INTERESTING  CASE <br />                          OF BACK ACHE<br />                                DR.ANIRUDH J SHETTY<br...
24 year old female came with the complaints of   <br /> pain in the lower back radiating to the right lower limb -5 days<b...
Patient was apparently normal 5 days back when she developed severe pain which radiated from the lower back uptill the rig...
Patient  specifically c/o of the pain in the lumbosacral region. <br />Patient also c/o not being able to appreciate hot o...
No h/o headache ,vomiting,blurring of vision <br />No h/o any cranial nerve involvement    <br />No h/o fever or night swe...
No h/o any involuntary movements <br />Past h/o – not a k/c/o DM/HTN/Tb/Seizure<br />                 disorder<br />Person...
O/E – Pt conscious<br />               oriented<br />afebrile<br />               hydration fair<br />               sever...
B.P – 110/70 mmHg<br />P.R – 88/min<br />JVP not elevated<br />
CNS – <br />Higher mental functions – normal<br />UL – Tone n power (N)<br />LL  -              RT             LT <br />BU...
                        RT                  LT<br /> POWER<br />         HIP          4-                    5<br />       ...
DTR                      RT                   LT<br />KNEE                     +                    ++<br />ANKLE         ...
SUPERFICIAL REFLEXES<br />CORNEAL REFLEX – (+)<br />CONJUCTIVAL REFLEX – (+)<br />ANAL REFLEX- ABSENT<br />PLANTAR     R  ...
CRANIAL NERVES – NORMAL<br />SENSORY SYSTEM<br />       LOSS OF ALL MODALITIES OF  SENSATION OVER LATERAL  ASPECT  OF RT F...
AUTONOMIC INVOLVEMENT<br />   URGE INCONTINENCE +<br />   BOWEL INCONTINENCE +<br /> NO CEREBELLAR SIGNS <br /> NO MENINGE...
CVS – S1S2 +<br />          No murmurs<br />RS – NVBS +<br />        no added sounds<br />P/A – Soft<br />hepatomegaly +<b...
IMPRESSION  :  COMPRESSIVE TYPE OF                                MYELORADICULOPATHY<br />MOTOR LEVEL : L1<br />   SENSORY...
2 PACKED CELLS<br />T.TRAMADOL<br />INJ.RANTAC<br />INJ CEFTRIAXONE<br />I.V FLUIDS<br />T.PARA<br />TREATMENT<br />
INVESTIGATIONS<br /> CBC<br />Hb-4.2<br />TC-17000<br />DC-P22,L76,E2<br />PLATLET-30000<br />RFT<br />RBS-96<br />UREA - ...
LFT <br />T.B-0.8<br />D.B-0.2<br />SAP-88<br />SGOT- 30                         <br />SGPT-40<br />ALBUMIN-4gm<br />ECG- ...
RBC’S :severe microcytichypochromic RBC’s <br />Anisopoikilocytosisseen.few target cells seen<br />WBC’S : Leukocytosis ob...
   PREVERTEBRAL  AND PARAVERTEBRAL  SOFT      TISSUE  LESIONS WITH INTRASPINAL        EXTENSION  AT D-11,D-12,L5 TO S3 <br...
Hb-6.2<br />PCV- 25%<br />TC-25,000<br />DC-BLAST  80%<br />?AML<br />Haematology  GH<br />
Hypercellular marrow<br />Abnormal premyelocytes and myelocytes seen.<br />Myeloblast 40%<br />Vacoulated  blast (+)<br />...
2 PACKED CELLS<br />2 PLATLETS<br />CYTOSINE ARBINOSIDE 150 mg od 7 days<br />ADRIAMYCIN 30 mg od 3 days<br />ETOPOSIDE 10...
Compression  of  the spinal cord  from<br />  metastatic  cancer located outside the spinal <br />cord,subarachnoid space ...
Metastatic epidural spinal cord compression (MESCC) is a devastating complication of cancer .<br />It is estimated to deve...
If left untreated, virtually 100% of these patients would become paraplegic; therefore, it is considered a true medical em...
Physically, MESCC occurs in one of three ways: <br />  (1) continued growth and expansion of vertebral bone metastasis int...
   Although multifactorial, the most significant damage caused by MESCC appears to be vascular in nature.<br />The epidura...
Back pain is the most common presenting symptom (88% to96%) <br />weakness (76% to 86%),<br />sensory deficits (51% to 80%...
  The most common level of the MESCC involvement is :                                                          <br />thora...
Breast cancer(29 %)<br />Lung cancer (17%)<br />Prostate cancer(14%)<br />Sarcomas<br />Melanomas<br />Lymphoma and leukem...
