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CPC1 – Degenerative Spine Disease  201 6  CPC 1: Degenerative Spine Disease GRAND MENTOR : DATO’ DR HAJI ZAMYN ZUKI BIN TAN SRI DATO’ HAJI MOHD ZUKI  MENTOR : MR. LIM SZE WEI  PREPARED BY : DR. NEERMALADEVI PARAMASIVA M

Degenerative spine disease

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CPC1 – Degenerative Spine Disease   201

6

 

CPC 1:

Degenerative Spine Disease

GRAND MENTOR : DATO’ DR HAJI

ZAMYN ZUKI BIN TAN SRI DATO’HAJI MOHD

ZUKI

  MENTOR : MR. LIM SZE WEI

  PREPARED BY : DR. NEERMALADEVI PARAMASIVAM

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Figure 1: Photo ith !" !entor Mr #i! S$e %ei

CONTENTS

 N0 TITLE PAGE

1 ACKNOWLEDGEMENT 1

2 INTRODUCTION

3 CASE STUDYCLINICAL HISTORY E!AMINATION

INVESTIGATIONS

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MANAGEMENT

PROGRESS

" DISCUSSION

# CONCLUSION

$ RE%ERENCES

AC&NO%#EDGEMENT

%&'() *+ ,-- I /*- -& )* ), )4&( *55*')6&)7 )* 85'(( 97 ',)&) ,6

(&6;' )4,6( )* 97 ',6 96)*' D,)*’ D'. H,<& Z,976 Z& +*' =&6 , /*6'+-

G',6 M6)*' ,6 , ;*6(),6) 5&--,' *+ 6;*',96) ,6 +*' )4 6>' 6&6

(55*') ,6 &,6;. H &( , ',) ),;4' ,6 ** &6(5&',)&*6 )* ( )4'*4*) 97

2 9*6)4( O')4*-&+ )',&6&6 &6 )4&( 5,')96) (* +,'. A-- 4&( &;,)&*6 ,6 ++*') 4, 5(4 9 )* ()'&> +')4' ,6 6',>- 97 */6 5*)6)&,-.

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CPC1 – Degenerative Spine Disease   201

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S;*6-7 I /*- -& )* &> 97 (5;&,- )4,6( )* 97 96)*' M'L&9 +*' 4&(

 5,)&6; &,6; ,6 (55*') )*/,'( 9 &6 )4&( 4*(9,6(4&5 )',&6&6 .H&(

 5'&;-(( 85'&6; ,6 6*/- )4,) 4 (4,' ,' >'7 (+- +*' 9 )* ;*6)&697 <*'67 &6 O')4*-&+ )',&6&6 ,( /-- ,( , *;)*'. L,() =) 6*) -,() )* ,-- 9&;,-

*++&;'( ,6 97 ;*--,(. T4,6( +*' )4 ,((&(),6; ,6 6;*',96) )4'*4*)

)4 *')4*5,&; 4*(9,6(4&5 )',&6&6.

'NTROD(CT'ON

S5&6,- ()6*(&( &( , ;*6&)&*6 ;4,',;)'&? =7 , 5'*'((&> 6,''*/&6 *+ )4

(5&6,- ;,6,- )4 >')&;,- )= +*'9 =7 )4 >')=', )4,) 4*(( )4 31 6'>( *+ )4

(5&6,- ;*'.T4 (795)*9( *+ ;*66&),- (5&6,- ()6*(&( 56 *6 /4&;4 5*')&*6( *+ )4

6'>( ,' =&6 ;*95'((S5&6,- ()6*(&( &( *+)6 '(-)( +'*9 ,&6 =) &) ;,6 ,-(*

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 = , ;*66&),- &(*''. W&)4 ;*66&),- (5&6,- ()6*(&( )4 5,)&6) &( =*'6 /&)4 ,

6,''*/ (5&6,- ;,6,- )* ,=6*'9,--7 +*'9 5,')( *+ )4 (5&6. T4&( ;*6&)&*6 &(

9*() ;*99*6 &6 5,)&6)( /&)4 , (4*') (),)'.G6',--7 6,''*/&6 &6 )4 55' *' ;'>&;,- (;)&*6 *+ )4 (5&6 5'*;(

 5,&6 ,6@*' 69=6(( &6 )4 (4*-'( )*'(* 4,6( *' ,'9(. N,''*/&6 &6 )4

 =))*;( )4&4( *' +) -*/' *' -9=,' '&*6 *+ )4 (5&6 5'*;( (&9&-,'

(795)*9( &6 )4 ;,->(. C*66&),- (5&6,- )6( )* /*'(6 5'*'((&>-7 /&)4 ,.

