RB: A Case of Tetraparesis

Block Y. Tagomata. Talan. Tayag. Tolibas. Toledo. Uy. Wi. Yu. Zaldivar. Zamora.

General DataRB• 25/M• From Camarines Norte• Roman Catholic• Married, with 1 child• R handed

Chief ComplaintInability to walk

History of Present Illness10 mos PTA,

(+) intermittent pain on R medial arm, described as “parang binabanat ang ugat”, NPS 10/10, occurring 3x/wk, aggravated by exertion (e.g. reaching out or lifting an object)relieved by an unrecalled analgesic 0/10 (-) numbness, (-) tingling, (-) skin lesions, (-) hx of trauma2 wks after, development of similar symptoms on L arm and both scapular areas, no consult was done

History of Present Illness9 mos PTA,

(+) weakness of R LE, (-) pain, (-) numbness, (-) tingling, (+) sensation of abdominal tightness, (+) dyspnea (-) hx of traumaconsult was done at BHC, given vitamins and analgesic

History of Present IllnessA few days later, (+) weakness of R LE, admitted to LH; CXR, holoab UTZ, cranial CT scan and labs done were allegedly normaldischarged and prescribed with unrecalled meds but stopped due to allergy (rashes on both thighs)

History of Present Illness8 mos PTA,

inability to walk/stand; assisted on ADLs(+) urinary/bowel incontinence(+) bedsore (approximately 1 cm, sacral)(-) fever

History of Present Illness5 mos PTA,

consult was done at V. LunaA> t/c Decompression sicknessP> recompression x 10 session

However, pt opted to discontinue after the third session due to fear of dyspnea inside the vessel

History of Present Illness(+) consult at PGH OPD OrthoA> Pott’s diseaseP> workup and follow-up x 2 mos

History of Present Illness3 mos PTA,

admitted at Spine Unit, started on anti-TB medsco-managed by Rehab

1 mo PTA, s/p anterior decompression, debridement, fusion(C6-T2) with fibular strut graft (7/18/12)

Day of admission, admitted at Rehab Ward for further therapy

Review of Systems (present) (-) Cough, colds, fever (-) headache, blurring of vision, dizziness (-) chest pain, difficulty of breathing (-) changes in appetite (-) heat or cold intolerance, irritability (-) muscle or joint pain (-) penile pain, discomfort, erectile

dysfunction

Past Medical History(-) HPN, DM, BA, CA, previous hosp(-) PTB/Primary Complex(?) drug allergy

Family Medical History(+) HPN, father(+) BA, 5 siblings(+) DM, uncle(-) PTB

Personal and Social History(-) smoking, alcohol intake, illicit drug useBreadwinner of the familyWorks as fisherman(diver)Married, with 1 daughterFinished 2nd yr HS

Functional HistoryPreviously independent on ADLPreviously works as a fisherman (diving,

swimming)

Environmental HistoryLives in a 1-storey concrete houseSafe from falls

Current Physical ExamGeneral: awake, NICRDBP 110/60 HR 90 RR 18 T afebrileHEENT: AS, pink PC, (-) CLAD/NVE (+) surgical scar

on L neck to anterior chestChest/Lungs: DHS, (-) murmur/thrills/heaves

ECE, clear BS (-) rales/wheeze/rhonchiAbdomen: Flat, normoactive BS, (-)

masses/tendernessSkin/Extremities: FEP, pink NB, (-)

edema/cyanosis/jaundice (+) sacral ulcer, healed

Current Physical Exam Motor:

(R) (L) (R) (L) C5 5/5 5/5 L2 5/5 5/5 C6 5/5 5/5 L3 5/5 5/5 C7 5/5 5/5 L4 4/5 5/5 C8 5/5 5/5 L5 4/5 5/5 T1 5/5 5/5 S1 3/5 5/5 (Score 97)

Sensory:ASIA Sensory: pin prick light touch (R) (L) (R) (L) C5-L3 2/2 2/2 2/2 2/2 L3 1/2 1/2 1/2 1/2 L4 1/2 2/2 1/2 2/2 L5-S4 S5 2/2 2/2 2/2 2/2

P.E. on Admission & Course

Physical Examination on AdmissionGeneral Survey: Awake, coherent, not in cardiorespiratory distress