MRI is the standard modality for imaging of the central nervous system in cancer<br />   patients. It has a very high sens...
In terms of predicting ambulatory outcome, one of the most important factors is the rapidity of symptom onset.            ...
CORTICOSTEROIDS<br />Corticosteroids must be started as soon as possible in anyone suspected of having<br />   MESCC even ...
Based on several studies, an IV loading dose of 10 mg dexamethasone followed<br />  by a maintenance dose of 4 to 6 mg (IV...
Palliative radiotherapy has long been the standard of care in the treatment of patients<br />   with MESCC.<br />   Althou...
 back pain relief<br /> maintenance of ambulation <br />    bladder function improvement <br />Motor function improvement<...
Upfront chemotherapy (with a planned<br />  consolidative radiation) may be<br />  considered in select, newly diagnosed<b...
Radiation alone has been the standard treatment for MESCC, although results<br />   with radiation alone are disappointing...
 (1) some tumors (eg, renal cell, sarcoma, and melanoma) are not radiosensitive;<br />(2) even in radiosensitive tumors, i...
 (3) the most commonly used radiation dose<br />   and schedule (30 Gy in 10 fractions) is insufficient to provide long-te...
For years laminectomy and postoperative radiotherapy were frequently combined.<br />Recently, many have advocated the use ...
Recently, many have advocated the use of direct decompressive and maximal-<br />debulking surgery with intraoperative stab...
The advantages of direct decompressive surgery include removal of the tumor with<br />   a resultant decrease in tumor bur...
THANK  YOU<br />
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A Case of Epidural Cord Compression

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A Case of Epidural Cord Compression

  1. 1. INTERESTING CASE <br /> OF BACK ACHE<br /> DR.ANIRUDH J SHETTY<br /> PROF.DR.G.ELANGOVAN’S UNIT<br />
  2. 2. 24 year old female came with the complaints of <br /> pain in the lower back radiating to the right lower limb -5 days<br />
  3. 3. Patient was apparently normal 5 days back when she developed severe pain which radiated from the lower back uptill the right malleoli .<br />Pain was sharp,constant,stabbing,electric shock like pain which was distributed in the region below the right buttock .Aggravated on walking ,change in posture,sneezing<br />
  4. 4. Patient specifically c/o of the pain in the lumbosacral region. <br />Patient also c/o not being able to appreciate hot or cold water on the lateral side of right feet or feel her clothing<br />h/o urge incontinence +<br />h/o bowel incontinence +<br />
  5. 5. No h/o headache ,vomiting,blurring of vision <br />No h/o any cranial nerve involvement <br />No h/o fever or night sweats <br />No h/o involvement or weakness of the upper limb<br />No h/o seizures<br />No h/o trauma<br />
  6. 6. No h/o any involuntary movements <br />Past h/o – not a k/c/o DM/HTN/Tb/Seizure<br /> disorder<br />Personal h/o - attained menarche at 14 yrs<br /> h/o menorrhagia + <br />
  7. 7. O/E – Pt conscious<br /> oriented<br />afebrile<br /> hydration fair<br /> severe pallor(+)<br /> no icterus,clubbing,cyanosis,LAN<br />sternal tenderness+<br />
  8. 8. B.P – 110/70 mmHg<br />P.R – 88/min<br />JVP not elevated<br />
  9. 9. CNS – <br />Higher mental functions – normal<br />UL – Tone n power (N)<br />LL - RT LT <br />BULK N N<br />TONE DECREASED N <br />
  10. 10. RT LT<br /> POWER<br /> HIP 4- 5<br /> KNEE 4- 5<br /> ANKLE 4- 5<br /> EHL WEAK N<br />
  11. 11. DTR RT LT<br />KNEE + ++<br />ANKLE ABSENT +<br />BICEPS ++ ++ <br />TRICEPS ++ ++<br />
  12. 12. SUPERFICIAL REFLEXES<br />CORNEAL REFLEX – (+)<br />CONJUCTIVAL REFLEX – (+)<br />ANAL REFLEX- ABSENT<br />PLANTAR R L <br /> MUTE FLEXOR<br />
