CNS CASE

Dr CHERIAN THAMPY

HISTORY

• 27 year old male patient left handed individual TV technician by occupation from vellore came with complaints of

Chief complaints

• DIFFICULTY IN USING BOTH LOWER LIMBS-5 MONTHS

• REDUCED SENSATIONS IN BOTH LEGS -4 MONTHS

HOPI

• Apparently normal patient 5 months back noticed difficulty in using both the lower limbs. Initially he noticed weakness in the LT leg in the form that when he was trying to climb a bus he had difficulty in in raising the LT leg,He also had difficulty in climbing up and down stairs, getting up from squatting position.

CONT…

• But he was able to walk witdifficulty.(Supporting the wall)

• After 3 days he noticed difficulty in gripping chappals and to walk with chappals in both lower limbs.

• After 15 days he noticed similar weakness in the right leg also.

• Both his upper limbs were normal.He was able to lift his head from the pillow and to get up from the lying position.

• After 15 days he developed numbness and burning sensation below the umbilicus initially in the lt side ,he had a feeling of walking over cotton,he had difficulty in feeling his clothes and to differentiate hot and cold water below umbilicus.same thing progressed to rt side also in 10 days.

• He had feeling of tightness of both his lower limbs.

• No H/O any band like sensations• Walking difficulty was not increasing in dark.• No h/o back pain or electric shock like

sensations.• No h/o involuntry movements.

• No h/o altered sensorium,no h/o disorientation.

• He was able to perceive the smell normally• He was able to read the news paper• No h/o double vision• No h/o reduced sensations over face and he

was able to chew the food.

• He was able to close the eyes and no h/o deviation of ankle of mouth or drooling of saliva.

• He was able to hear properly, no vertigo• No h/o dysphagia,nasal regurgitation• No h/o dysarthria

• He was able to feel the sensation of the bladder, initiate and control micturiation and completely evacuate the bladder. No frequency or urgency

• No h/o bowel incontinence, constipation.• No h/o any altered sweating pattern or

erectile dysfunction.

• No h/o fever, headace,seizures• No h/o weight loss• No h/o skin rashes• No h/o trauma• No h/o spinal anaesthesia • No h/o recent vaccination

• He was admitted in a hospital and he was told that he had some compression of the nerves, and he underwent a surgery.

• He underwent anterolateral decompression and excision of posteriolateral portion of vertebral body and the disc.

• His motor symptoms worsened after surgery as he was not able to get up the bed or sit.He was not able to raise both his lower limbs.His tightness over both the lower limbs increased.

• After surgery there was mild improvement in sensory symptoms as he was able to feel the sensations.he was able to feel his clothes,differntiate hot and cold water.Sensory symtoms slowly improved in 3 months

• He was catheterised from the day of surgery.• Bowel incontinance present after surgery.

Past history

• No h/o DM,HTN,BA,TB• h/o chicken pox in 2002• No similar history in the past• No h/o surgeries in the past other than the

present surgery.

Personal history

• Not an alcoholic,smoker• Mixed diet• Sleep normal• Bowel incontinence present• Bladder is catheterised

Family history

• No similar history In the family• Born out of non consanguineous marriage• He is not married

Treatment history

• Taken siddha medications for the same• Surgery done as previously mentioned

History summary

• 27 year old male patient with no comorbidities ,no h/o trauma presented with sub acute to chronic paraplegia started asymmtrically associated with b/l sensory involvement below umbilicus ,with no cranial nerve and autonomic involvement.For which he underwent surgery and post surgery there is worsening of motor symptoms and autonomic symptoms.

History diagnosis

• Tracts involved-corticospinal tract anterior and lat spinothalamic posterior coloumnMostly extramedullary compressive myelopathy at

T10 levelEtiology –to consider both intra and extradural causes

like neurofibroma/meningioma/av malformation. extradural-potts spine,ivdp

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GPE

• PATIENT CONSCIOUS AND ORIENTED• NO PALLOR,ICTERUS,CYANOSIS,CLUBBING• AFEBRILE• PR-90/MIN• BP-110/70MMHg in RT UL IN SUPINE POSITION• RR-18/MIN• NO NEUROCUTANEOUS MARKERS• BED SORES PRESENT IN RT GLUTEAL REGION• SURGICAL SCAR PRESENT LEFT CHEST WALL FROM THE 5TH

ICSGOING POSTERIORLY AND HIGHEST POINT ENDING AT D6 LEVEL.

