SPONDYLITIS TUBERCULOSA

PARAPLEGY DUE TO BURST FRACTURE ON VERTEBRAE 12th THORACAL, COMPRESSION FRACTURE ON VERTEBRAE 3rd LUMBAL

Presented by:Paramitha Rizky C111 08 113Advisor :dr. Ariesdr. Luthfi

Department Of Orthopaedic and TraumatologyFaculty Of Medicine Hasanuddin University Makassar 2014Supervisor: Dr. dr. Karya Triko Biakto, Sp. OT (K) SpinePATIENT IDENTITYName:Mrs. NAge:42 years oldAdmission Date:July 24th 2014Registration Number:673278HISTORY TAKINGChief Complaint : cannot move on both legsAnamnesis :Suffered since 5 days before admitted to the hospital, after fall from tree with height about 5 meter in the sitting position. Shortly after fall, both legs cant be moved and numbness from thigh to the feet. The patient unable to stand, sit and walk. There is no loss of consciousness, nausea, and vomiting.Urinary and defecation were incontinensia.

PHYSICAL EXAMINATION General Status well nourished / conscious Vital SignBP: 120/70 mmHgHR: 80 times/minuteRR: 20 times/minuteT : 36.7 CPHYSICAL EXAMINATIONHead region: anemia (-), icteric (-), cyanosis(-)Neck region: thyroid enlargement (-), nodule (-), tenderness (-)Thorax region: breath sounds : vesicular additional sounds : Rh: -/-, Wh: -/-Heart region: heart sounds: S1-S2 normal, regular, murmur (-)Abdomen region: peristaltic (+), tympani, H/L palpable (-)Extremities region: warm, swelling (-)

PHYSICAL EXAMINATIONVERTEBRAL REGIONInspectionDeformity (+), hematoma (-), swelling (-), wound (-), skin lesion (+)

PalpationTenderness (+) as level Th 11 , step off (-)CLINICAL PICTURES

7MOTOR FUNCTION EXAMINATION

SCORING555555555550000000000We now entering the neurologic examination.the score for the upper extremities strength were 5 which is normal and the score for the lower extremities strength were below 5, so we can say that there is a weakness of the lower extremeties of this patient.8

2222222222222222222222222222222222222222222222222222222222222222100000000222210000000022221000000002222100000000From sensoric examination, we devide the examination by doing light touch and pin prick. The result of this examination shows the decrease of sensebility on level CV L1 to S4-5, so the patient experienced the decrease of sensitivity from inguinal to his feet

9REFLEXESSacral exam: voluntary anal contraction: absent

LABORATORY FINDINGRBC : 4,26 x 10^3/LHGB: 10,8 g/dlWBC: 6,1 x 10^3/LPLT: 125 x 10^3/LGDS : 103 mg/dlUr/Cr: 39/0,6SGOT: 25 U/lSGPT: 22 U/l

RADIOLOGY FINDING

Chest x-ray

Chest x-ray PA View shows : Lung within normal limit. Cardiomegaly and dilatation et elongatio aortae

12RADIOLOGY FINDING

Thoracolumbalx-ray

13RADIOLOGY FINDING

ThoracolumbalCT Scan

14RADIOLOGY FINDING

ThoracolumbalCT Scan

15RESUME, 42 y o came to the hospital with paraplegy on both legs that suffered since 5 days before admitted to the hospital, after fall from tree with height about 5 meter in the sitting position. Physical examination well nourished and vital sign within normal limit.The motor power in the right and left lower limb was 0.Hipostesia was found at the both of lower limbs area L1Anesthesia was found at the both of lower limbs area (below L2).Physiologic reflex were decrease on KPR and APRRadiological findings there was burst fracture on vertebrae 12th thoracal, compression fracture 3rd lumbal.