M,67 5*5- =*'6 /&)4 )4 ;*6&)&*6 9,7 >-*5 (795)*9( ,( ,'-7 ,( )4 , *+

1#. I) &( , 5??-&6 ;*6&)&*6 )4,) ;,6 6&)4' = 5'&;) 6*' 5'>6). I) *( 6*)

&()&6&(4 =7 (8 ',; *' )46&;&)7. N*' &( &) ,((*;&,) /&)4 ,67 5,')&;-,'

*;;5,)&*6 *' ,67 5,')&;-,' =*7 )75.

A6 ,;;',) &,6*(&( &( ((6)&,- ,6 ;,6 )75&;,--7 = 9, /&)4 )4 4-5 *+

&9,&6 &596) (;4 ,( MRI( !',7( *' CT (;,6(. %*' )4*( (++'&6 +'*9

;*66&),- (5&6,- ()6*(&( (''7 ;,6 *++' '-&+. A ;*95'((&> -,9&6;)*97 ,6

*5',)&*6 )4,) /&6( )4 (5&6,- ;,6,- &( 9*() +'6)-7 ( )* )',) ;*66&),-

(5&6,- ()6*(&(.

CASE ST(DY

CHIE% COMPLAINT :

T4 (=<;) *+ 97 ()7 &( , # 7,'( *- I6&,6 /*9,6 /&)4 ;* 9*'=&( *+

7(-&5&9&, 475')6(&*6 (;4&?*54'6&, (&6; 2001 ,6 4&()*'7 *+ 6*9)'&,- /&)4

47()';)*97 *6 +*--*/ =7 ',&*)4',57. S4 5'(6) )* ED HSB *6 @10@1#/&)4 ;*95-,&6)( *+ 6',-&( /,6(( *>' 55' ,6 -*/' -&9=( (&6; 2 /(

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 5'&*' )* ,9&((&*6. B(&( (4 6,=- )* 5,(( '&6 +*' 3 ,7( ,6 6,=- )* 5,((

9*)&*6 +*' 1 / 5'&*' )* ,9&((&*6.

HISTORY O% PRESENTING ILLNESS :

S4 (),') )* 4,> 6',-&( /,6(( *>' 55' ,6 -*/' -&9=( (&6; 2

/( ,* /4&;4 55' -&9=( /' 9*' (>' ;*95,' )* -*/' -&9=(.

S=(6)-7 6,=- )* 5,(( '&6 +*' 3 ,7( ,6 6,=- )* 5,(( 9*)&*6 +*' 1 /

 5'&*' )* ,9&((&*6.

T4' /,( ,6 &6;&6; *+ +,-- ,) 4*9 *6 2@@1# 5'(6) )* HSB ,) 5*()

)',9, ,7 11F S4 ;-,&9 +-&6 *+ &&6(( ,6 6( ,> /,7 )*

/,6(( (=(6)-7 +-- =,;/,'( 4' *6 =))*;(. A+)' )4 +,-- (4 /,(

6,=- )* ,9=-,) =) ()&-- ,=- )* &; )4 /,-- )&-- 6&4=*' 4,'( 4' ,6 ;,9

*>' /&)4&6 )/* 4*'(. O)4'/&( )4' /,( 6* -*(( *+ ;*6(;&*(6(( 6* ;'>&;,-

 5,&6 6* >*9&)&6 *+ ENT =-(. S4 /,( )46 ='*4) )* H*(5&),- T- I6),6 >&,

,9=-,6;. T4 6',-&( =*7 /,6(( (),') (&6; +/ 4*'( ,+)' +,-- 55'

-&9=( ,' 9*' (>' )4,6 -*/' -&9=(. T4 /,6(( /' ,((*;&,) /&)4 =&-,)',-

55' -&9= ,6 -*/' -&9= 69=6(( +'*9 )4 ->- *+ 55' ,=*96. A) )4,) 5*&6)

(4 ()&-- ,=- )* 5,(( '&6 ,6 9*)&*6.

