CASE PRESENTATION DR. KRANTHI SWAROOP DAYAL IInd YEAR PG DEPT OF - - PowerPoint PPT Presentation

CASE PRESENTATION

• DR. KRANTHI SWAROOP DAYAL

IInd YEAR PG DEPT OF ORTHOPAEDICS

CASE 1

• Patient Name -XX
• Age/Sex - 35years/male
• Resident of - narketpally,nalgonda
• Occupation - computer operator

Chief Complaints

• Lower backache since 9 months
• Radiating pain to the Left lower limb

since 9 months

History of Present Illness

• Patient was apparently

asymptomatic 9 months back, then he developed lower backache, which was insidious in onset and gradually progressive, associated with radiating pain to the left lower limb upto the foot.

• Pain aggravated with prolonged sitting, standing,

and walking, on bending forwards

• Pain was temporarily relieved by lying down on

bed or by using medication, reappeared after stopping medication

• No associated weakness of lower limbs
• No bladder and bowel disturbances
• No h/o any other joint involvements
• No h/o trauma

Past history

• h/o similar complaints in the past

for which he was advised conservative management

Personal history

• Diet: Mixed
• Sleep: Adequate
• Apetite: Normal
• Bowel & Bladder Movements:

Regular

• no addictions

General examination

• Patient stable, conscious, coherent, and cooperative
• Moderately built, and moderately nourished
• no pallor, no clubbing, no icterus ,no generalised lymphadenopathy
• Temp: 98.3F
• PR: 78/min
• BP: 120/80mmHg
• CVS: S1, S2 heard, no murmurs
• Respiratory: Normal Breath Sounds heard, no added sounds
• Per abdomen: soft, non tender, no organomegaly

Local Examination

Local Examination of Spine:

• No swelling/deformities over the spine
• No local rise of temperature
• Thrust tenderness (+) at L4-L5
• Step sign (-)
• Movements of the spine : painless

Neurological Examination

• Oriented to time, place, and

person

• Cranial Nerves Examination done

and found to be Normal

• Upper Limbs, Sensory, Motor and

Reflexes: Normal

Right Left Power Hip Flexors(L2) 5/5 5/5 Hip Extension(L5S1 )1 5/5 5/5 Knee Flexion (L5,S1) 5/5 5/5 Knee Extensor(L3) 5/5 5/5 Abductors 5/5 5/5 Adductors

5/5

5/5

Neurological examination of lower limbs

Right Left Passive SLRT contralateral SLRT 90 50 Ankle Dorsiflexion(L4) 5/5 5/5 Ankle Plantar Flexion(S1) 5/5 5/5 EHL(L5) 5/5 5/5 FHL(S1) 5/5 5/5 Knee Reflex (++) (++) Ankle Reflex (++) (++) Sensory examination Normal normal

Provisional Diagnosis

• prolapse intervertebral disc L4-L5 without

neurological deficits

Radiographs of Lumbar Spine

AP View Lateral View

MRI

Disc Extrusion

Final Diagnosis

• Central disc extrusion at L4-L5 vertebral level

causing mild to moderate central canal stenosis and compression of bilateral traversing nerve roots

PLAN OF TREATMENT

• Patient treated conservatively

TREATMENT:

• T. aceclofenac MR BD
• T. Pantoprazol 40mg OD
• T. Pregabalin 75mg H/S
• Back strengthening exercises

Discharge Advice

• Patient advised not to lift heavy weights
• Not to bend forwards to lift the weights
• Physiotherapy and back strengthening

exercises

CASE 2

• Patient Name - XX
• Age/Sex - 28 years/Female
• Resident of - Dothrapally,

Yadagirigutta, Bhongir

• Occupation - Housewife

Chief Complaints

• Lower backache since 4 months
• Radiating pain to the Left lower limb

since 4 months

History of Present Illness

• Patient was apparently

asymptomatic 4 months back, then she developed lower backache, which was insidious in onset and gradually progressive, associated with radiating pain to the left lower limb upto the foot, with tingling sensation and numbness

continued…

• Pain aggravated with prolonged sitting, standing,

walking, and on bending forwards

• Pain was temporarily relieved by lying down on bed or

by using medication, reappeared after stopping medication and on minimal day to day activities

• No associated weakness of lower limbs
• No bladder and bowel disturbances
• No h/o any other joint involvements
• No h/o trauma

Past History

• Nil significant past history
• No associated co-morbidities
• H/o LSCS 4 years ago
• Gynecological examination : nil

particular

Local Examination

Local Examination of Spine:

