a pre operative case presentation on spastic paraplegia due to intramedullary SOL @C7-D1

1. Preoperative case presentation
Dr. Md. Toufiq Hasan
Resident, Phase-A(R-9)
Department Of Neurosurgery
Dhaka Medical College Hospital
On behalf of NSU-Green Unit

2. Particulars of the patient
Name : Mr. Alamin
Age : 22 years
Sex : Male
Occupation : Salesman
Marital status : Unmarried
Address : Jurain Railgate, Postagola,Dhaka
Registration no : 82285/85
Ward : 200
Bed No : 07 (Non paying)
DOA : 28/05/2023

3. Chief Complaints
Heaviness on lower limb during walking for 2 month
Upper back pain for same duration.
Constipation and Difficulty in micturition for same duration.

4. History of present illness
According to the statement of the patient, he was reasonably well 2 months back. Then,
he developed heaviness on lower limb during walking primarily on right then both limb
which was insidious, intermittent, intensity of weakness gradually progressive with
duration of walking ,day by day activities and relieved by stopping walking, activities and
taking rest on bed.

5. History of present illness (Cont.)
He also complained upper back pain which was insidious onset, gradually
progressive, mild to moderate in intensity, dull aching in nature with no
radiation, aggravated at night during sleep and partially relieved after
taking analgesics.

6. History of present illness (Cont.)
He gave history of bowel and bladder dysfunction in form of constipation and
difficulty in micturition followed by hesitancy and urgency.
During the course of his illness, he gave no history of headache, neck pain,
trauma, prolonged fever, unexplained weight loss, anorexia, cough, hemoptysis,
prolong use of steroid or close contact with known TB patient.

7. History of present illness (Cont.)
With the above complaints, he visited Mugda Medical college hospital and then
referred to Neurosurgery department ,DMCH for better management.

8. Associated illness
He has no history of Diabetes, Hypertension,any heart, kidney ,lung
disease

9. Past medical history
He has no H/O major childhood illness, previous surgery,
accident or injury.

10. Immunization History
Vaccinated as per EPI schedule and 1 dose of covid vaccine

11. Family history
Nothing significant. Boy of a non consanguineous married parents.
Other family members are leading a healthy life.

12. Personal history
He is non smoker, non alcoholic, non betel nut chewer

13. Socio economic history
He belongs to a family with low socio-economic condition

14. Drug history
Nothing significant.

15. General Physical Examination
Appearance: Anxious
Body built: Average
 Co-operative
Decubitus: On choice
Nutritional status: Average
Pulse: 84 b/m
BP: 130/80 mmHg
Temp: Not raised
RR: 18 /m
 Jaundice
 Clubbing
 Cyanosis
 Anemia
 Leukonychia
 Edema
 Dehydration
 Koilonychia
 Lymphadenopathy
 Catheter in situ
No abnormality
detected

16. Systemic Examination
Cardiovascular System-No abnormality detected
Respiratory System-No abnormality detected
Alimentary System-No abnormality detected

17. Nervous System Examination
Higher psychic function: Intact
Memory: Intact
GCS: E₄V₅M₆
Gait: Spastic
Right handed person
Cranial nerves Intact
Speech : Normal
No sign of cerebellar dysfunction
No sign of meningeal irritation

18. Motor examination of upper limb
Right Left
Tone Normal Normal
Bulk Normal Normal
Fasciculation Absent Absent
Power Elbow flexors 5 5
Wrist extensors 5 5
Elbow extensors 5 5
Finger flexors 5 5
Finger adductors 5 5
Jerks Biceps ++ ++
Triceps ++ ++
Supinator ++ ++
Hoffman Negative Negative

19. Motor examination of Lower limb
Right Left
Tone Increased Increased
Bulk Normal Normal
Fasciculation Absent Absent
Power Hip flexors 4+ 4+
Knee extensors 4+ 4+
Ankle Dorsiflexion 4+ 4+
EHL 4+ 4+
FHL 4+ 4+
Jerks Knee ++++ +++
Ankle ++++ +++
Planter Extensor Extensor
Clonus Present Absent

20. Sensory Examination
Sensory examination reveals pain, touch, pressure, vibration,
proprioception intact.

21. Examination of spine
No scoliosis, gibbus, kyphotic deformity
No visible midline or paraspinal mass
Overlying skin condition –normal
Local temperature –not raised
Focal tenderness is absent

22. Provisional diagnosis

23. Provisional diagnosis
A case of spastic paraparesis due to dorsal spinal Space
occupying lesion

24. INVESTIGATIONS

25. MRI of Dorsal Spine with screening of
whole spine

26. MRI of Dorsal spine T2WI with
multiple sagittal section with screening
of whole spine

27. MRI of dorsal Spine T1W1
multiple sagittal section

28. MRI of dorsal Spine
T2W1 multiple sagittal
section

29. MRI of dorsal spine with multiple Sagittal section with contrast

30. T1W1 multiple axial
section

31. T2WI Multiple axial section

32. MRI of dorsal spine with
multiple axial section with
contrast

34. Clinico radiological diagnosis
Spastic paraparesis due to Intradural intramedullary space
occupying lesion @C7 to D1 level

35. Differential Diagnosis

36. Plan
Laminotomy and laminoplasty of C7 and D1 vertebra and excision of
intradural intramedullary SOL

37. Position of patient:

38. Dissection of paraspinal muscle

39. Laminotomy of C7 & D1

40. Durotomy

41. Removal of SOL

42. Laminoplasty
Various methods commonly used for laminoplasty.
(a) Single-door suture
technique. (b) Double-door allograft. (c) Single
door
allograft. (d) Single-door plate fixation.

43. Complication
1. Risks of spinal cord or nerve root injury
2. CSF leak
3. Infection
4. Dural scarring
5. Postoperative hematoma

44. THANK YOU

46. Points in favour Points against
Schwannoma Most common nerve sheath mass
•
"dumbbell-shaped' transforaminal mass
• Hemorrhage, cystic, or fatty degeneration
• Solitary spinal lesion more likely schwannoma than NF
• Bony remodeling– Thinned pedicle
.
• No uniform enhancement pattern
Neurofibroma • Target sign
• Hemorrhage, cystic, or fatty degeneration
Bulky multilevel spinal nerve root tumors
in patient with
stigmata of neurofibromatosis type 1
extramedullary
ependymoma
Ependymoma: Unusual
differential for a totally
No Cap sign: Hemosiderin at cranial or
caudal margin