S=(6)-7 (4 /,( ,9&)) +*' 11 ,7( &6 H*(5&),- T- &6),6 ;-,&9( )4,)

,+)' 3 ,7( (4 /,( ,-',7 ,9=-,)&6 =) )46 +-- ,,&6 9-)&5- )&9( &64*(5&),- )* /,6(( *+ =&-,)',- -*/' -&9=(. I6 +,;) )4&( &( 6*) )4 +&'()

,9&((&*6 )* H*(5&),- T- I6),6. T4' /,( , ';6) ,9&((&*6 &6 H*(5 T-

I6),6 *6 2@@1# /&)4 4&()*'7 *+ +,-- ,) 4*9 ,((*;&,) /&)4 &&6(( +-&6( *+

-)4,'7 ,6 4&()*'7 *+ 4,6 ;',95( +*' 1 / ',)&*6.

C*95) T*9*',547 *+ =',&6 /,( *6 *6 2@@1# )* '- *) ,67 =',&6()9

&6<'7 ,6 '(-) ,( 6*'9,- /&)4 6* &6)',;',6&,- 4,9*''4,. S4 /,( '>&/ =7

 5(7;4&,)'7 &6 >&/ *+ ((5;)&6 )4 ,6)&5(7;4*)&; 9&;,)&*6 ;,(&6 4' 67(),9(

 5'&*' )* +,-- =) ;-,&9 6-&-7 )4 ;,((. C'>&;,-)4*',;* ! ',7 ,) H*(5&),- )-&6),6 (4*/ '* -+) 5&;- ,) T# ;4,6( /4&- ;'>&;,- ! ',7 4, &6,,)

>&/ /&)4 6* *=>&*( 5,)4*-*7. H6; (4 /,( '+'' )* *')4*5,&; 5,')96)

&6 H*(5&),- S-,7,6 +*' ;'>&;,- 97-*5,)47 ,=*> C". H*(5&),- S-,7,6

&(;4,' 4' /&)4 T,= G,=,56)&6 ,6 5-,66 +*' MRI ,( *)5,)&6).

U6+*')6,)-7 5'&*' )4 TCA *+ MRI (4 5'(6) )* )4&( H*(5&),- S B-*4 *6

@10@1# ,( (4 ;*- 6*) 5,(( '&6 +*' 2,7( ,6 6*) 5,(( 9*)&*6( +*' ,7( ,*. T4

(795)*9( ,((*;&,) /&)4 9&6&9,- ,=*9&6,- &(;*9+*'). ;-,&9( +-- ,,&6 )*

-*/' -&9=( /,6(( &6 +'*6) *+ )4 4*(5&),- /46 ;,9 *) +'*9 ),8&.

A--'&; 4&()*'7 :

 N&-

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CPC1 – Degenerative Spine Disease   201

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P,() 9&;,- 4&()*'7 :

1@ D7(-&5&9&, *6 T,= (&9>,(),)&6 209 ON2@ HPT *6 T,= A9-*&5&6 #9 OD ,6 T,= A)6*-*- 1009 OD

3@ S;4&?*54'6&, *6 T '&(5'&*6 (&6; 2001 6' HTI +*--*/ 5

P,() ('&;,- 4&()*'7 :

H&()*'7 *+ 6*9)'&,- ;,6;' /4&;4 &,6*( &6 200 ,) H*(5&),- I5*4.

H7()';)*97 /,( *6 +*--*/ =7 5*() *5 ',&*)4',57. P,)&6) 6(' *+ (),&6

*+ &(,( =) (4 &( 6' 7,'-7 ('>&--,6; ,) *6;*-*7 HKL. L,() CT (;,6 /,(

*6 2 7,'( ,* ,6 5,)&6) /,( )*- &(,( +'.

%,9&-7 4&()*'7 :

 N* +,9&-7 4&()*'7 *+ 9,-&6,6;7.

M&;,)&*6 H&()*'7 :

T,= A9-*&5&6 #9 OD

T,= A)6*-*- 1009 OD

T,= C,'&5'&6 1009 OD

T,= (&9>,(),)&6 209 ON

T,= C, L,;),) 3009 OD

T,= %*-,) 1@1 ODT,= R&(5'&*6 29 OD

T,= %-'*8,9&6 #09 OD

S*;&,- H&()*'7 :

S4 &( =-(( /&)4 1 ;4&- =) /,( &>*'; 5'>&*(-7. H' (*6 &( (),7&6 /&)4 4'

84(=,6 ,6 *( 6*) 5 &6 )*;4 /&)4 4' S4 &( (),7&6 &6 T- I6),6 ,-*6.

