Paraplegia a textbook case

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