Vital signs: BP 100/70 HR 87 RR 20 T afebrile

HEENT: Anicteric sclerae, pink palpebral conjunctivae, no cervical lymph nodes, no tonsillopharyngeal congestion

Chest/Respiratory: Equal chest expansion, clear breath sounds, no thoracic spine deformity

Cardiovascular: Adynamic precordium, normal rate regular rhythm, distinct S1 & S2, no murmurs

Gastrointestinal: Flat abdomen, normoactive bowel sounds, no tenderness

Genitourinary: (+) weak sphincteric tone, (+) BCR

Physical Examination on Admission

Extremities: Full and equal pulses, no edema,(+) multiple pressure ulcers - sacral area, grade 2 with undermining(+) well healing pressure ulcer on right posterior auricular area, right shoulder(+) grade 1 ulcer on heel, bilateral; medial knee, bilateral; lateral malleolus, bilateral

Physical Examination on Admission

ASIA MotorRight Left

C5 5/5 5/5C6 5/5 5/5C7 4/5 4/5C8 3/5 3/5T1 3/5 3/5L2 2/5 2/5L3 2/5 2/5L4 3/5 3/5L5 3/5 3/5S1 3/5 4/5

Physical Examination on Admission

ASIA Sensory

Pin Prick Light TouchRight Left

C5-C7 2/2 2/2C8 2/2 1/2

T1-L2 2/2 2/2L3-S3 1/2 1/2S4-S5 1/2 1/2

Right LeftC5-C7 2/2 2/2

C8 2/2 1/2T1-L2 2/2 2/2L3-S3 1/2 1/2S4-S5 1/2 1/2

Physical Examination on Admission

Tone: (+) grade 1 – 1+ spasticity on both lower extremitiesDTRs: hyporeflexia on both lower extremities, (+) flexor spasm on both lower extremities(+) clonus(-) Babinski(-) Hoffman’s

Physical Examination on Admission

Laboratory Tests ESR and CRP: elevated Sputum AFB x 3: all negative All else normal

Imaging

Differential Diagnoses for Tetraparesis Trauma Tumors Infection Inflammatory Vascular Vertebral Disease Others

Radiographic differentiation

ImpressionTetraplegia secondary to multiple

compression deformity secondary to Pott’s disease (Asia D) NL: C6, AL: C6-T2, ML: C7, SL: C7

Neurogenic bowel and bladderNephrolithiasis, rightSacral decubitus ulcer, grade 2

Course in the Wards Upon Ward admission: - noted (+) flexor spasm 1-3x/hr upon

movement- able to tolerate sitting > 1 hr. during OT- fair sitting balance unsupported but cannot be totally challenged- still dependent in transition with sitting and transfer from bed- able to eat his dinner, can sit with brace on, independent with setup

Course in the WardsUnderwent PT exercises during the 1st month: Practiced transitions from supine to sitting

sit to stand Table tilt at 30o increasing by 15o

Standing with || bars with PKS on (B) knees, increasing in duration and number of reps || bars with one PKS || bars without PKS

Ambulating using walker with PKSusing BAC with 4 pt gait3 pt gait(B) Axillary crutches

Course in the Wards 8/27 – ASIA MMT: (R) (L) (R) (L) C5 5/5 5/5 L2 2/5 2/5 C6 5/5 5/5 L3 2/5 2/5 C7 4/5 4/5 L4 3/5 3/5 C8 3/5 3/5 L5 3/5 3/5 T1 3/5 3/5 S1 3/5 4/5 - ASIA Sensory: pin prick light touch (R) (L) (R) (L) C2-C7 2/2 2/2 2/2 2/2 C8 2/2 1/2 2/2 1/2 T1-L2 2/2 2/2 2/2 2/2 L3-S4 S5 1/2 1/2 1/2 1/2DTR: hyporeflexia on (B) LE (+) flexor spasm (B) LE pathologic reflexes: (+) clonus (-) Babinski (-) Hoffman

Course in the Wards 9/18 – (R) (L) (R) (L) C5 5/5 5/5 L2 4/5 4/5 C6 5/5 5/5 L3 4/5 4/5 C7 4/5 4/5 L4 4/5 4/5 C8 4/5 4/5 L5 3/5 4/5 T1 4/5 4/5 S1 4/5 4/5