  13. 13. CRANIAL NERVES – NORMAL<br />SENSORY SYSTEM<br /> LOSS OF ALL MODALITIES OF SENSATION OVER LATERAL ASPECT OF RT FOOT <br /> LOSS OF SENSATION OVER THE PERIANAL REGION<br />
  14. 14. AUTONOMIC INVOLVEMENT<br /> URGE INCONTINENCE +<br /> BOWEL INCONTINENCE +<br /> NO CEREBELLAR SIGNS <br /> NO MENINGEAL SIGNS <br />
  15. 15. CVS – S1S2 +<br /> No murmurs<br />RS – NVBS +<br /> no added sounds<br />P/A – Soft<br />hepatomegaly +<br /> no spleenomegaly<br />
  16. 16. IMPRESSION : COMPRESSIVE TYPE OF MYELORADICULOPATHY<br />MOTOR LEVEL : L1<br /> SENSORY LEVEL:BELOW L-5<br /> REFLEX LEVEL : L-5 <br /> AUTONOMIC INVOLVEMENT : S2,3,4<br />
  17. 17. 2 PACKED CELLS<br />T.TRAMADOL<br />INJ.RANTAC<br />INJ CEFTRIAXONE<br />I.V FLUIDS<br />T.PARA<br />TREATMENT<br />
  18. 18. INVESTIGATIONS<br /> CBC<br />Hb-4.2<br />TC-17000<br />DC-P22,L76,E2<br />PLATLET-30000<br />RFT<br />RBS-96<br />UREA - 26<br />CREAT-0.6<br />SODIUM- 140<br />K+ -4.2<br />
  19. 19. LFT <br />T.B-0.8<br />D.B-0.2<br />SAP-88<br />SGOT- 30 <br />SGPT-40<br />ALBUMIN-4gm<br />ECG- WNL<br />CHEST X RAY- WNL<br />USG ABDOMEN<br /> LIVER SPAN-15.2 CM<br /> SPLEEN- 12.1 CM<br />
  20. 20. RBC’S :severe microcytichypochromic RBC’s <br />Anisopoikilocytosisseen.few target cells seen<br />WBC’S : Leukocytosis observed. Lymphocyte predominence more than 10% blasts seen.<br />PLATLETS: Severe thrombocytopenia seen.<br />IMPRESSION: To r/o acute leukemia<br />P/S STUDY<br />
  21. 21.
  22. 22.
  23. 23.
  24. 24. PREVERTEBRAL AND PARAVERTEBRAL SOFT TISSUE LESIONS WITH INTRASPINAL EXTENSION AT D-11,D-12,L5 TO S3 <br /> VERTEBRAL LEVEL. <br /> S/0 METASTATIC DEPOSITS <br />MRI REPORT<br />
  25. 25. Hb-6.2<br />PCV- 25%<br />TC-25,000<br />DC-BLAST 80%<br />?AML<br />Haematology GH<br />
  26. 26.
  27. 27.
  28. 28.
  29. 29.
  30. 30.
  31. 31.
  32. 32. Hypercellular marrow<br />Abnormal premyelocytes and myelocytes seen.<br />Myeloblast 40%<br />Vacoulated blast (+)<br />Erythroid progenitors reduced<br />Occasional megakayocytes seen.<br />Impression – AML Type 4 with dysplasia<br />BONE MARROW REPORT <br />
  33. 33. 2 PACKED CELLS<br />2 PLATLETS<br />CYTOSINE ARBINOSIDE 150 mg od 7 days<br />ADRIAMYCIN 30 mg od 3 days<br />ETOPOSIDE 100mg od 3 days<br />INJ DEXA 8 mg iv bd<br />InjTramadol 1gm iv hs<br />RADIOTHERAPY – Total dose of 180cGY in 10 fractions <br />TREATMENT<br />
  34. 34.
  35. 35. Compression of the spinal cord from<br /> metastatic cancer located outside the spinal <br />cord,subarachnoid space and duramater. <br />METASTATIC EPIDURAL SPINAL CORD COMPRESSION<br />
  36. 36. Metastatic epidural spinal cord compression (MESCC) is a devastating complication of cancer .<br />It is estimated to develop in approximately<br /> 5% to 14% of all cancer patients.<br />Although most patients with MESCC have limited survival, up to one third will survive beyond 1 year.<br />METASTATIC EPIDURAL SPINAL CORD COMPRESSION<br />
  37. 37. If left untreated, virtually 100% of these patients would become paraplegic; therefore, it is considered a true medical emergency and immediate intervention is required.<br />Thus, it is essential to consider aggressive therapy to preserve or improve the quality of life and prevent paraplegia.<br />
  38. 38. Physically, MESCC occurs in one of three ways: <br /> (1) continued growth and expansion of vertebral bone metastasis into the epidural space. (2) destruction of vertebral cortical bone, causing vertebral body collapse with displacement of bony fragments into the epidural space. <br /> (3) neural foramina extension into the epidural space by a paraspinalmass.<br />PATHOPHYSIOLOGY<br />
  39. 39.