HMF

• MINI MENTAL SCORE-30/30• NO APHASIA,NO DYSARTHRIA• MEMMORY NORMAL• NO DELUSIONS,HALLUCINATIONS

CRANIAL NERVE RIGHT LEFTOLFACTORY.N NORMAL NORMAL

OPTIC.NVISUAL ACUITYFIELD OF VISIONCOLOUR VISIONFUNDUS

NORMAL NORMAL

OCCULOMOTOR.N/TROCHLEAR.N/ABDUCENT.N

SACCADES AND PERSUITSEOMPUPILREACTION TO LIGHT

NORMALNO PTOSIS

NO DIPLOPIAFULL,NO NYSTAGMUS3MM NORMAL

NORMALNO PTOSIS

NO DIPLOPIAFULL,NO NYSTAGMUS3MM NORMAL

TRIGEMINAL NSENSATIONS OVER FACECLENCHING TEETH,JAW MOVEMENTS ,JAW JERK

NORMAL NORMAL

FACIAL NTIGHT CLOSURE OF EYESFRONTAL FISSURESDEVIATION OF ANGLE OF MOUTHDROOLING OF SALIVANASOLABIAL FOLDHYPERACUSISLACRIMAL/NASAL/SALIVARY SECRETIONS

NORMAL NORMAL

VESTIBULO COCHLEAR.NRINNES TESTWEBER TESTABC TEST

AC >BC POSITIVENO LATERALISATIONNORMAL

AC >BC POSITIVENO LATERALISATIONNORMAL

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MOTOR SYSTEM

• NUTRITION-NO OBVIOUS WASTING,B/L SYMMTRICAL

• MEASURMENTS- RT LT• ARM 24cm 24cm • FOREARM 19cm 19cm • THIGH 49cm 49cm • LEG 27cm 27cm

TONE

RT LT

UL NORMAL NORMAL LL SPASTIC SPASTIC

POWER

RT LT

NECK - FLEXION GOOD EXTENSION GOOD SHOULDER-FLEXION 5/5 5/5 EXTENSION 5/5 5/5 ADD 5/5 5/5 ABD 5/5 5/5ELBOW -FLEXION 5/5 5/5 EXTENSION 5/5 5/5

RT LT WRIST -FLEXION 5/5 5/5 EXTENSION 5/5 5/5 HAND GRIP GOOD GOOD BEVORS SIGN - POSITIVE

RT LT HIP-FLEXION 0/5 0/5 EXTENSION 0/5 0/5 ABD 0/5 0/5 ADD 0/5 0/5 KNEE-FLESION 0/5 0/5 EXTENSION 0/5 0/5ANKLE-DORSIFLEXION 1/5 1/5 PLANTARFLEXION 1/5 1/5 INVERSION 1/5 1/5 EVERSION 1/5 1/5TOE GRIP WEAK WEAK

REFLEXES

SUPERFICIAL RT LTCORNEAL PRESENT PRESENTCONJ PRESENT PRESENTABDOMINAL UPPER PRESENT PRESENT LOWER ABSENT ABSENTCREMASTRIC ABSENT ABSENTPLANTAR EXTENSORS EXTENSOR

DEEP RT LT BICEPS PRESENT PRESENT TRICEPS PRESENT PRESENT SUPINATOR PRESENT PRESENT KNEE EXAGERATED EXAGERATED ANKLE EXAGERATED EXAGERATED

NO ANKLE/PATELLAR CLONUS

CO ORDINATION

UL RT LT NORMAL NORMAL

LL NOT ASSESED

GAIT NOT ASSESED

INVOLUNTORY MOVEMENTS FLEXOR SPASMS PRESENT

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SENSORY SYSTEM

FINE TOUCH PAIN TEMP B/L REDUCED BELOW

JOINT POSITION UMBILICUS VIBRATION

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CEREBELLAR SIGNS

• UL NORMAL B/L LL NOT ASSESED NO NECK RIGIDITY

SPINE-NO GIBBUS NO TENDERNESS NO KYPHOSIS/SCOLIOSISCRANIUM-NORMAL

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OTHER SYSTEMS

• RS NVBS• CVS S1 S2+NO MURMURS• ABD SOFT NON TENDER BS+

DIAGNOSIS

• INTRADURAL COMPRESSIVE MYELOPATHY• MOTOR LEVEL T 10• SENSORY LEVEL T11• REFLEX LEVEL T11

• PROBABLE ETIOLOGY 1,TUMOURS NEUROFIBROMA /MENINGIOMA

• AV MALFORMATIONS

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• THANKS