Tracts involved-corticospinal tract anterior and lat spinothalamic posterior coloumn Mostly extramedullary compressive myelopathy at T10 level Etiology –to consider both intra and extradural causes like neurofibroma/meningioma/av malformation. extradural-potts spine,ivdp

1. CNS CASE
Dr CHERIAN THAMPY

2. HISTORY
• 27 year old male patient left handed
individual TV technician by occupation from
vellore came with complaints of

3. Chief complaints
• DIFFICULTY IN USING BOTH LOWER LIMBS-5
MONTHS
• REDUCED SENSATIONS IN BOTH LEGS -4
MONTHS

4. HOPI
• Apparently normal patient 5 months back
noticed difficulty in using both the lower
limbs. Initially he noticed weakness in the LT
leg in the form that when he was trying to
climb a bus he had difficulty in in raising the LT
leg,He also had difficulty in climbing up and
down stairs, getting up from squatting
position.

5. CONT…
• But he was able to walk witdifficulty.(Supporting
the wall)
• After 3 days he noticed difficulty in gripping
chappals and to walk with chappals in both lower
limbs.
• After 15 days he noticed similar weakness in the
right leg also.
• Both his upper limbs were normal.He was able to
lift his head from the pillow and to get up from
the lying position.

6. • After 15 days he developed numbness and
burning sensation below the umbilicus initially
in the lt side ,he had a feeling of walking over
cotton,he had difficulty in feeling his clothes
and to differentiate hot and cold water below
umbilicus.same thing progressed to rt side
also in 10 days.

7. • He had feeling of tightness of both his lower
limbs.
• No H/O any band like sensations
• Walking difficulty was not increasing in dark.
• No h/o back pain or electric shock like
sensations.
• No h/o involuntry movements.

8. • No h/o altered sensorium,no h/o
disorientation.
• He was able to perceive the smell normally
• He was able to read the news paper
• No h/o double vision
• No h/o reduced sensations over face and he
was able to chew the food.

9. • He was able to close the eyes and no h/o
deviation of ankle of mouth or drooling of
saliva.
• He was able to hear properly, no vertigo
• No h/o dysphagia,nasal regurgitation
• No h/o dysarthria

10. • He was able to feel the sensation of the
bladder, initiate and control micturiation and
completely evacuate the bladder. No
frequency or urgency
• No h/o bowel incontinence, constipation.
• No h/o any altered sweating pattern or
erectile dysfunction.

11. • No h/o fever, headace,seizures
• No h/o weight loss
• No h/o skin rashes
• No h/o trauma
• No h/o spinal anaesthesia
• No h/o recent vaccination

12. • He was admitted in a hospital and he was told
that he had some compression of the nerves, and
he underwent a surgery.
• He underwent anterolateral decompression and
excision of posteriolateral portion of vertebral
body and the disc.
• His motor symptoms worsened after surgery as
he was not able to get up the bed or sit.He was
not able to raise both his lower limbs.His
tightness over both the lower limbs increased.

13. • After surgery there was mild improvement in
sensory symptoms as he was able to feel the
sensations.he was able to feel his
clothes,differntiate hot and cold
water.Sensory symtoms slowly improved in 3
months
• He was catheterised from the day of surgery.
• Bowel incontinance present after surgery.

14. Past history
• No h/o DM,HTN,BA,TB
• h/o chicken pox in 2002
• No similar history in the past
• No h/o surgeries in the past other than the
present surgery.

15. Personal history
• Not an alcoholic,smoker
• Mixed diet
• Sleep normal
• Bowel incontinence present
• Bladder is catheterised

16. Family history
• No similar history In the family
• Born out of non consanguineous marriage
• He is not married

17. Treatment history
• Taken siddha medications for the same
• Surgery done as previously mentioned

18. History summary
• 27 year old male patient with no
comorbidities ,no h/o trauma presented with
sub acute to chronic paraplegia started
asymmtrically associated with b/l sensory
involvement below umbilicus ,with no cranial
nerve and autonomic involvement.For which
he underwent surgery and post surgery there
is worsening of motor symptoms and
autonomic symptoms.

19. History diagnosis
• Tracts involved-corticospinal tract
anterior and lat spinothalamic
posterior coloumn
Mostly extramedullary compressive myelopathy at
T10 level
Etiology –to consider both intra and extradural
causes like neurofibroma/meningioma/av
malformation.
extradural-potts spine,ivdp

20. 1

21. GPE
• PATIENT CONSCIOUS AND ORIENTED
• NO PALLOR,ICTERUS,CYANOSIS,CLUBBING
• AFEBRILE
• PR-90/MIN
• BP-110/70MMHg in RT UL IN SUPINE POSITION
• RR-18/MIN
• NO NEUROCUTANEOUS MARKERS
• BED SORES PRESENT IN RT GLUTEAL REGION
• SURGICAL SCAR PRESENT LEFT CHEST WALL FROM THE
5TH ICSGOING POSTERIORLY AND HIGHEST POINT
ENDING AT D6 LEVEL.

