Spinal Cord Compression
GENERAL DATA
•
•
•
•
•
•
•
Marlyn Aguirre
52/M
Married
Unemployed, formerly a factory worker
from Manila
Roman Catholic
Right-handed
CHIEF COMPLAINT
• Left lower extremity weakness
HISTORY OF PRESENT ILLNESS
Patient was ambulatory, independent in all ADLs
and apparently well until . . .
 2 yrs PTA – (+) gradual heaviness & weakness of
the L leg, noticed while standing up & walking.
Pt loses control of her gait, sometimes causing
her to kneel down. (-) hx of trauma, (-) assoc.
numbnesss, (-) paresthesia, (-) pain, (-) loss of
consciousness, (-) headache, (-) nausea , (-)
vomiting, (-) blurring of vision, (-) diplopia, (-)
tinnitus, (-) slurring of speech, (-) bowel &
bladder incontinence.
HISTORY OF PRESENT ILLNESS
 Sought consult c/o private MD in Malaysia.
Assessment was unrecalled, prescibed with
unrecalled medications including Calcium
supplements which provided minimal relief. Pt
still able to ambulate independently, still able
to do all ADLs independently. Until . . .
HISTORY OF PRESENT ILLNESS
 1 yr PTA – Noted progression of weakness,
same character. Pt had difficulty in ambulation.
Sought consult c/o another MD in Malaysia.
Assessment was also unrecalled, given
unrecalled medication that was injected at the
waist. (-) relief of symptoms. CT scan was done
which revealed a spinal canal narrowing at L4L5 level 20 to disc bulge & at L3-L4 20 to disc
protrusion
HISTORY OF PRESENT ILLNESS
 Pt eventually decided to come home. Sought
consult @ Fatima Medical Center. Pt advised
to undergo physical therapy x 2 months.
Noted relief of symptoms after the program.
Pt was again able to ambulate & perform all
ADLS independently . Until . . .
HISTORY OF PRESENT ILLNESS
 8 months PTA – Pt experienced progressive
weakness of her Left lower extremity. Pt was
still able to ambulate & perform all ADLs
independently. (-) noted bowel/bladder
incontinence.
HISTORY OF PRESENT ILLNESS
 3 months PTA – Noted worsening of symtoms
which now included numbness of her Left
lower extremity. Pt consulted at St. Luke’s,
lumbar MRI was done which showed
unremarkable findings. Thoracic MRI was
eventually done which showed a mass. A>
Hemangioma. Pt was referred to NSS for
evaluation. Pt was advised to undergo
operation.
HISTORY OF PRESENT ILLNESS
 Pt eventually decided to transfer to PGH due to
financial constraints. This time, (+) beginning
bowel incontinence, (-) urinary incontinence.
 1 ½ months PTA – Pt was seen @ NSS-OPD. Pt
was admitted on May 24, 2009. Laminectomy
w/ Excision of Mass done May 28, 2009. after 4
days, pt was discharged well. However, after 1
day @ home, pt developed DOB. Pt was
readmitted @ NSSCU. A> HAP. Pt was intubated
& stayed for 15 days.
HISTORY OF PRESENT ILLNESS
 July 3, 2009 – Pt was extubated & stabilized. Pt
was transferred from NSSCU to Rehab ward for
further management.