(Score 8375)

- ASIA Sensory: maintained at Score of 97

Course in the WardsUnderwent PT exercises during the 2nd

month: Started stepping exercises Ambulating using BAC with 3 pt gait2

pt gaitBAC/3 pt. gait on level surface up/down stairs using BAC using quad cane Quad cane/3 pt. gait with ramp, stairs(B) axillary crutches Using Walker

Course in the Wards 9/26 – Fall while ambulating in bathroom (+) pain (R) lateral aspect of foot

- maintain MMT Score of 87 - ASIA Sensory: pin prick light touch (R) (L) (R) (L) C2-C7 2/2 2/2 2/2 2/2 C8 1/2 1/2 1/2 1/2 C9-L3 2/2 2/2 2/2 2/2 L4-S4 S5 1/2 1/2 1/2 1/2

A> Quadparesis and SCC secondary to Pott’s diseaseASIA D, NLC7 MLC7 SL C8AL: C6-T1, T4 T5 T8Sacral decubitus ulcer Gr 2Cystitis

Course in the Wards 10/2 – increase in flexor spasm/ankle clonus ~ (R) LE (R) (L) (R) (L) C5 5/5 5/5 L2 4/5 5/5 C6 5/5 5/5 L3 4/5 4/5 C7 5/5 5/5 L4 5/5 5/5 C8 5/5 5/5 L5 4/5 4/5 T1 4/5 4/5 S1 3/5 5/5 (Score 9187) - ASIA Sensory: pin prick light touch (R) (L) (R) (L) C2-C7 2/2 2/2 2/2 2/2 C8 2/2 1/2 2/2 1/2 C9-L3 2/2 2/2 2/2 2/2 L4-L5 1/2 1/2 1/2 1/2 S1-S4 S5 2/2 2/2 2/2 2/2 (Score 10797)

Course in the Wards 10/8 – ambulate on level surface with ramp using quad cane. Not Stairs

- increase in flexor spasm/ankle clonus ~ (R) LE (R) (L) (R) (L) C5 5/5 5/5 L2 5/5 5/5 C6 5/5 5/5 L3 5/5 5/5 C7 5/5 5/5 L4 4/5 5/5 C8 5/5 5/5 L5 4/5 5/5 T1 5/5 5/5 S1 3/5 5/5 (Score 9791) - ASIA Sensory: pin prick light touch (R) (L) (R) (L) C5-L3 2/2 2/2 2/2 2/2 L3 1/2 1/2 1/2 1/2 L4 1/2 2/2 1/2 2/2 L5-S4 S5 2/2 2/2 2/2 2/2

Course in the Wards 10/21 – ambulate using walker

- able to do vocational training- (+) flexor and bladder spasm on CMG

10/24 – ambulate using walker- still with weakness of (R) plantar flexion

10/27 – still with poor proprioception of (B) feet

Problem Listo Medical

s/p ADDTSCC sec to Pott’s Disease C7-T1Neurogenic Bladder

o Altered Body FunctionTetraparesisSensory impairment below C8Grade I spasticity of bilateral LEPoor proprioception

Pott’s Disease Secondary to an extraspinal source of

infection. Osteomyelitis + arthritis. Anterior aspect of the vertebral body

adjacent to the subchondral plate: usual site

Spreads to adjacent intervertebral disks. Adults: spreads from the vertebral body. Children: primary site (disk highly vascuarized)

Pott’s Disease Vertebral collapse and kyphosis, narrowed

spinal canal, cord compression Kyphotic deformity: anterior spine collapse

(thoracic > lumbar) Cervical: minimal collapse Healing: gradual fibrosis and granulomatous

tuberculous tissue calcification Paravertebral abscess formation is common

(Lumbar-psoas fascial sheath; Thoracic-anterior chest wall, parasternal area)

LesionThe lesion could be: Florid - invasive and destructive lesion Non destructive Encysted disease Carries sicca Hypertrophied Periosteal lesion

2 Patterns Classic: spondylodiscitis (SPD) Atypical: spondylitis without disk

involvement (SPwD); more common pattern of spinal TB

Regional Distribution 1 Cervical 12%

2 Cervicodorsal 5%

3 Dorsal 42%

4 Dorsolumbar 12%

5 Lumbar 26%

6 Lumbosacral 3%

Anatomical1. Paradiscal - destruction

of adjacent end plates and diminution of disc space.