S4 4,( , (&()' &6 K,-, L95' =) 6,=- )* = 9,&6 ;,' ),'.

PHYSICAL E!AMINATION :P,)&6) GCS +-- /,'9 5'&54'&( CRT 2 (;( ** 5-( >*-9

49*76,9&;,--7 (),=- 6(55*') ,6 (,)',)&6 /-- 6' '**9 ,&'.

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O6 ,(;-),)&*6 -6( /,( ;-,' =&-,)',--7 /&)4 ** ,6 ,- ,&' 6)'7. S1 ,6 S2

4,' *6 4,') ,(;-),)&*6 /&)4 6* 9'9'( );). .A=*96 /,( (*+) 6*) )6' ,6 6*) &()6.

 N'*-*&;,- E8,9&6,)&*6.

O6 )4 6; ,6 =,; 6* +*'9&)7 (6.

O6 5,-5,)&*6

 N'*-*&;,- 8,9&6,)&*6:

P*/': @10@201#2@10@1#

R&4) L+)

C# " "

C$ " "

C " "

C 3 3

T1 3 3 L2 " "

L3 " "

L" " "

L# " "S1 " "

T4' &( &95,&' (6(,)&*6 69=6((F +'*9 55' ,=*96 */6/,'( T" S1F

M(;- )*6 ,' 475*)*6&, *>' =&-,)',- 55' -&9=( =) ,55,'( 6*'9,- *>' -*/'

-&9=(

B,'=6(& (&6( ,' &>*;,- =&-,)',--7.

O6 5' ';),- 8,9&6,)&*6 ,6,- )*6 &( -,8 /&)4 &95,;) ()**- 5 ,6 (5'+&;&,-

(6(,)&*6 &6),;). B-=*;,'>6*(( '+-8 5'(6).

 

INVESTIGATIONS

1F H9,)*-*&;,-

P'*5',)&> '(-) *6

%-- B-** C*6) %BCF WCC 11.$2 HB 10 HCT 3. PLT 30

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P*()*5',)&> '(-) *6

%-- B-** C*6) %BCF WCC 10 HB . HCT 33. PLT 2$R6,- P'*+&- RPF U', " N, 13 K ".3 C',)&6&6 ".3

L&>' %6;)&*6 T() L%TF T*),- 5'*)&6 2 A-=9&6 "" T*),- =&-&'=&6

ALT "" AST 12 ALP 10

C*,-,)&*6 P'*+&- PT 12.$@ INR 1.1#@ APTT 31."

E-;)'*-7)( C,-;&9 2.13 M,6(&9 0.$ P4*(54,) 1.# 

2F R,&*-*&;,-

!',7 )4*',;*-9=,' ,) H*(5&),- T- I6),6 *6 @10@1#

M,6)&; R(*6,6; I9,&6 MRIF W4*- S5&6 *6 *6 *6 @10@1# )* '- *);,, &6 (76'*9 /&)4 (5&6 9),(),)(&(.

T4 +&6&6( ,' ,( =-*/ :

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CPC1 – Degenerative Spine Disease   201

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L*(( *+ ;'>&;,- -*'*(&(. V')=',- ,-&696) &( 5'('>.

L&6,' T2 475'&6)6(&)7 &( (6 ,) C$ T$ ,6 T ,((*;&,) /&)4 /&6 *+

)4 >')=',- =*&( (()&> *+ ;*95'((&*6 +',;)'(. M*&; )75 II +,))7F ;4,6( ,) )4 *55*(&6 6 5-,)( *+ T10@11 ,6 L"@#.

D(&;;,)&*6 *+ )4 ;'>&;,- &(;( /&)4 9-)&->- ;&';9+'6)&,- &(;( =-

%'*9 C3@" )* C@T1F.

T4 -&,96)9 +-,>9 ,) )4( ->-( ,' ,-(* (>'-7 )4&;6 ,6

*((&+&.

T4 ,=*> ;4,6( '(-) &6 (>' ;'>&;,- ;,6,- 6,''*/&6 ,6 (5&6,- ;*'

;*95'((&*6 /&)4 ;*' *9, +'*9 C3 )* C ->-(.

T4 6,''*/() AP &,9)' 9,('( $.#99 ,) C$ ->-.