REVIEW OF SYSTEMS
(-) fever, (-) anorexia, (-) malaise, (-) weight loss
(-) BOV, (-) diplopia, (-) tinnitus, (-) hearing changes
(-) cough, (-) colds, (-) dyspnea , (-) hemoptysis
(-) chest pain, (-) orthopnea, (-) PND, (-) easy fatigability,
(-) palpitations
(-) abdominal pain, (-) vomiting, (-) diarrhea, (-) constipation,
(-) melena, (-) hematochezia, (-) ascites
(-) dysuria, (-) nocturia, (-) hematuria, (-) oliguria,
(-) frothy urine
REVIEW OF SYSTEMS
(-) heat/cold intolerance, (-) diaphoresis, (-) fine tremors,
(-) polyuria, (-) polydipsia, (-) polyphagia
(-) paresthesia, (+) numbness (L lower ext), (+) weakness (L
lower ext), (-) headache, (-) dysarthria,
(-) dysphagia, (-) dysphonia, -) seizures, (-) dizziness
(-) headache (-) loss of consciousness (-) insomnia
(-) changes in sensorium
(-) arthralgia, (-) myalgia
(-) easy bruisability, (-) gum bleeding
(-) jaundice, (-) edema, (-) palllor
PAST MEDICAL HISTORY
 (+) HPN (Dx in 2005, HBP 140/90,
UBP 110-120/70-80
maintained on Normatin? 50 mg OD)
 (-) DM
 (-) PTB, (-) Bronchial Asthma, (-) CA
 (-) heart/liver/kidney disease
 (-) history of seizures
 (-) previous hospitalization
 s/p Laminectomy (5/28/09)
 (-) allergy to food and drugs
FAMILY MEDICAL HISTORY
•
•
•
•
•
•
•
(+) DM – sister
(-) CVD
(-) HPN, PTB, bronchial asthma, CA
(-) history of early cardiac death
(-) liver disease
(-) kidney disease
(-) similar symptoms
OB-GYN HISTORY
•
•
•
•
•
•
•
•
Menarch @ 14 y/o
LNMP = June 2009
RMI until Jan 2009
3-4 days duration
2-3 ppd, (-) dysmenorrhea
G4 P4 (4004)
All SVD c/o Midwife @ home & lying-in Clinic
(-) Feto-Maternal Complications
PERSONAL/SOCIAL HISTORY
•
•
•
•
(-) smoker
(-) alcoholic bev. drinker
(-) use of illegal drugs
Unemployed, previously worked in a garments
factory x 15 years
• Lives with family in 3-storey house made of concrete.
–
–
–
–
13 steps from the ground, 4 rooms in the 2nd floor
Patient lives at the sala on the 1st floor
Bathroom located on the 1st floor, 9 meters from sala
Main door opens to a concrete pavement which can
accommodate one wheelchair
– House is 50 meters away from main road
FUNCTIONAL HISTORY
Pre-Morbid
Post-Morbid
A. Eating
7
7
B. Grooming
7
7
C. Bathing
7
7
D. Dressing – Upper Body
7
7
E. Dressing – Lower Body
7
7
F. Toileting
SPHINCTER CONTROL
7
4
G. Bladder Management
7
3
H. Bowel Management
7
4
I. Bed, Chair, Wheelchair
7
7
J. Toilet
7
7
K. Tub, Shower
7
7
SELF-CARE
TRANSFERS
FUNCTIONAL HISTORY
Pre-Morbid
Post-Morbid
L. Walk/Wheelchair
7
6
M. Stairs
7
6
N. Comprehension
7
7
O. Expression
7
7
105
93
P. Social Interaction
7
7
Q. Problem Solving
7
7
R. Memory
7
7
COGNITIVE SUB-TOTAL
21
21
TOTAL SCORE
126
114
LOCOMOTION
COMMUNICATION
MOTOR SUB-TOTAL
SOCIAL COGNITION
PHYSICAL EXAMINATION
• Awake, conscious, coherent, NICRD
• BP 120/70, HR 96, RR 20, Temp 36.9oC
• Pink conjunctivae, anicteric sclerae, (-) neck vein
engorgement, (-) anterior neck mass, (-) cervical
lymphadenopathy, (-) tonsillopharyngeal congestion
• Equal chest expansion, clear breath sounds,(-) rales,
(-) wheezes
• (-) heaves, (-) thrills, distinct heart sounds, normal
rate, regular rhythm, (-) murmurs, (-)S3, (-) S4, PMI at
5th ICS LMCL
PHYSICAL EXAMINATION
• Flabby, normoactive bowel sounds, (-)
bruits, soft, nontender, (-) masses, (-)
hepatosplenomegaly, (-) CVA tenderness
• Spine midline, (+) 5 x 1 cm hyperpigmented,
flat surgical scar, midline @ Level T3-T4, (-)
discharge, (-) swelling, (-) erythema
• Pink nailbeds, full and equal pulses, (-)
cyanosis, (-) edema, (-) jaundice
PHYSICAL EXAMINATION
Thigh Circumference
Distance from patella
6 cm
8 cm
10 cm
R
34 cm
35.5 cm
36
L
34 cm
34 cm
34 cm
widest circumference
Leg Circumference
R
L
29 cm
27.5 cm
PHYSICAL EXAMINATION
PULSES
Popliteal
Dorsalis Pedis
Posterior Tibialis
R
++
++
++
L
++
++
++
NEUROLOGIC EXAM
 Patient is awake, cooperative, conversant, and
follows commands . GCS 15 (E4V5M6)
 Patient is oriented to person, place and time.
