Department Of Orthopaedics&Traumatology.SheedSuhrawardyMedical College Hospital, Dhaka-1207, Bangladesh.

Case Presentation-

From -

“A patient with gradual walking impairment”

Presenting By- Dr. GolamMahamud Suhash,From Department of Orthopedic & Traumatology, Shaheed Suhrawardy Medical College Hospital, Dhaka-1207. Bangladesh.

Prepared By-Dr. Md Nazrul IslamMBBS, M . sc. (B M E).

“A patient with gradual walking impairment”

PARTICULARS OF THE PATIENT

• Name- Mr. Ali Akbar• Age- 57 Years• Sex- Male• Occupation- govt.

Service Holder• Address- B-14,G-

8,Agargong• Date of Admission -

20/10/2009.

CHIEF COMPLAINTS

• Weakness of left leg – one & half months.

• Unable to walk – one & half months.

• Evening rise of temperature – one & half months.

HISTORYOF PRESENT ILLNESS

Mr. Ali Akber was alright – two & half months back.

Then he noticed gradual weakness of his left leg which lead him initially only to able to stand and walk for about 1-2 min. with help.

After 2-3 days, he can only able to stand only but fails to walk.

HISTORYOF PRESENT ILLNESS(continues)

He also complains of evening rise of temperature for the same duration lasting for about 4-5 hours that relived spontaneously followed by sweating.He denied any H/O trauma, heavy weight lifting or abnormal jerking. Patient is Asthmatic, but free from Hypertension and Diabetes. His bowel and bladder habit is normal

HISTORY OF PAST ILLNESS

• History of low back pain for last 7-8 years. History of pleural effusion – 7 years back. He is asthmatic and hypertensive but non diabetic.

• No history of exposure of TB case. • Family History- Nothing Contributory.• Socioeconomic History- Middle class

family.• Personal History-Patient is non

alcoholic/smoker.• Drug History: (At present continuing) - Tab. Diola, Tab. Bukof, Tab. Contin,

Salmolin inhaler, Anti TB ( For 6 weeks) .

• Immunization History- Patient is properly Immunized.

PHYSICAL EXAMINATION

General Examination• Appearance – Normal.• Cooperation –

Cooperative.• Mental Status –

Intelligent.• Decubitus – Lying.• Body Build – Average.• Skin Condition – Normal.• Hair Distribution –

Normal.• Anemia – Absent• Jaundice – Absent• Cyanosis – Absent.

General Examination( Continues)

Clubbing – AbsentTemperature - 98°FPulse – 82/ min.BP – 140/80mm/HgLymph node – • Cervical• Axillary• Inguinal • Para-aortic• Others.

General Examination

Not

Pal

pab

le

LOCAL EXAMINATION

LOOK – Bulging in the middle

of Lumber spine. No scar mark, discharging sinus or pigmentation.

FEEL – Overlying skin is free.

Fullness of mid Lumber region with spasm. Size - about 2cm×2cm.

MOVE – Flexion Extension Lateral bending

Pain

ful

SYSTEMIC EXAMINATION

Locomotors system:

Gait:- Unable to walk. Limb Joints :- Normal. Spinal movement: Restricted & Painful. Deformity:-Absent .

SYSTEMIC EXAMINATION

Nervous System

Motor Assessment:ROM:SLR – Lt 30 dreg,Rt 60 dregPower of muscle: Lt-2/5,Rt-4/5Tone: Decreased at Lt lower limb.Bulk: NormalSensory: All sensory response at L5 & S1 reduced on left leg., and on right side intact.

SYSTEMIC EXAMINATION(Continues)

Reflexes: Planter- Bilaterally Flexor. Ankle jerk : Left -

diminished Right -normal Knee jerk: Left - normal. Right- normal. Clonus: Absent.

SYSTEMIC EXAMINATION(Continues)

Patient has been suffering from asthma over the past few years, but continues to keep well by proper medical management.

