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Clinical case presentation spine
- 1. Clinical case presentation- spine Dr. Guru Prasad DNB Orthopaedics
- 2. Case no .1 Dr.Guru prasad
- 3. Patient Details • Name: G.Ashwin kumar • IP Number: 817 • Age: 28 y • Gender: male • Residence : Hyderabad • Profession : salesman • DOA: 19/5/15 • DOD: 25/5/15
- 4. Chief complaints : lowbackache since 20 days
- 5. History of presentillness • Patient was apparently alright 9 months back, when he developed lower backache • Which was insidious in onset, • Gradually progressive • Radiating to his right leg • Associated with tingling sensation.
- 6. • Pain wasdragging in nature • Radiating from lower back to back of the thigh till the right foot • Pain increases with coughing and sneezing • Patient develops pain and tingling sensation or heaviness in both lower limbs. More so in the right after walking a certain distance • Pain becomes so severe that he has to take rest(sit) immediately for a few minutes • Then the symptoms settle down temporarily and allow him to walk further the same distance • Patient feels comfortable with Forward bending
- 7. No history of… •Significant trauma • Constitutional symptoms (fever, loss of weight) • Burning micturition • Other joint pains • Morning stiffness
- 8. • Not aknown case of ... • Diabetes • Hypertension • Tuberculosis • Asthma • Epilepsy • Hypothyroidism
- 9. • Past history: no significant past history no h/o of any hospital admissions , previous medications • Personal history : not significant bowel and bladder habits normal sleep disturbed appetite normal no h/o allergies Mixed diet Known alcoholic and a smoker • Family history : not significant
- 10. General examination • Moderatelybuilt and nourished • No pallor /icterus /cyanosis/clubbing/lymphadenopathy/edema • Pulse 86/min right radial • Blood pressure 110/80 mmHg right upperlimb
- 11. Spine examination • Inspection: no obvious deformity no swellings no scars or sinuses no paraspinal muscle spasm • Palpation : Tenderness over the L4- L5 and L5-S1 region Movements : extension was painful
- 12. Special Tests Name LeftRight Straight leg raising test (SLRT) 80 degrees 40 degrees Lasegue test Negative positive FABER test Negative Negative Femoral stretch reflex Negative Negative
- 13. Neurological examination • Highermental function - NAD • Cranial nerves - NAD
- 14. Motor system Muscle LeftRight Hip flexors (L1 /L2) 5/5 5/5 Quadriceps (L3) 5/5 5/5 Ankle dorsiflexors(L4) 5/5 5/5 Extensor hallusis longus(L5) 5/5 3/5 Ankle Plantar flexion(S1) 5/5 5/5 Nutrition : Bulk equal on both sides Tone : Normal on both sides Power :
- 15. Sensory system No neuro-deficitwas observed in - Touch - Temperature - Pain
- 16. Reflexes Reflexes Left Right Kneejerk (L4) Brisk Brisk Ankle jerk (S1) Brisk Brisk Plantar reflex (S1) Flexor (down going) Flexor (down going) No bladder dysfunction (S2 S3 S4)
- 17. Hip examination • Noabnormality detected • Rotations were normal
- 18. Other systems • Cardiovascular examination – NAD • Respiratory system – NAD • Per Abdomen – NAD
- 19. Differential diagnosis Prolapsed intervertebraldisc Lumbar canal stenosis Spondylolisthesis Tumors
- 20. Diagnostic tests Sr. Investigation19/5/15 1 Hb 15.3gm% 2 TC 6900/cumm 3 DC 60,34,03,03,00 4 Platelet 2.6 lakhs/cmm 5 ESR 30mm 6 CUE WNL 7 RBS 93 mg% 8 B.Urea 24mg% 9 S.Creatinine 1.0mg% 10 BT 2.10 11 CT 4.20 12 Blood group B – Positive 13 HIV Non Reactive 14 HbsAg Non Reactive 15 S.Electrolytes Na – WNL K – Cl - 16 TSH 1.52 microIU /ml
- 22.
- 27. Diagnosis • Prolapsed intervertebraldisc L4 – L5 with lumbar canal stenosis • Which correlates clinically with patient symptoms
- 31. Treatment plan • Laminectomywith discectomy was done on 20 /5/15
- 32. Anaesthesia • General anaesthesia •Prone position
- 39.