He has pleasant mood and appropriate affect,
good immediate, recent & remote memory,
good calculation ability, good insight and good
judgment.
 (-) right and left confusion, (-) hemineglect, (-)
visual field cuts, (-) dysarthria
 (-) aphasia, (-) apraxia
NEUROLOGIC EXAM
Cranial Nerves
•
•
•
•
•
•
•
•
•
•
I
II
III, IV, VI
V
V, VII
VII
VIII
IX, X
XI
XII
Grossly intact
Pupils 2-3mm EBRTL, (+) consensual reflexes
Full and equal EOMs
Intact sensation at V1, V2, V3
Brisk corneal reflexes, OU
(-) facial palsy
Intact gross hearing
Intact gag reflex, uvula in midline
Weak shoulder shrug on the L
Tongue in midline
NEUROLOGIC EXAM
MOTOR
Manual Muscle Testing
UPPER
EXTREMITIES
MUSCLE
R
L
C5
C6
C7
Elbow flexors
Wrist extensors
Elbow extensors
5
5
5
5
5
5
C8
Finger flexors
5
5
T1
Small finger abductor
5
5
NEUROLOGIC EXAM
Manual Muscle Testing
LOWER
EXTREMITIES
L2
L3
L4
L5
S1
MUSCLE
R
L
Hip flexors
Knee extensors
Ankle dorsiflexors
Long toe
extensors
Plantar flexor
5
5
5
5
3
3
3
3
5
3
RANGE OF MOTION
Flexion
0-180
Right
Active
0-180
Extension
180-0
180-0
Abduction
0-180
Adduction
Shoulder
Normal
Right
Passive
0-180
Left Active Left Passive
0-180
0-180
180-0
180-0
180-0
0-180
0-180
0-180
0-180
0-45
0-45
0-45
0-45
0-45
Internal
rotation
External
rotation
Elbow
0-90
0-90
0-90
0-90
0-90
0-90
0-90
0-90
0-90
0-90
Flexion
0-150
0-150
0-150
0-150
0-150
Extension
0-150
0-150
0-150
0-150
0-150
Pronation
0-90
0-90
0-90
0-90
0-90
Supination
0-90
0-90
0-90
0-90
0-90
RANGE OF MOTION
Flexion
0-90
Right
Active
0-90
Extension
0-80
0-80
Radial
Deviation
0-20
Ulnar
Deviation
MCPs
Wrist
Normal
Right
Passive
0-90
Left Active Left Passive
0-90
0-90
0-80
0-80
0-80
0-20
0-20
0-20
0-20
0-30
0-30
0-30
0-30
0-30
Flexion
0-90
0-90
0-90
0-90
0-90
Extension
0-40
0-40
0-40
0-40
0-40
Abduction
0-20
0-20
0-20
0-20
0-20
Adduction
20-0
20-0
20-0
20-0
20-0
RANGE OF MOTION
0-120
Right
Active
120
Right
Passive
120
0-90
90
0-30
Hip
Normal
Flexion–
knee flexed
Flexion–
knee extended
Extension–
knee flexed
Extension–
knee extended
Left Active Left Passive
80
120
90
50
90
30
30
20
30
0-40
40
30
20
40
Abduction
0-45
45
45
20
45
Adduction
0-30
30
30
15
30
Internal
rotation
External
rotation
0-35
35
35
20
35
0-45
45
45
25
45
RANGE OF MOTION
0-135
Right
Active
0-135
Right
Passive