L*/ (&6,- &6)6(&)&( ,' *=('> ,) )4 (5&6,- 5'*;(( *+ C$ ,6 )4 ';)*'9(;-( 9,7 '5'(6) ;,-;&+&;,)&*6@*((&+&;,)&*6.

 N,''*/&6 *+ )4 C"@# C#@$ C$@ 6',- +*',9&6, 9*' *6 )4 -+) (&

;,(&6 8&)&6 6'> '**) &95&696).

S5&6,- ;*' 6( ,) L1 ->-. N* ;*95'((&*6 *+ )4 ;,, &6,.

 N* ,=6*'9,- (5&6,- 64,6;96) *' 5,',>')=',- 9,((.

I95'((&*6: S>' ;'>&;,- ;,6,- ()6*(&( /&)4 ;*' ;*95'((&*6 +'*9 C3 )*

C ->-( ,6 ;'>&;,- 6'> '**)( &95&696) ,( (;'&=.

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CPC1 – Degenerative Spine Disease   201

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MANAGEMENT:

P'*5',)&> 5,)&6) /,( 4,>&6 ,;) '&6,'7 ')6)&*6 46; /,( 5) *6 CBD 6)&-*5',)&*6 &6 /,'

S'&;,- O5',)&*6

P,)&6) 6'/6) -,9&6*5-,()7 *+ C" C#C$ *6 =7 M' L&9 M' T4',& ,((&()

 =7 D' H,+&? *6 2@10@1# ,) 1#:2H 1:"#H

P*() *5 &,6*(&(:

C*66&),- S5&6,- S)6*(&( *>' C3C$

 

I6), *5 +&6&6:

C*66&),- S5&6,- S)6*(&( *>' C3C$

T4&; +&='*( )&(( *>'-7&6 ',- (4,)4

L,9&6*5-,()7 O>' C"C$

I95-,6) (:

M)'*6&; *56 **' 5-,) 109983

S;'/( 2.$998998$

2.$998#998#

3.0998#9981

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PROGRESS

P*()*5',)&>-7 5,)&6) /,( ,9&)) )* ICU I6)6(&> C,' U6&) F *>'6&4))* 9*6&)*' ;-*(-7. I6&)&,--7 (4 /,( &6)=,) (,) ,6 49*76,9&;,--7 (),=-

6(55*'). S4 /,( 8)=,) /-- ,6 /,( )',6(+'' )* /,' ,) 5*() *5',)&>

,7 1. I6 /,' (4 /,( 49*76,9&;,--7 (),=- 6(55*'). P,&6 (;*' /,( /--

)*-',=- 5*()*5',)&>-7 /&)4 )4 (, *+ 5,)&6) ;*6)'*-- ,6,-(&, 9*'54&6

PCAMF ,6 (=(6)-7 /,6 *++ )* *',- ,6,-(&,. S4 &( 5) *6 C'>&;,- C*--,'

 5'*5 5 "# '( ,6 ;*>' /&)4 IV ;+'*8&9 #09 TDS. W*6 &6(5;)&*6

/,( *6 *6 ,7 3 5*()*5',)&> *6 1@11@201#. I) /,( ;-,6 6* ,55&6 6* 5(

&(;4,'. D',&6 /,( *++ *6 )4 (,9 ,7 ,( /--. T*),- ',&6 /,( 9&6&9,- -(( )4,6

#09-. C4; !',7 /4*- (5&6 '>&/ =7 (5&6 ),9 ,6 /,( ,;;5),=-.

P,)&6)( 6'*-*&;,- (),)( /,( &95'*> ,+)' *5',)&*6. S4 (),') )*

9*=&-&? +'*9 -7&6 )* (&))&6 5*(&)&*6 /&)4 ,((&(),6; *6 ,7 3 5*()*5',)&>. O6

,7 $ 5*()*5',)&> 5,)&6) /,( ,=- )* ,9=-,) )* ;4,&' /&)4 )4 4-5 *+

 547(&*)4',57 ),9.

 N'*-*&;,- 8,9&6,)&*6 5*() *5 ,7 $P*/' : R&4) L+)

C# # #

C$ # #

C " "C # "

T1 3 " L2 " #

L3 # #

L" # #

L# # #

S1 # #

S6(,)&*6: B() (6(*'7 ,) C$ ->- 5'*5'&*;5)&*6 &6),;)

P' ';),-: ,6,- )*6 ()&-- -,8 BCR 5'(6) 5 ,6 (5'+&;&,- ,6,- (6(,)&*6 &6),;)S4 ()&-- '&' ,& &6 ,&-7 ,;)&>&)&( ,6 ,9=-,)&6 )* ;4,&'( /&)4 4-5(.

