Upload
james-hazelrigg
View
217
Download
0
Embed Size (px)
Citation preview
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 Admission
General 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 5/5
C6 5/5 5/5
C7 4/5 4/5
C8 3/5 3/5
T1 3/5 3/5
L2 2/5 2/5
L3 2/5 2/5
L4 3/5 3/5
L5 3/5 3/5
S1 3/5 4/5
Physical Examination on Admission
ASIA Sensory
Pin Prick Light Touch
Right Left
C5-C7 2/2 2/2
C8 2/2 1/2
T1-L2 2/2 2/2
L3-S3 1/2 1/2
S4-S5 1/2 1/2
Right Left
C5-C7 2/2 2/2
C8 2/2 1/2
T1-L2 2/2 2/2
L3-S3 1/2 1/2
S4-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!