0-135
0
0
Dorsiflexion
0-20
Plantar flexion
Knee
Normal
Left Active Left Passive
0-135
0-135
0
0
0
0-20
0-20
0-20
0-20
0-50
0-50
0-50
0-50
0-50
Eversion
0-5
0-5
0-5
0-5
0-5
Inversion
0-5
0-5
0-5
0-5
0-5
Flexion
0-40
0-40
0-40
0-40
0-40
Extension
0-70
0-70
0-70
0-70
0-70
Abduction
0-15
0-15
0-15
0-15
0-15
Adduction
0-10
0-10
0-10
0-10
0-10
Flexion
Extension
Ankle
MTPs
NEUROLOGIC EXAM
• DTRs: +2 R upper & lower extremities,
+2 L upper & lower extremities,
• (+) Babinski, bilateral
• (-) clonus
NEUROLOGIC EXAM
Sensory
Level
Pain
Light Touch
R
L
R
L
C2
100%
100%
100%
100%
C3
100%
100%
100%
100%
C4
100%
100%
100%
100%
C5
100%
100%
100%
100%
C6
100%
100%
100%
100%
C7
100%
100%
100%
100%
C8
100%
100%
100%
100%
T1
100%
100%
100%
100%
T2
100%
100%
100%
100%
T3
100%
100%
100%
100%
NEUROLOGIC EXAM
Sensory
Level
Pain
Light Touch
R
L
R
L
T4
100%
100%
100%
100%
T5
100%
100%
100%
100%
T6
100%
100%
100%
100%
T7
100%
100%
100%
100%
T8
100%
100%
100%
100%
T9
100%
100%
100%
65%
T10
100%
65%
100%
70%
T11
100%
60%
100%
50%
T12
100%
80%
100%
90%
L1
100%
60&
100%
75%
NEUROLOGIC EXAM
Sensory
Level
Pain
Light Touch
R
L
R
L
L2
100%
75%
100%
65%
L3
100&
60%
100%
90%
L4
100%
80%
100%
65%
L5
100%
65%
100%
65%
S1
100%
70%
100%
50%
S2
100%
60%
100%
75%
S3
100%
70%
100%
70%
NEUROLOGIC EXAM
CEREBELLARS
 (-) dysmetria (-) dysdiadochokinesia, (-)
nystagmus
MENINGEALS
 (-) nuchal rigidity, (-) Kernig’s, (-) Brudzinski
Labs
• 7/3 Hgb 133, Hct 0.425, Plt Ct 462, WBC 8.33
• 7/3 U/A yellow, clear, 1.015, pH 6.0, sugar (-),
protein (-), RBC (-), WBC 0-1
• 7/3 BUN 1.54, Crea 50, Na 138, K 3.9
Present Working Impression
• Spinal Cord Compression, Incomplete, ASIA C,
Motor Level T8, Sensory Level T8, 20 to
Hemangioma T5-T6
• s/p Laminectomy (5/28/09)
• HPN St I, Good Control
• t/c HHD in SR, NIF
• Neurogenic bowel & bladder
• HAP, resolved
Present Meds
•
•
•
•
Citicoline 500 mg/cap 2 caps Q6H
Amlodipine 5 mg/tab 1 tab OD
Omeprazole 40 mg/tab 1 tab OD @ HS
Paracetamol 500 mg/tab PRN for T > 37.8
Course in the Wards
• 7/3 Admitted to Rehab Ward Bed 15,
CBC, BUN, Crea, Na, K, urinalysis
• 7/6 Pt started on physical therapy, on-going
intermittent urinary catheterization Q6
• 7/14 Pt still on physical therapy, still w/
on-going intermittent urinary
catheterization Q6