2. Appendeceal (Posterior) - involvement of pedicles, laminae, spinous process.

3. Central - Cystic or lytic, concertina collapse.

4. Anterior –longitudinal lig, Aneurysmal phenomenon

5. Synovitis in posterior facet

History Presentation depends on:

Stage of disease Site Presence of complications such as neurologic

deficits, abscesses, or sinus tracts On diagnosis, already with the disease for 3-

4 mos. Back pain- earliest and most common

symptom, can be spinal or radicular Constitutional symptoms (fever and weight

loss)

50% with neurologic abnormalities (spinal cord compression with paraplegia, paresis, impaired sensation, nerve root pain, or cauda equina syndrome)

If cervical, can present with pain and stiffness, dysphagia or stridor, torticollis, hoarseness, and neurologic deficits.

HIV positive > HIV negative patients

History

Pott’s on ImagingXRAY Signs of infection with lytic

lucencies in anterior portion of vertebrae

Disk space narrowing Erosions of the endplate Sclerosis resulting from chronic

infection Compression fracture Continuous vertebral body

collapse Kyphosis; gibbous (severe

kyphosis)

CT scan Soft tissue

findings: abscess with calcification is diagnostic of spinal TB

Pattern and severity: framentary, osteolytic, localized and sclerotic, and subperiosteal

Complications of tuberculosis1. Paraplegia 2. Cold abscess3. Sinuses4. Secondary infection5. Amyloid disease6. Fatality

Surgical indications1. No sign of neurologic recovery after trial of

3-4 weeks therapy2. Neurologic complication during treatment3. Neurologic deficit becoming worse4. Recurrence of neurologic complication5. Prevertebral cervical abscesses, neurological

signs, & difficulty in deglutition & respiration6. Advanced cases: sphincter involvement,

flaccid paralysis, severe flexor spasms

Other indications Recurrent paraplegia Painful paraplegia– d/t root compression,

etc Posterior spinal disease--involving the

post elements of vertebrae Spinal tumor syndrome resulting in cord

compression Rapid onset paraplegia due to thrombosis,

trauma, etc. Severe paraplegia econdary to cervical

disease and cauda equina paralysis

1 Decompression +/- fusion

Failed response,Too advanced

2 Debridement+/- fusion Failed response after 3-6 months, doubtful diagnosis, instability

3 Debridement +/-DECOMP+/- fusion

Recrudescence of disease

4 Debridement+/- fusion Prevent severe kyphosis

5 Anterior transpostion Severe kyphosis + neural deficit

6 Laminectomy STS, secondary stenosis, posterior disease

Problem List

Medical ProblemsSpinal cord compressionNeurogenic bowelNeurogenic bladderPressure ulcers

(Possible) Medical Problems Cardiovascular complications

Hypertension Deep vein thrombosis and Pulmonary

embolism Orthostatic hypotension Cardiac arrhythmia

Pulmonary complications Musculoskeletal complications

Osteoporosis Fractures Heterotrophic Ossification

Altered Body Structure and Function

Bilateral LE paresis Bilateral LE loss of sensation Neurogenic bladder Neurogenic bowel Pressure sores Sexual dysfunction and possible loss of

sexual desire Possible MSK, cardiovascular and

pulmonary complications

Limitations in Activities of Daily Living

Independence in feeding Dependence in self-care ADLs

Bathing Grooming Dressing up

Dependence in ambulation and transfers

Poor sexual activity

Limitations in Instrumental Activities Independence

Communication (cellphones, etc.) Entertainment (watching TV, etc.)