22. HMF
• MINI MENTAL SCORE-30/30
• NO APHASIA,NO DYSARTHRIA
• MEMMORY NORMAL
• NO DELUSIONS,HALLUCINATIONS

23. CRANIAL NERVE RIGHT LEFT
OLFACTORY.N NORMAL NORMAL
OPTIC.N
VISUAL ACUITY
FIELD OF VISION
COLOUR VISION
FUNDUS
NORMAL NORMAL
OCCULOMOTOR.N/TROCHL
EAR.N/ABDUCENT.N
SACCADES AND PERSUITS
EOM
PUPIL
REACTION TO LIGHT
NORMAL
NO PTOSIS
NO DIPLOPIA
FULL,NO NYSTAGMUS
3MM
NORMAL
NORMAL
NO PTOSIS
NO DIPLOPIA
FULL,NO NYSTAGMUS
3MM
NORMAL

24. TRIGEMINAL N
SENSATIONS OVER FACE
CLENCHING TEETH,JAW
MOVEMENTS ,JAW JERK
NORMAL NORMAL
FACIAL N
TIGHT CLOSURE OF EYES
FRONTAL FISSURES
DEVIATION OF ANGLE OF
MOUTH
DROOLING OF SALIVA
NASOLABIAL FOLD
HYPERACUSIS
LACRIMAL/NASAL/SALIVAR
Y SECRETIONS
NORMAL NORMAL
VESTIBULO COCHLEAR.N
RINNES TEST
WEBER TEST
ABC TEST
AC >BC POSITIVE
NO LATERALISATION
NORMAL
AC >BC POSITIVE
NO LATERALISATION
NORMAL

25. 2

26. MOTOR SYSTEM
• NUTRITION-NO OBVIOUS WASTING,B/L
SYMMTRICAL
• MEASURMENTS- RT LT
• ARM 24cm 24cm
• FOREARM 19cm 19cm
• THIGH 49cm 49cm
• LEG 27cm 27cm

27. TONE
RT LT
UL NORMAL NORMAL
LL SPASTIC SPASTIC

28. POWER
RT LT
NECK - FLEXION GOOD
EXTENSION GOOD
SHOULDER-FLEXION 5/5 5/5
EXTENSION 5/5 5/5
ADD 5/5 5/5
ABD 5/5 5/5
ELBOW -FLEXION 5/5 5/5
EXTENSION 5/5 5/5

29. RT LT
WRIST -FLEXION 5/5 5/5
EXTENSION 5/5 5/5
HAND GRIP GOOD GOOD
BEVORS SIGN - POSITIVE

30. RT LT
HIP-FLEXION 0/5 0/5
EXTENSION 0/5 0/5
ABD 0/5 0/5
ADD 0/5 0/5
KNEE-FLESION 0/5 0/5
EXTENSION 0/5 0/5
ANKLE-DORSIFLEXION 1/5 1/5
PLANTARFLEXION 1/5 1/5
INVERSION 1/5 1/5
EVERSION 1/5 1/5
TOE GRIP WEAK WEAK

31. REFLEXES
SUPERFICIAL RT LT
CORNEAL PRESENT PRESENT
CONJ PRESENT PRESENT
ABDOMINAL UPPER PRESENT PRESENT
LOWER ABSENT ABSENT
CREMASTRIC ABSENT ABSENT
PLANTAR EXTENSORS EXTENSOR

32. DEEP RT LT
BICEPS PRESENT PRESENT
TRICEPS PRESENT PRESENT
SUPINATOR PRESENT PRESENT
KNEE EXAGERATED EXAGERATED
ANKLE EXAGERATED EXAGERATED
NO ANKLE/PATELLAR CLONUS

33. CO ORDINATION
UL RT LT
NORMAL NORMAL
LL NOT ASSESED
GAIT NOT ASSESED
INVOLUNTORY MOVEMENTS FLEXOR SPASMS
PRESENT

34. 3

35. SENSORY SYSTEM
FINE TOUCH
PAIN
TEMP B/L REDUCED BELOW
JOINT POSITION UMBILICUS
VIBRATION

36. 4

37. CEREBELLAR SIGNS
• UL NORMAL B/L
LL NOT ASSESED
NO NECK RIGIDITY
SPINE-NO GIBBUS
NO TENDERNESS
NO KYPHOSIS/SCOLIOSIS
CRANIUM-NORMAL

38. 5

39. OTHER SYSTEMS
• RS NVBS
• CVS S1 S2+NO MURMURS
• ABD SOFT NON TENDER BS+

40. DIAGNOSIS
• INTRADURAL COMPRESSIVE MYELOPATHY
• MOTOR LEVEL T 10
• SENSORY LEVEL T11
• REFLEX LEVEL T11
• PROBABLE ETIOLOGY 1,TUMOURS
NEUROFIBROMA /MENINGIOMA
• AV MALFORMATIONS

41. 6

42. • THANKS