• No swelling/deformities over the spine
• No local rise of temperature
• Thrust tenderness (+) at L4-L5, S1 vertebral level
• Step sign (-)
• MOVEMENTS OF THE SPINE
• flexion is painfull
• extension painless
• left lateral movement painless
• right lateral painful

Personal History

• Diet: Mixed
• Sleep: Adequate
• Appetite: Normal
• Bowel & Bladder

Movements: Regular

• no addictions

General Examination

• Patient stable, conscious, coherent, and cooperative
• Moderately built, and moderately nourished
• no pallor, no clubbing, no icterus ,no generalised lymphadenopathy
• Temp: afebrile PR: 78/min
• BP: 120/80mmHg
• CVS: S1, S2 heard, no murmurs
• Respiratory: Normal Breath Sounds heard, no added sounds
• Per abdomen: soft, non tender, transverse scar (+), no
• rganomegaly

• Oriented to time, place, and person
• Cranial Nerves Examination : Normal
• Upper Limbs: Sensory, Motor and

Reflexes: Normal

Neurological Examination

Neurological examination of lower limbs

• Lower Limbs:power

Right Left Hip Flexors(L2) 5/5 5/5 Hip Extension(L5 5/5 5/5 Knee Flexion (L5,S1) 5/5 5/5 Knee Extensor(L3 L4) 5/5 5/5 Abductors(L5) 5/5 5/5 Adductors(L2,L3)

5/5

5/5

Right Left PASSIVE SLRT

90 45

Ankle Dorsiflexion(L4) 5/5 5/5 Ankle Plantar Flexion(S1) 5/5 3/5 EHL(L5) 5/5 5/5 FHL(S1) 5/5 3/5 Knee Reflex (++) (++)

Provisional Diagnosis

• L5-S1 disc prolapse with Left S1

nerve root compression with paresthesias and motor deficits without bladder and bowel involvement

Investigations

• Blood Grouping & Typing: O

positive

• Hemoglobin 12.7gm%
• Total Count: 9,000/cumm
• Platelet Count:

2.3lakhs/cu.mm

• Bleeding/Clotting Time:

Normal

• ESR: 25mm
• RBS: 121mg/dl
• RFT: Within Normal Limits
• LFT: Within Normal Limits
• HIV, HbsAg, VDRL: NR

Radiographs of Lumbar Spine

AP View Lateral View

flexion ,extension X-rays

No instability

MRI

Disc Extrusion

Final Diagnosis

• L5-S1 Left paracentral disc extrusion

causing significant compression over left traversing nerve root with neurological deficits, with intact bladder and bowel function

PLAN OF TREATMENT

• Minimally Invasive Lumbar Discectomy

L5-S1on Left side

Operative Procedure

• Patient is in prone position under general anaesthesia, surgical site painted and draped.
• A 3cm midline skin incision given over L5- S1 disc space after confirming the level under C-arm guidance.
• Subcutaneous tissue and deep fascia incised in the line of incision
• Paraspinal muscles elevated subperiosteally on left side up to lamina.
• Then laminotomy of inferior part of L5 was done on left side
• Ligamentum flavum removed on Lt. side
• Dura and traversing nerve root were identified, Left S1 nerve root retracted medially .
• Prolapsed disc identified, Annulotomy done, Protruded disc removed.
• Dura and Traversing nerve root decompressed.
• Gelfoam applied over the Exposed dura and nerve root
• Wound sutured in layers.
• Patient shifted to post operative ward
• Condition stable after extubation

Intra Operatively

Inferior part of L5 lamina on

• Lt. side

Disc Traversing Nerve Root Dura

Treatment Given Post Operatively

• Patient was treated

supportively with Antibiotics and Analgesics in post

• perative period
• Symptomatically,

patient improved and no radiating pain in the immediate post

• perative period

POD 1 Started Mobilising

• Patient is able to walk comfortably

POD10

Right Left Ankle Dorsiflexion 5/5 5/5 Ankle Plantar Flexion 5/5

5/5

EHL 5/5 5/5 FHL 5/5

5/5

Knee Reflex (++) (++) Ankle Reflex (++) (++) Sensations Normal Normal

• Paraesthesia disappeared

Discharge Advice

• SUTURE

REMOVAL DONE ON 11 POD

• PATIENT

ADVISED NOT TO LIFT HEAVY WEIGHTS

• ADVISED NOT

TO BEND FORWARD

• PHYSICAL

THANK YOU