to forementioned forms </li></ul><ul><li>Percutaneous vertebroplasty, the injection of acrylic cement mat benefit </li></ul>
  32. 40. <ul><li>Treatment of spinal epidural metastasis improves patient survival and functional state </li></ul><ul><li>Osama O. Zaidat, MD and Robert L. Ruff, MD PhD From the Neurology Service and Rehabilitation and Spinal Cord Injury and Dysfunction Care Line, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, and Department of Neurology, Case Western Reserve University, Cleveland, OH. </li></ul><ul><li>Objectives: To determine factors affecting the success of radiation therapy (RT) of spinal epidural metastases and patient survival after RT. </li></ul><ul><li>Design/Methods: One hundred thirty-nine male veterans with an initial spinal epidural metastases treated with dexamethasone and RT were evaluated prospectively. Patients were followed until death. </li></ul><ul><li>Results: At presentation, 84 patients could walk. After RT, 119 patients walked. The likelihood of regaining ambulation increased if treatment began <12 hours after loss of ambulation and if patients had bladder and bowel function and sacral sensory sparing. Treatment reduced pain levels, and ambulatory patients had less pain compared with nonambulatory patients. Median length of survival was 104 weeks for ambulatory patients and 6 weeks for nonambulatory patients. Mean interval between loss of ambulation and death was 4.0 ± 0.5 weeks. Recurrent spinal epidural metastases occurred in 8.63% of patients. </li></ul><ul><li>Conclusions: Patients who walked after treatment lived longer, were ambulatory for most of their remaining life, had less pain, and had a lower incidence of depression. </li></ul>
  33. 41. <ul><li>Causes of Misdiagnosis and Mistreatment of Spinal Tuberculosis With Radiotherapy in Nonendemic Areas: A Pitfall in Diagnosis and Treatment: Hazards of Radiotherapy on the Tuberculous Lesion. Case Report Spine. 30(11):E300-E304, June 1, 2005. Jutte, Paul C. MD *; van Altena, Richard MD +; Pras, Elisabeth MD, PhD ++; Thijn, Cees J.P. MD, PhD [S] </li></ul><ul><li>Abstract: Study Design. Report of initially misdiagnosed and mistreated cases. </li></ul><ul><li>Objectives. To report a previously undescribed misdiagnosis and subsequent mistreatment with radiation for tuberculosis of the spine and to promote awareness for tuberculosis in nonendemic areas. </li></ul><ul><li>Summary of Background Data. It is not seldom that radiation therapy is provided for suspected malignant spinal lesions without histologic confirmation. Literature is not available on harmful effects of radiation therapy for tuberculosis of the spine. </li></ul><ul><li>Methods. Clinical case analysis for initial misdiagnosis and mistreatment, analysis of subsequent clinical course. </li></ul><ul><li>Results. Two patients received radiotherapy on spinal lesions of suspected malignant origin. In both patients, the lesions were of tuberculous origin and the lesions increased during radiotherapy. In Case 2, the paraplegia did not heal. </li></ul><ul><li>Conclusion. In cases of a spinal lesion of unknown origin, tuberculosis should always be considered. Adequate biopsy for cultures and histology is mandatory. Radiotherapy locally aggravates tuberculous spinal lesions. </li></ul>
  34. 42. ACKNOWLEDGEMENTS <ul><li>DR SUKUMAR,INTERVENTIONAL RADIOLOGIST,SGE </li></ul><ul><li>DEPT. OF PATHOLOGY </li></ul><ul><li>PATIENT AND HIS FAMILY </li></ul>
  35. 44. THANK U

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