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
Neurological examination of lower limbs Right Left Hip Flexors(L2) 5/5 5/5 Hip Extension(L5S1 5/5 5/5 )1 Power Knee Flexion 5/5 5/5 (L5,S1) Knee 5/5 5/5 Extensor(L3) Abductors 5/5 5/5 Adductors 5 /5 5/5
Right Left Passive SLRT 90 50 contralateral SLRT Ankle Dorsiflexion(L4) 5/5 5/5 Ankle Plantar 5/5 5/5 Flexion(S1) 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 • organomegaly
Neurological Examination Oriented to time, place, and person • Cranial Nerves Examination : Normal • Upper Limbs: Sensory, Motor and • Reflexes: Normal
Neurological examination of lower limbs Lower Limbs:power • Right Left Hip Flexors(L2) 5/5 5/5 Hip 5/5 5/5 Extension(L5 Knee Flexion 5/5 5/5 (L5,S1) Knee 5/5 5/5 Extensor(L3 L4) 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 5/5 3/5 Flexion(S1) 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 • RBS: 121mg/dl • positive RFT: Within Normal Limits • Hemoglobin 12.7gm% • LFT: Within Normal Limits • Total Count: 9,000/cumm • HIV, HbsAg, VDRL: NR • Platelet Count: • 2.3lakhs/cu.mm Bleeding/Clotting Time: • Normal ESR: 25mm •
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 Dura Nerve Root
Treatment Given Post Operatively Patient was treated • supportively with Antibiotics and Analgesics in post operative period Symptomatically, • patient improved and no radiating pain in the immediate post operative period
POD 1 Started Mobilising • Patient is able to walk comfortably
POD10 • Paraesthesia disappeared Right Left Ankle Dorsiflexion 5/5 5/5 5/5 Ankle Plantar Flexion 5/5 EHL 5/5 5/5 5/5 FHL 5/5 Knee Reflex (++) (++) Ankle Reflex (++) (++) Sensations Normal Normal
Discharge Advice SUTURE • REMOVAL DONE ON 11 POD PATIENT • ADVISED NOT TO LIFT HEAVY WEIGHTS ADVISED NOT • TO BEND FORWARD PHYSICAL •
THANK YOU
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