  40. 40. Although multifactorial, the most significant damage caused by MESCC appears to be vascular in nature.<br />The epidural tumor causes epidural venous plexus compression, which leads to<br /> spinal cord edema. The increased vascular permeability and edema lead to increased<br /> pressure on the small arterioles. Capillary blood flow diminishes as the disease progresses, leading to white matter ischemia. Prolonged ischemia eventually results in infarction and permanent cord damage.<br />
  41. 41. Back pain is the most common presenting symptom (88% to96%) <br />weakness (76% to 86%),<br />sensory deficits (51% to 80%)<br />autonomic dysfunction (40% to 64%)<br />CLINICAL PRESENTATION<br />
  42. 42. The most common level of the MESCC involvement is : <br />thoracic spine (59% to 78%),<br /> lumbar (16% to 33%)<br /> cervical spine (4% to 15%)<br />
  43. 43. Breast cancer(29 %)<br />Lung cancer (17%)<br />Prostate cancer(14%)<br />Sarcomas<br />Melanomas<br />Lymphoma and leukemia<br />TUMOURS CAUSING MESCC<br />
  44. 44. MRI is the standard modality for imaging of the central nervous system in cancer<br /> patients. It has a very high sensitivity (93%), specificity (97%), and accuracy<br /> (95%) in diagnosing MESCC <br /> Since patients can have synchronous, multifocal MESCC, an MRI of the entire spine should be performed promptly in<br /> anyone suspected of having MESCC<br />DIAGNOSIS<br />
  45. 45. In terms of predicting ambulatory outcome, one of the most important factors is the rapidity of symptom onset. Other important prognostic factors<br /> include radiosensitive histology (eg, multiple myeloma, germ-cell tumors, lymphomas,<br /> and small-cell carcinoma) and pretherapy ambulatory function.<br />PROGNOSIS<br />
  46. 46. CORTICOSTEROIDS<br />Corticosteroids must be started as soon as possible in anyone suspected of having<br /> MESCC even before radiographic diagnosis, because they can be discontinued<br /> rapidly with a negative diagnosis. <br /> They decrease cord edema, and they<br /> serve as an effective bridge to definitive therapy<br />THERAPY<br />
  47. 47. Based on several studies, an IV loading dose of 10 mg dexamethasone followed<br /> by a maintenance dose of 4 to 6 mg (IV or orally) every 6 to 8 hours should be sufficient for most patients. <br />Furthermore, patients should be started on a proton-pump inhibitor for GI prophylaxis.<br />
  48. 48. Palliative radiotherapy has long been the standard of care in the treatment of patients<br /> with MESCC.<br /> Although multiple fractionation schedules have been reported in the literature, a total of 30 Gy in 10 fractions is the one most<br /> frequently employed<br />RADIOTHERAPY<br />
  49. 49. back pain relief<br /> maintenance of ambulation <br /> bladder function improvement <br />Motor function improvement<br />
  50. 50. Upfront chemotherapy (with a planned<br /> consolidative radiation) may be<br /> considered in select, newly diagnosed<br /> patients with excellent neurological status<br /> and very chemosensitive tumors<br />
  51. 51. Radiation alone has been the standard treatment for MESCC, although results<br /> with radiation alone are disappointing.<br /> There are several reasons for this:<br />SURGERY<br />
  52. 52. (1) some tumors (eg, renal cell, sarcoma, and melanoma) are not radiosensitive;<br />(2) even in radiosensitive tumors, it may take several days to deliver a radiation dose large enough to cause a response during which time the spinal cord damage may continue <br />
  53. 53. (3) the most commonly used radiation dose<br /> and schedule (30 Gy in 10 fractions) is insufficient to provide long-term local<br /> control of gross tumor (except for radiosensitive tumors), so tumor may regrow<br /> to cause a recurrence of MESCC even after initial clinical response<br />
  54. 54. For years laminectomy and postoperative radiotherapy were frequently combined.<br />Recently, many have advocated the use of direct decompressive and maximal-<br />debulking surgery with intraoperative stabilization of the spine (in appropriate<br /> cases) followed by postoperative radiation therapy<br />
  55. 55. Recently, many have advocated the use of direct decompressive and maximal-<br />debulking surgery with intraoperative stabilization of the spine (in appropriate cases) followed by postoperative radiation therapy. Since over 85% of<br /> spinal metastases arise anterior to the spinal cord, direct attempts at anterior<br /> spinal decompression seems logical.<br />
  56. 56. The advantages of direct decompressive surgery include removal of the tumor with<br /> a resultant decrease in tumor burden that allows for more effective postoperative<br /> radiotherapy.<br /> immediate relief of the cord compression and immediate stabilization<br /> of the spinal column, which can be achieved by the same operation.<br />
  57. 57. THANK YOU<br />

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