- 40. Day - 1 •Patient got relief from the pain • Advised lumbo - sacral corset belt
- 41. Day - 2 •Patient was doing well • Drain removal was done • Patient was made to sit
- 42. Day - 3 •Patient was made to walk with walker support
- 43. Day – 4 •Patient discharged and called on 10th day for suture removal • Physiotherapy started after 2 weeks
- 45. Case no 2 Dr.Guru prasad
- 46. Patient Details • Name: P. Madhu babu • IP Number: 674 • Age: 34 y • Gender: male • Residence : Hyderabad • Profession : businessman • DOA: 09/5/15 • DOD: 14/5/15
- 47. Chief complaints • lowbackache since 15 days
- 48. History of presentillness • Patient was apparently alright 2 years back, when he developed lower backache,
- 49. • Pain wasdragging in nature • Radiating from lower back to back of the thigh till the left foot • Increased with sitting , rising from a seat, standing and walking a few metres which led to restriction of his activities • Pain was also more while lying on his back • Patient was comfortable lying prone
- 50. No history of… •Significant trauma • Constitutional symptoms (fever, loss of weight) • Burning micturition • Other joint pains • Morning stiffness • Tingling and numbness
- 51. • Not aknown case of ... • Diabetes • Hypertension • Tuberculosis • Asthma • Epilepsy • Hypothyroidism
- 52. • Past history: no significant past history no h/o of any hospital admissions , previous medications • Personal history : not significant bowel and bladder habits normal sleep disturbed appetite normal no h/o allergies Mixed diet Non alcoholic non smoker • Family history : not significant
- 53. General examination • Moderatelybuilt and nourished • No pallor /icterus /cyanosis/clubbing/lymphadenopathy/edema • Pulse : 84/min • Blood pressure : 130/70 mmHg
- 54. Spine examination • Inspection: lumbar spine curvature convexity towards right no swellings no scars or sinuses paraspinal muscle spasm • Palpation : Tenderness over the L4- L5 and L5-S1 region Paraspinal muscle spasm
- 55. Special Tests Name RightLeft Straight leg raising test (SLRT) 50 degrees 30 degrees Lasegue test Negative positive FABER test Negative Negative Femoral stretch reflex Negative Negative
- 56. Neurological examination • Highermental function - NAD • Cranial nerves - NAD
- 57. Motor system Muscle RightLeft Hip flexors (L1 /L2) 5/5 5/5 Quadriceps (L3) 5/5 5/5 Ankle dorsiflexors(L4) 5/5 5/5 Extensor hallusis longus(L5) 5/5 3/5 Ankle Plantar flexion(S1) 5/5 5/5 Nutrition : Bulk equal on both sides Tone : Normal on both sides Power :
- 58. Sensory system No neuro-deficitwas observed in - Touch - Temperature - Pain
- 59. Reflexes Reflexes Right Left Kneejerk (L4) Brisk Brisk Ankle jerk (S1) Brisk Brisk Plantar reflex (S1) Flexor (down going) Flexor (down going) No bladder dysfunction (S2 S3 S4)
- 60. Hip examination • Noabnormality detected • Rotations were normal
- 61. Other systems • Cardiovascular examination – NAD • Respiratory system – NAD • Per Abdomen – NAD
- 62. Differential diagnosis prolapsed intervertebraldisc spondylolisthesis Lumbar canal stenosis spondyloarthropathy Tumours
- 63. Diagnostic tests Sr. Investigation9/5/15 1 Hb 17.8gm% 2 TC 9500/cumm 3 DC 68,26,03,03,00 4 Platelet 2.8 lakhs/cmm 5 ESR 20mm 6 CUE WNL 7 RBS 99 mg% 8 B.Urea 22mg% 9 S.Creatinine 0.8mg% 10 BT 2.15 11 CT 4.10 12 Blood group O Positive 13 HIV Non Reactive 14 HbsAg Non Reactive 15 S.Electrolytes Na – WNL K – Cl - 16 TSH 3.07 microIU /ml
- 64.
- 65.
- 67. Diagnosis • Prolapsed intervertebraldisc L4 - L5 more so in the left side • Which correlates clinically with patient symptoms
- 69. Treatment plan • Laminotomywith micro-discectomy at L4-L5 level was done on 10 /5/15
- 72. Anaesthesia • General anaesthesia •Prone position
- 79.
- 80. Day - 1 •Patient got immediate relief from the pain • Advised lumbo - sacral corset belt
- 81. Day - 2 •Patient was doing well • Drain removal was done • Patient was made to sit
- 82. Day - 3 •Patient was made to walk with walker support With lumbo sacral corset belt
- 83. Day – 4 •Patient discharged and called on 10th day for suture removal
- 84.