Respiratory System:

SYSTEMIC EXAMINATION(Continues)

•Cardiovascular System : NAD.

•GI System : NAD.•Genito-Urinary System : NAD.

Other Systems:

Salient feature

Mr. Ali Akbor aged 57 admitted on 20/10/09 with the complaints of Weakness of left leg – Two & half months, Evening rise of temperature – and half months, Unable to walk – one & half months.He had no H/O trauma, heavy weight lifting or abnormal jerking. His bowel and bladder habit is normal. Muscle power at left side is 2/5, reduced sensation at L5 & S1. ROM:SLR – Lt. 30 dreg, Rt. 60 deg. Tone: Decreased at Lt lower limb. Ankle jerk is diminished.

DIFFERENTIAL DIAGNOSIS

• Pyogenic Infection• ProlapseIntervertebralD

isc (PLID)• Primary Bone Tumor• Secondary Bone Tumor.• Pot's disease.

INVESTIGATION

CBC - Hb%: 12 gm/dlESR : 120mm/1sthourTotal Count of WBC:11000/cmmDifferential Count of WBC:

N-62%L- 35%E-02%M-01%

RBS : 13.6mg/dl

General

INVESTIGATION( Continues)GENERAL

Urine for R/M/E:RBC : nil/HPFPus cell : 01-03/HPFEpithelial cell:

2-3/HPFS. Creatinine :1.2mg/dlChest X-ray :NormalECG : Normal ECG

findingUSG of whole abdomen:

No itraabdominallymphadenopathy.

Specific investigation

MT: 18mm Anti TB IgG, IgM, IgA:

Positive

X-ray L-S- spine both view:

Disc space between L4 & L5 and L5&S1 is reduced with destruction of adjacent end plate. No obvious Para vertebral soft tissue swelling is noted.

SPECIFIC INVESTIGATION

MRI:

Tubercular spondylitis at L4 &L5 level with peri-vertebral mass.Vertebral posterior bulging causing indentation of thecal sac.Disc space between L5 & S1 is reduced.Rt. Para-vertebral abscess .

DIAGNOSIS -

(Pot's Disease).

Spinal Tuberculosis

Management Objective of Treatment-

• To eradicate or at least arrest the disease.

• To prevent or correct deformity.

• To prevent or treat the major complication.

For this patient the choice of Treatment is Operative(Clearance & Spinal fixation) adjunctive to Chemotherapy.

(Chemotherapy include –

Initially four drugs combination(Rifampicin + INH + Ethambutol + Pyrazinamide) – 2 months.

Followed by- Two drugs combination-Rifampicin + INH ) for 12 to 14 months.)

Management(Cont.)

•Conservative Management failure.

•Progressive Neurological deficit.•Persistent neurological deficit.•Progressive enlargement of

abscess.•Decompression of large abscess.

Indication for operation

Management(Cont.)

Drainage of abscess.Decompression and scraping of infected lesion.Decompression with bone graft.In presence of deformity- Correction of deformity and stabilization by internal fixation and fusion.

Management(Cont.)

Types of Surgery-

Management(Cont.)

Management(Cont.)

Management(Cont.)

Management(Cont.)

Other treatment modalities

Medical Management-• Continuous bed rest with

chemotherapy.• Ambulant with chemotherapy• Ambulant, Chemotherapy with

spinal brace.Operative treatment-• Naked eye per-operative

appearance - Para-vertebral abscess which

is to be drained. With courtesy : Dr. Sk. Abbas uddin Ahmed.

Management(Cont.)

Cautious movement. Continue medical treatment according to prescription. 3 months interval follow up.

Management(Cont.)

Special thanks are due to –

Dr. (Associate Professor)Sheikh Abbas Uddin Ahmed,

&Dr. Subir Hossain for their nice co-operation.

Orthopedics & Traumatology Department, Shaheed Suhrawardy Medical College and Hospital, Dhaka- 1207, Bangladesh.

Thank you very much For Patience.