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Case conference
Presendted by R3 李偉群Supervisor: VS 鄭錦昌
CGMH JIAI 2008/12
Patient data
• 69 y/o female, housewife
• DM, HTN history under medication control
• Denied betel nut
• Denied alcohol
• Denied smoking
• Allergy: NKA
Chief complaint
• Low back pain with bilateral legs weakness for 10+ days after falling down
History summary
• Falling down on 2008/10/30 at bathroom• Progressive low back pain with bilateral legs
weakness since then• After using Chinese herb, LBP relieved but
legs weakness progressed, disability since 11/12
• Difficult urine voiding for one day• 11/13 at our ER: ICP more than 1000c.c.
Physical examination
• Knocking pain of back(+) over iliac crest level• Muscle power of lower limbs Right Left
– hip flexion(L2) 4 4 – knee extension(L3) 4 4– ankle dorsiflexion(L4) 4 4– big toe dorsiflexion(L5) 4- 4 – plantar flextion(S1) 4- 4– walk on heels can’t can’t – walk on toes can’t can’t
Physical examination
• Sensation:soreness(+) over left lateral calf (L5 dermatone)
• Reflex: – ankle jerk: right(+) , left (++) – knee jerk : right(+) , left(++)
• Babinski sign: right(-) , left (-)• SLRT : right 90 (-), left 90 (-)• FABER test: bilateral (-)
Lab of ER (11/13)
• CBC/DC: WBC 10500– band 2% seg 94%
• Glucose: 597
• BUN/Cr: 35/4.8 GFR: 9
• Na: 131.8 K: 3.84
• CRP: 57
11/13 L-spine
What’s your impression?
11/13 Myelography
11/13 MRI - T12
11/13 MRI - T12
11/13 MRI - T12
11/13 MRI - L4/L5
11/13 MRI - L4/L5
11/13 MRI - L4/L5
Impression
• T12 burst fracture with spinal stenosis
• L4 compression fracture combined with L4-5 herniated disc
• Acute renal failure due to urine retention, r/o cauda eqina dyndrome
• Diabetes mellitus
• Hypertension
Course & treatment
• Pain control, legs MP monitor
• On foley -> renal function recovery
• LBP(local tender over iliac crest level) and paresthesia (left calf soreness), urine retention persist, no stool incontinence, no paddle anesthesia
Examination
• 11/17 Urodynamic study – Incomplete relaxing sphincter– Acontractile detrusor with
urine retention
• 11/19 NCV/EMG– Bilateral tibia neuropathy and
left L5/S1 radiculopathy with denervative change
What’s your diagnosis?How to manage?
11/22 OP record
• Osteoporosis and ligament hypertrophy at L4-5 and T12 L1 level
• Laminectomy T12, lower L4, L5• Check bilateral L5, S1 root• Dural adhesion with flavum ligament and
some tophi intraligament• T12 burst fracture & L4 compression fracture
--> open vertebroplasty with PMMA• L4-5 posterolateral fusion
11/27 post-OP
12/12 Latest follow up
• Bilateral legs muscle power full, ambulation well
• Left calf paresthesia improved
• Lower back pain improved
• Urine retention persist, no improvement
Discussion
• D/D of low back pain? Diagnosis of compression fracture?
• The effect of vertebroplasty?
• Surgical management for cauda equina syndrome- timing V.S. prognosis
Low back pain
• Traumatic– Fracture: compression, burst…– Dislocations– Herniated discs– Ligament tears
• Atraumatic: degenerative disc disease, degenerative spinal stenosis, inflamatory arthritis, spondylolysis or spondylolisthesis, tumor, infection
Diagnosis of compression fracture
• Osteoporotic vertebral fracture– Wedge fracture– Biconcave deformity– Compression fracture
• Radiographic findings– Anterior wedging with vertebral collapse– Vertebral end-plate irregularity– General demineralization
Compression fracture
• Stable: pure flexion injuries• Unstable (may involve middle
column)– Severe compression (>50% height)– Significant fracture kyphosis (>30º)– Rotational component to the injury– Multiple levels compression fracture
Vertebroplasty
• Improve vertebral height of 47% compression fracture patients
• Vertebroplasty group V.S. conservative therapy: lower pain scores at 24 hours and six weeks, no difference at 12 and 24 months
Dublin AB et al, AJNR 2005
Diamond TH et al, Med J Aust.2006
Cauda Equina Syndrome: OP Timing V.S. Prognosis
• Acute onset (10/31): poorer prognosis, especially for the return of bladder function
• Bladder function: most seriously affected function preoperatively and postoperatively
• The prognosis for return of motor function was good, 90% regained normal
• no correlation of OP time with return of function
JP Kostuik et al, JBJS 1986
Cauda Equina Syndrome: OP timing V.S. Prognosis
• 7/8 patients had complete recovery of bladder function
• No distinct correlation between timing of operation and results
• Even late surgery due to delayed presentation, significant improvement in the bladder function can still be expected
Raj. D, Acta Orthop Belg.,2008
Cauda Equina Syndrome:OP Timing V.S. Prognosis
• meta-analyses of observational cohort studies, evidence level III
• 5 breakpoints: 12, 24, 36, 48, or 72 hours
• supports early surgery for CES
DeLong WB et al, J Neurosurg Spine. 2008
Return to our patient
• Bilateral legs weakness --> T12 burst fracture with spinal stenosis --> decompression and vertebroplasty
• LBP and urine retention --> cauda equina syndrome from L4/5 disc herniation, worsened by further L4 compression fracture --> decompression and vertebroplasty
Thanks for your attention!!