Post on 07-May-2015
description
PARAPLEGIAA TEXTBOOK CASE
Chair:- Prof. Dr. Baby PaulPresenter: Dr.Shybin Usman
STRIKE ONE
Mr. Gopakumar, 28 years from Neyyatinkara.Working in the BSF & posted in Bengal.Developed a nagging backache.Admitted in a local hospital near his base on
17/10/07.D/D on 20/10/07 as he was better.
STRIKE TWOBackache was back by 23/10/07.Shooting pain radiating from back to
umbilicus.Noticed gradually developing weakness of
both lower limbs.Admitted from 23/10/07 to 31/10/07.Symptoms grew worse and he got on the next
train home.
STRIKE THREE
Reached here on 3/11/07.Weakness of lower limbs was complete.Had lost all sensation in both lower limbs.In the final day of journey high grade fever set
in.Backache was very severe with difficulty in
lying on his back.
SNIPPETS
No significant medical past history.H/o haemorrhoidectomy 7 years ago.Occasional alcoholic.Non smoker.
PRESENTING PICTUREModerately built and nourished.Concious and oriented.Febrile.No PICCLE, conjunctival congestion.Chest – Clear.CVS – WNL.Abdomen – Bladder distended.Spine - Tenderness at D12 spine.
NEUROLOGIC DEFICITS
Grade 0 power both LL.Reflexes totally absent below the level of
umbilicus.Sensations totally absent below the level of
umbilicus.Bladder was distended.Rest of the nervous system examination was
normal.
INVESTIGATIONSHb-11.4, TC-22700, N82 P15 E3, ESR-76.RBS-113.B.Urea- 62, S.Creat- 0.9 Na⁺- 139, K⁺-3.9Bili- 1.4(T)/0.5(D), SGOT- 112, SGPT- 222, ALP-156 Prot- 6.0, S.Alb- 2.6APTT- 31 sec, INR- 1.2
PRIMA FACIE
ACUTE TRANSVERSE MYELOPATHYwith
SPINAL SHOCK
SUSPECTS
Pott’s spineSpinal extradural tumour with bleedTransverse myelitisEpidural abscessIVDP
MRI SPINE
Diffuse posterior dorsal epidural abscess with spinal cord compression.
Altered spinal cord signal intensity s/o edema.Multiple vertebral body (D12,L4,L5,S1)
destruction with involvement of posterior elements & abscess formation.
Extensive paravertebral & iliopsoas abscess formation.
FINAL DIAGNOSIS
SPINAL EPIDURAL ABSCESS
EPILOGUE
Patient was handed over to the NS1 unit of the Dept.of Neurosurgery for further
management on 6/11/07.He underwent posterior decompression with posterior decompression with
abscess evacuationabscess evacuation on 13/11/07.
INNARDSHistopathology report:-
Section shows fragments of a lesion composed of numerous granulomas composed of epitheloid cells, multinucleated giant cells of Langhans type & inflammatory cells composed of mainly lymphocytes & also neutrophils. Areas show extensive caseation necrosis. The inflammatory infiltrate seems to invade the adjacent adipose tissue.
Caseating granulomatous inflammatory lesion consistent with Tuberculosis.
FOOTNOTE
Patient was put on daily regimen of ATT.
He bettered during the rest of his hospital stay.
He was discharged on 21/11/07 with grade 1+ power in both LL.
SPINAL EPIDURAL ABSCESS
AN OVERVIEW
Remains a challenging problem that often eludes diagnosis and receives suboptimal
treatment.
Vague symptomatology & non-specific clinical findings in the early stages can make diagnosis
difficult.
AETIOLOGY
Predisposing factors:-• Underlying disease (DM, alcoholism, HIV, etc)• Spinal abnormality/intervention (Joint degeneration, Sx)• Source of infection- local/systemic
Mode of spread:-• Hematogenous- 50% cases• Contiguous- 33% cases• Rest- unknown
• Abscess can spread locally or via bloodstream
ORGANISMS
Staph. aureus- 67% MRSA on the increaseS.epidermidis (invasive procedure)E.coli (UTI)P.aeruginosa (iv drug abuse)Rare- Actinomycetes, Nocardia, Mycobacteria,
Fungi.
COURSE OF DISEASESTAGE I- Pain @ affected spine(s)
STAGE II- Nerve root pain from involved area
STAGE III- Motor weakness, sensory deficit, bowel & bladder dysfunction.
STAGE IV- Paralysis
CLINICAL FEATURES
CLASSIC TRIAD (infrequently seen):-• Back pain- 75% pts• Fever- 50% pts• Neurologic deficit- 33% pts (pattern depends on site)
Duration & progression of symptoms vary widelySource of infection may be identifiable
SITES
More in infection-prone fat & larger epidural spaces
Posterior > Anterior Thoracolumbar > CervicalUsually span 3-4 vertebraeCan involve the whole spine- Panspinal
infection
DIAGNOSISClinical features + clinical findings + lab data +
investigation + high degree of suspicionLab data (not specific):-• Leukocytosis- 66%• CRP & ESR increased- almost 100%• Bacterimia- 60%• CSF (mostly)- Protein ↑, Glucose N Leukocytosis (neutro+lympho) Gram stain- neg
Culture- CSF +ve 25% (= Blood +ve 100%)
INVESTIGATIONS
LP to be avoided:- Not much helpful Meningitis Subdural infection Neurologic deterioration if below complete block
X-ray spine- Narrowed disc space Bone lysis
CT myelography- 90% specific, but unadvisable
IMAGING MODALITY OF CHOICE
MRI + Gadolinium (best)Less invasiveDelineates lesion bestDiff b/w infection & tumours
DIFFERENTIALSMeningitisTransverse myelitis Spinal tumourSpinal hematomaOsteomyelitis of vertebraeDiskitisIVDPDegenerative joint diseaseDemyelinating illnessSepsis
TREATMENT
Surgical- Decompression laminectomy and debridement. (Rate of progress of symptoms cannot be predicted. Sx as early as possible)
Appropriate systemic antibiotics (min 6 weeks)
Emperical- Vancomycin + 3rd /4th gen Cephalosporin MSSA- Cefazolin/Naficillin
MONITORINGNeurological status (esp. antibiotic only)-
Deterioration – Extension/incomplete evacuation
Signs of sepsis
Repeat imaging (esp. antibiotic only)
PROGNOSIS
Best predictor of post-op final neurologic outcome is pre-op neurologic status.
Paralysis of <24-36 hrs= better prognosis.
Recovery can continue till about 1 year.
COMPLICATIONS
Irreversible paralysis Bladder dysfunctionDecubitiSupine hypertensionRecurrent sepsis
THANK YOU