1. Spondylolisthesis with
Osteoporosis

11. Patient Details
IP Number: 716
Age: 34 y
Gender: Female
Weight: 49 kg
Unit: Orthopaedics II
DOA: 25/3/14
DOD: 31/3/14

12. Reason for Admission:
c/o lower backache since 2 months
Patient was apparently normal 8 months
back, when she developed lower
backache, which was insidious in onset,
gradually progressive, non radiating,
digging type and not associated with
tingling sensation.

13. Pmhx: NS
Fhx: NS
Diet: Vegetarian
Appetite: Normal
Bowel & Bladder: Normal
Sleep: Normal
Allergies: NKA

14. Spondylolisthesis with
Osteoporosis

15. DAY 1
PULSE: 82 bpm BP: 120/80 mmHg
o/e:
Spine
Inspection: no visible spinal deformity
no scars, swelling
Palpation: spinous tenderness + over L4
and L5 spinous processes
paraspinal spasm +
no paraspinal tenderness
B/L SI joint tenderness +

16. SLR Examination
Right Left
SLR 45° 30°
LF + +
PF + +
FHL 5/5 5/5
EHL 5/5 5/5
Reflex Examination
Right Left
Knee + +
Ankle + +
Plantar

17. Adv: Hb, BC, CT, PT-INR, Blood
Urea, Serum Creatinine, Urine
Routine, X-ray
Referred for Physiotherapy

18. Treatment Chart
Current Drugs Dose Route Freq
Calcitriol + Calcium
Carbonate + Zinc
0.25 mcg+ 500
mg + 7.5 mg
PO 1-0-0
Nimesulide +
Tizanidine
100 mg + 2 mg PO 1-0-1
Pyridoxine + Folic
Acid + Alpha Lipoic
acid
PO 0-0-1

19. DAY 2
BP: 130/70 mmHg
Case reviewed
GC fair
Vitals stable
CST

20. Laboratory Investigations
Hematology
Hb 11.1 gm/dl (13.5 ± 2)
WBC 7,500 cells/cu.mm
(4000-11,000)
DLC N 68%
E 03%
B 00%
L 26%
M 03%
PLT 2.39 l/cu.mm (1.5-5)
ESR 48 mm/hr (0-20)
Biochemistry
RBS 94 mg/dl (70-150)
Urea 23 mg/dl (19-43)
Secr 0.8 mg/dl (0.6-1.5)
Urine Analysis
Pus cells 2-4

21. Electrolytes
Na 132 mEq/L (133-144)
K 4.1 mEq/L (3-5.5)
Cl 102 mEq/L (95-105)

22. X-RAY Report
Lumbar X-ray shows first degree
spondylolisthesis with gross
osteoporosis

23. Treatment Chart
Current Drugs Dose Route Freq
Calcitriol + Calcium
Carbonate + Zinc
0.25 mcg+ 500
mg + 7.5 mg
PO 1-0-0
Nimesulide +
Tizanidine
100 mg + 2 mg PO 1-0-1
Pyridoxine + Folic
Acid + Alpha Lipoic
acid
PO 0-0-1

24. DAY 3
BP: 100/70 mmHg
Case reviewed
GC fair
Vitals stable
CST

25. Treatment Chart
Current Drugs Dose Route Freq
Calcitriol + Calcium
Carbonate + Zinc
0.25 mcg+ 500
mg + 7.5 mg
PO 1-0-0
Nimesulide +
Tizanidine
100 mg + 2 mg PO 1-0-1
Pyridoxine + Folic
Acid + Alpha Lipoic
acid
PO 0-0-1

26. DAY 4
BP: 100/62 mmHg
Case reviewed
GC fair
Vitals stable
Pre-operative instructions:
Posted for epidural steroid
tomorrow

27. Drugs Dose Route Freq
Alprazolam 0.5 mg PO HS
Ranitidine 150 mg PO HS

28. Treatment Chart
Current Drugs Dose Route Freq
Calcitriol + Calcium
Carbonate + Zinc
0.25 mcg+ 500
mg + 7.5 mg
PO 1-0-0
Nimesulide +
Tizanidine
100 mg + 2 mg PO 1-0-1
Pyridoxine + Folic
Acid + Alpha Lipoic
acid
PO 0-0-1

29. DAY 5
BP: 110/60 mmHg
Operative Procedure:
Injection Methylprednisolone 80
mg + 6cc 0.25% bupivacaine

30. Treatment Chart
Current Drugs Dose Route Freq
Calcitriol + Calcium
Carbonate + Zinc
0.25 mcg+ 500
mg + 7.5 mg
PO 1-0-0
Nimesulide +
Tizanidine
100 mg + 2 mg PO 1-0-1
Pyridoxine + Folic
Acid + Alpha Lipoic
acid
PO 0-0-1

31. DAY 6
BP: 110/60 mmHg
Post epidural 80% pain relief
GC fair
Vitals stable
CST

32. Treatment Chart
Current Drugs Dose Route Freq
Calcitriol + Calcium
Carbonate + Zinc
0.25 mcg+ 500
mg + 7.5 mg
PO 1-0-0
Nimesulide +
Tizanidine
100 mg + 2 mg PO 1-0-1
Pyridoxine + Folic
Acid + Alpha Lipoic
acid
PO 0-0-1

33. DAY 7
BP: 110/60 mmHg
Case reviewed
GC fair
Vitals stable
Adv: Discharge

34. Discharge Medications
Current Drugs Dose Route Freq
Calcium Carbonate
+ Vitamin D3
625 mg + 125
IU
PO 1-0-0
Nimesulide +
Tizanidine
100 mg + 2 mg PO SOS
Pyridoxine + Folic
Acid + Alpha Lipoic
acid
PO 0-0-1

35. Pharmaceutical
Care Plan

36. Subjective
Evidence
• Low backache
since 2 months
Objective
Evidence
• Spinal
examination
• X-ray
• Elevated ESR

37. Final Diagnosis
Spondylolisthesis with
gross osteoporosis

38. Goals of Therapy
For Spondylolisthesis
• To relieve the back pain (associated with an irritated
nerve)
• Restoring spinal flexibility and improving range of
motion
• Stopping the progression of slippage
For Osteoporosis
• To decrease pain
• To prevent bone loss
• To prevent fractures
• To help the patient to return to the highest level of
function and independence possible, while improving
the overall quality of life

39. Goals Achieved
• 80% pain reduction was
observed by day 6

40. Specific Treatment Options
For Spondylolisthesis
• Conservative treatment
NSAIDS
Epidural steroid
injections
Brace
Physical therapy

41. For Osteoporosis
• Non pharmacological therapy
Calcium
Vitamin D
Exercise

42. Monitoring Parameters
Disease Specific
X-ray
BMD
Drug Specific
Serum calcium level
Kidney Stones
LFTs

43. Problems Identified
• BMD was not performed
• Serum calcium and phosphorous
levels were not determined
• Use of nimesulide

44. Patient Counseling about
Disease
Spondylolisthesis Osteoporosis

45. Medication Counseling

46. Lifestyle Modifications
• Vit K
• Mg
• Phytoestrogen
• Protein