DIAGNOSISParaplegy due to burst fracture on vertebrae 12th thoracal, compression fracture vertebrae 3rd lumbalMANAGEMENTOperativePlan for decompression and posterior stabilization

DISCUSSION

THORACOLUMBAL INJURYANATOMY OF THE SPINE

Seeley Stephen. Anatomy and Physiology, 6th Edition. The McGraw-Hill Companies, 2004.*gambar 1*The normal anatomy of the spine is usually described by dividing up the spine into 3 major sections: the cervical, thethoracic, and the lumbarspine. Each section is made up of individual bones calledvertebrae. There are 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae.

*gambar 2&3*The vertebrae are separated by intervertebraldiscs which act as cushions between the bones. An individual vertebra is made up of several parts. Thebodyof the vertebra is the primary area of weight bearing and provides a resting place for the fibrous discs which separate each of the vertebrae. 20Thompson JC. Spine. In: Thompson JC, editor. Netters Concise Orthopaedic Anatomy. Second ed. China: Saunders Elsevier 2010. p. 29-74.

Damage to the neural elements due to trauma or disease resulting in neurological deficit.paralysisloss of sensationloss of body reflexes, micturation & defecation.

Solomon Louis. Apley, System of Orthopaedics and Fractures. 9th Edition. Butterworths Medical Publications. 201022Mechanism of InjuryA. Axial compression forces usually result in compression or burst fractures. B. Flexion forces may result in compression or burst fractures or, if the force is severe, Chance injuries. C. Lateral compression forces usually result in lateral wedge fractures, which are asymmetric compression and burst fractures. D. Shear forces tend to produce unstable injuries such as fracture-dislocations. E. Extension forces usually cause injuries in ankylosed spines but occasionally may cause injuries in patients with normal spinal anatomy. F. Flexion-distraction combined forces cause Chance fractures and Chance variant injuries. G. Flexion-rotation forces cause a variety of fracture patterns involving vertebral body fracture and disruption of the posterior elements.Eisenstein S, Tuli S, Govender S. The Back. In: Solomon L, Warwick D, Nayagam S, editors. Apley's System of Orthopaedics and Fractures. Ninth ed. London: Hodder Arnold an Hachette UK Company; 2010. p. 453-91.Denis Classification, 1983

The three columns of the spine, as proposed by Francis Denis. The anterior column (A) consists of the anterior longitudinal ligament, anterior part of the vertebral body, and the anterior portion of the annulus fibrosis. The middle column (B) consists of the posterior longitudinal ligament, posterior part of the vertebral body, and posterior portion of the annulus. The posterior column (C) consists of the bony and ligamentous posterior elements. (Modified from Denis F. The three-column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine 1983;8:817831.) Kenneth A.Egol, Kenneth J.Koval, Joseph D. Open fracture in: Handbook of Fracture, Fourth edition, chapter 3. USA: Lippincot Williams & Wilkins.2010Specific Injury of ThoracolumbalCompressionBurstFlexion-distraction injury ( Chance Fractures)Fracture-dislocation

Eisenstein S, Tuli S, Govender S. The Back. In: Solomon L, Warwick D, Nayagam S, editors. Apley's System of Orthopaedics and Fractures. Ninth ed. London: Hodder Arnold an Hachette UK Company; 2010. p. 453-91.

Eisenstein S, Tuli S, Govender S. The Back. In: Solomon L, Warwick D, Nayagam S, editors. Apley's System of Orthopaedics and Fractures. Ninth ed. London: Hodder Arnold an Hachette UK Company; 2010. p. 453-91.

Hyper flexion or compressive failureAnterior columnStable injury

CompressionEisenstein S, Tuli S, Govender S. The Back. In: Solomon L, Warwick D, Nayagam S, editors. Apley's System of Orthopaedics and Fractures. Ninth ed. London: Hodder Arnold an Hachette UK Company; 2010. p. 453-91.

Failure of anterior and middle columnsPredominantly axial loadNo posterior column disruptionStable injuries< 50% retropulsion