Difficulty in child-rearing Cannot anymore drive his motorcycle

Limitations in Participation Inability to return to previous job Difficulty in finding another job Difficulty in community ambulation

Long-term Goals To treat the underlying cause of the SCI

Spinal TB To implement acceptable bowel and

bladder management programs To address pressure ulcers and maintain

skin integrity

Long-term Goals To maintain socially acceptable bladder and

fecal continence To prevent possible complications of neurogenic

bladder and bowel To prevent and treat accordingly the

complications that may arise from the thoracic-level SCI

To minimize the functional limitations and allow the patient to complete ADLs independently or with assistive equipment

Management of Spinal Cord Injury and Its Various Complications

Neurogenic Bladder When pathologic CNS/PNS conditions

cause disruption of the nerve control to the urinary bladder, causing urinary retention and/or urinary incontinence

Bladder InnervationPelvic Nerves Parasympathetic signals from S2-S3 segments to the

detrusor muscles for bladder emptying/voiding

Hypogastric Nerves Sympathetic signals from T11-L2 segments for bladder

filling/storage

Pudendal Nerves Somatic nerve fibers from S3-4 segments to voluntary

skeletal muscles & external sphincter

Management Goals To prevent urinary tract infections and

other long-term urologic sequelae To maintain a socially acceptable

bladder continence by developing and implementing a

bladder management program that will allow patient to reintegrate back into the community

Medical/Pharmacologic Management Targeting the autonomic receptors For urinary retention

Cholinergics (for detrusor contraction) Alpha receptor antagonists (for sphincter

relaxation) For urinary incontinence

Anticholinergics ( for detrusor relaxation) Alpha receptor agonists (for sphincter contraction)

Behavioral/Non-Pharmacologic Management Catheterization programs

Independent intermittent catheterization every 4 to 6 hours, if the patient has preserved hand function and does not have UTI

Limitation of fluid intake Timed voiding

Schedule voiding Use of a voiding diary

Behavioral/Non-Pharmacologic Management Bladder training programs Maneuvers

Valsalva maneuver, suprapubic application of pressure

Use of appliances Condom, foley, straight catheters

Surgical ManagementWhen the mentioned medical and behavioral strategies fail… Augmentation cystoplasty Artificial sphincter Sphincterotomy Pudendal neurectomy Bladder outlet surgery Balloon dilatation Interruption of innervation Neurostimulation

Neurogenic Bowel When pathologic CNS/PNS conditions

cause disruption of the bowel innervation, causing stool incontinence (lax anal sphincter) and constipation (disrupted parasympathetic supply)

Management Goals To achieve socially acceptable fecal

incontinence Prevention of gastrointestinal

complications Fecal impaction (most common)

Medical/Pharmacologic Management Stool softeners (e.g. docusate sodium) Colonic stimulants (e.g. senna) Colonic irritants (e.g. glycerin,

bisacodyl) Prokinetic agents (e.g. metoclopramide) Rectal suppositories Oral medications

Behavioral/Non-Pharmacologic Management

Timed/regular bowel movement Taking advantage of the gastrocolic reflex

(about 30-60 minutes after meal) Dietary modification

High fiber diet Increased fluid intake

Digital stimulation Manual extraction

Surgical Management Colostomy/ileostomy

Decreases time required for bowel management

Increases independence

Pressure Sores Stages of pressure sores/ulcers (NPUAP)

Stage I : Nonblanchable erythema not resolved within 30 minutes (epidermis intact)

Stage II : Partial thickness skin loss; blisters with erythema, abrasion, shallow ulcer (possibly into dermis)

Stage III: Full-thickness destruction of the skin; deep crater (into subcutaneous tissue)

Stage IV: Full-thickness skin loss with deep-tissue destruction (up to fascia, muscle, bone, joint)

Pressure Sores Management:

Wound cleansing with plain NSS Debridement Wound dressing Topical antibiotics (e.g. Flammazine) Wound Care Modalities

Whirlpool therapy, UV light, ultrasound Surgery

skin grafts and skin flaps

Pressure Sores Prevention:

Egg mattress Proper turning frequency (at least

every 2 hours) Adequate cushioning (e.g. surgical

gloves with water)

Others Osteoporosis Fractures Heterotopic ossification Pulmonary complications Hypertension and coronary artery disease Deep vein thrombosis Orthostatic hypotension Cardiac arrhythmia Sexual dysfunction Depression

Functional Rehabilitation Focuses on helping the patient to function at optimal

levels Supervised PT and OT to improve strength in all active

muscle groups and ROM in all joints Adaptive equipment

Long-handled shoehorns Reachers Ambulation equipment

Low-back wheelchairs are feasible because patients with lower-level SCIs have better truncal stability.

Thank You!