S4 &( ,=- )* (6( +-- ';)9 =) &++&;-) )* &6&)&,) +-- =*/- *56&6 ,6 ()&-- *6

CBD. S4 /,( '+'' )* '4,=&-&),)&*6 ),9 (),') /&)4 )'&,- *+ ;,)4)' 

9*=&-&?,)&*6 ()'6)46&6 8';&(( ,6 '(5&',)*'7 8';&( /&)4 )'&+-*/

(5&'*9)'. S4 (),') =*/- *56&6 /&)4 4-5 *+ (7'5 -,;)-*( 1#9- BD ,6

(55*(&)*'7 D-;*-,8 20 9 >'7 *)4' ,7. A) 5*()*5',)&> ,7 5,)&6)’(

/*6 4, 49*('*( &(;4,'(. P( CS ),6 *6 3@11@1# '/ 5(*9*6,(

,'&6*(, /4&;4 &( (6(&)&> )* ,9&,;&6 ,6 ;+5&9. O' ),9 ;*6(-)

&6+;)&*( &(,( *6 #@11@1# &6 >&/ *+ 5,)&6) ;-&6&;,--7 /-- (5)&; 9,''( 6*)',&( 46; /,( 5-,66 )* *++ ,6)&=&*)&;( ,6 *=('> /*6. S4 &( 5) *6 ,;)&;

,;& ,6 =,;)&',(( '((&6 ,&-7 &6 /,'. A) 5*()*5',)&> ,7 13 5,)&6) /,(

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&(;4,' )* H*(5&),- T- I6),6 &6 >&/ -*&()&; 5'*=-9. U5*6 &(;4,' 5,)&6)

,=- )* ,9=-,) (&6 /,-&6 +',9 /&)4 1 5'(*6 9&6&9,- ,((&(). S4 /,( ,-(* ,=-

)* 5'+*'9 +6;)&*6,- ,;)&>&)&( -& + 4'(-+ ='(4 ))4 ,6 (-+ 47&64*/>' ()&-- 6 ,((&(),6; +*' '((&6. W*6 &6(5;)&*6 /,( *66*) ;-,6

,6 '7. P,)&6) /,( *6 =-,' &,'7 ,6 =*/- '+-8( '&9. H' 6'*-*&;,-

 5*/' =&-,)',- 55' ,6 -*/' -&9=( ,' # 8;5) CT1 ,' ".

S4 ;*9( +*' TCA *')4*5,&; ;-&6&;( ,( *)5,)&6) 3@12@1# 1 9*6)4 5*()

*5',)&>F (4 &( ,=- )* ,9=-,) /&)4 /,-&6 +',9. P,)&6) ;-,&9( )4' &(

9&6&9,- 5,&6 *>' )4 6; /&)4 5,&6 (;*' 2@10 9&6&9,- ,6 ,=- )* (-5 /--.

O)4'/&( (4 &( ,=- )* ;*6)'*- =*/- ,6 =-,' 4,=&) ,6 ,)&6 /--. S4

;*95-&,6)( )* ;'>&;,- ;*--,'.

 N'*-*&;,- 8,9&6,)&*6 '&6 ;-&6&;( TCA

P*/' : R&4) L+)

C# # #

C$ # #

C " "

C " "

T1 " " 

L2 # #L3 # #

L" # #

L# # #

S1 # #

H6; (4 &( &(;4,' /&)4 TCA ,+)' 2 9*6)4( /&)4 LMS ;',9 5-,66 +*'

;*6)&6*( 547(&*)4',57 ,) )- &6),6 ,6 5 )4 (*+) ;*--,'.

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%&' A: !',7 C'>&;,- ,+)' -,9&6*5-,()7 *+ C" C#C$ ,) @10@1#F

P*() *5 8 ',7 ;'>&;,- ,) 30@10@1#F

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Post op ) ra" *ervi*a+ ,at 11-.-1/0

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MR' one on 1/-12-1/ pre operative

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Cervi*a+ ) ra" one at ortho *+ni*s 3o++o up 4-1.-1/

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DISCUSSION

1@ HISTORY