NNSD is a 32-year-old female who presented with back pain radiating to both legs for 2 months. Examinations found tenderness and limited range of motion in her thoracolumbar spine. Imaging showed a pathological fracture at TH12 and L1 levels. She underwent debridement, decompression, stabilization, fusion surgery with biopsy and culture. Post-operative X-rays showed instrumentation in her thoracolumbar spine.

1. Identity
Name : NNSD
Sex : Female
Age : 32 yo
CM : 2202xxxx
Address : Karangasem
Phone : -
Insurance : BPJS
Admitted : 12/07/2022
Ward : Angsoka

2. HISTORY
Chief Complaint
Pain on her back
Present history
• Patient complained pain on her back since 2 months prior to admission (May 2022) and
getting worse since 2 weeks ago. The complaints appears slowly continuous, getting worse
over time and not affected by activities.
• Patient complained radiating pain from her back to his both legs, weakness was denied
but tingling sensation was appeared at same time with radiating pain.
• Patient denied any numbness.
• Patient can feel urinating and defecating.
Past History
• History of trauma since 2 month (May 2022), patient got falling when she walking in the
yard with her back bumped to the ground.
• History of hypertension (-), diabetes mellitus (-), medications, allergies (-), and other
comorbidities were denied.
• Patient was referral from the neurology department with a diagnosis of LBP ec suspect
fracture
Social History
• Patient is a fruit seller

3. Thoracolumbar Region:
L : Deformity (-), Bruise (-), Swelling (-)
F : Midline Tenderness (+) at level L4-5,
hypoesthesia (+) at level L5, anesthesia (-)
M: Flexion: limited due to pain (NR: 80o)
Extension: limited due to pain (NR: 30o)
Lateral Flexion: limited due to pain (NR: 45o)
Rotation: limited due to pain (NR: 80o)
Physiological Reflex ++/++
Pathological Reflex -/-
Clonus (-/-)
Deformity (-), Bruise (-),
Swelling (-)
L5 L5

4. Motor Grading System
Motoric Evaluation
Right Muscles Left
5 Hip flexor (L2) 5
5 Knee extensor (L3) 5
5 Ankle dorsoflexor (L4) 5
5 Toe extensor (L5) 5
5 Ankle Plantarflexor (S1) 5
Motoric Evaluation
Right Muscles Left
5 Elbow flexor (C5) 5
5 Wrist extensor (C6) 5
5 Elbow extensor (C7) 5
5 Finger flexor (C8) 5
5 Finger abductor (T1) 5

5. Lumbosacral X-Ray AP/Lateral View
Sanglah Hospital (20/05/2022)
Lumbosacral X-Ray AP/Lateral View
Sanglah Hospital (27/05/2022)

6. Lumbosacral X-Ray AP/Lateral View
Sanglah Hospital (27/05/2022)
Interpedi
cular
Widening
None
KA 25.66o
LOH 63%

7. Lumbosacral CT-Scan Sagittal view
Sanglah Hospital (04/07/2022)

8. Lumbosacral CT-Scan Axial view
Sanglah Hospital (04/07/2022)
TH10 TH11
TH12 L1

9. Lumbosacral CT-Scan Axial view
Sanglah Hospital (04/07/2022)
L2

10. Lumbosacral CT-Scan Coronal view
Sanglah Hospital (04/07/2022)

11. Myelography
Sanglah Hospital (04/07/2022)

12. Lumbosacral MRI T2W Sagittal View
Sanglah Hospital (19/07/2022)

13. Lumbosacral MRI T1W Sagittal View
Sanglah Hospital (19/07/2022)

14. Whole Spine MRI T2W Axial View
Sanglah Hospital (19/07/2022)
Th 12
Th 12-L1
L1 L1-2
L2 L2-3

15. Whole Spine MRI T1W Axial View
Sanglah Hospital (19/07/2022)
Th 12 Th12-L1
L1 L1-2
L2 L2-3

16. Whole Spine MRI Coronal View
Sanglah Hospital (19/07/2022)

17. Myelography
Sanglah Hospital (19/07/2022)

18. Diagnosis :
• Pathological Fracture CV Th12, L1 ec Susp Infection dd/ MBD
• Pleural Effusion Loculated Sinistra ec. Susp. Malignancy
Treatment :
Debridement + Decompression – Stabilization – Fusion + Biopsy + Culture

19. Positioning

20. Clinical Picture Durante Op

21. C-Arm Durante Op

22. Clinical Picture Post Op

23. X-Ray Thoracolumbar AP/Lateral View
Sanglah Hospital (22/07/2022)