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OCTOBER 2016
CERVICAL MYELOPATHY
PATIENT
IDENTITY
CASE
REPORT
Name
: MR
Age
: 30 y.o
Sex
: Male
Reg. Number
: 765375
Date of Admission
: 22 July 2016
Date of Consulted
from neurology to
Orthopaedic Dept.
: 30 July 2016
HISTORY
TAKING
Chief Complaint
Weakness on four limbs
History Taking
Patient was consulted by Neurology Department with weakness
on four limbs, mainly on lower limbs since 3 months ago. This
complaint was suffered gradually until hes bedridden and can not
even stand. He also complained numbness at his four limbs and
trunk.
History of trauma: Theres a history of motorcycle accident 4
months ago. Patient didnt know the details mechanism of trauma.
He can do normal activity after accident.
HISTORY
TAKING
History of unconciousness (-)
History of nausea(-), history of vomiting (-)
patient had the history of operation 3 months ago for urinary problem
Family history with same complaint (-)
PHYSICAL
EXAMINATION
GENERAL STATUS
Moderately Ill/ Conscious
BP
: 120/80 mmHg
Pulse : 80x/ Menit
RR
: 20x/ Menit
Temp : 36,5 C
Body Weight
: 41 kg
Body Height
: 160 cm
Body Mass Index
: 16,01 kg (underweight)
PHYSICAL
EXAMINATION
LOCALIZED STATUS
Head
: Within normal limit
Neck
: Within normal limit
Lungs : Within normal limit
Heart
: Within normal limit
Abdomen
: Within normal limit
Genitalia : Urine catheher installed
Extremity
: Edema (-), atrophy (+) on
all limbs
PHYSICAL
EXAMINATION
LOCALIZED STATUS
Spine Region
Look
: Edema (-), Deformity (-), scar (+) on
coccygeal region, hematome (-),
gibbus (-)
Feel
: Tenderness (-), step off (-)
PHYSICAL
EXAMINATION
Whole Body
PHYSICAL
EXAMINATION
Posterior
View
PHYSICAL
EXAMINATION
Lateral
View
PHYSICAL
EXAMINATION
Dorsal Hand
Palmar Hand
PHYSICAL
EXAMINATION
LOCALIZED STATUS
Hand Region
Look
Right : Athrophy on thenar, hipothenar, interosseus
muscles
Left : Athrophy on thenar, hipothenar, and interosseous
muscles
Feel
Right : Hipostesia on index finger, middle finger, ring
finger, and little finger
Left : Hipostesia on index finger, middle finger, ring
finger, and little finger
PHYSICAL
EXAMINATION
LOCALIZED STATUS
Hand Region
Finger Escape Signs : Right (+), Left (+)
Grip and release test : Patient can make a fist and
release 20 times in more than 10 seconds
Spurlings test (-)
PHYSICAL
NEUROLOGICAL STATUS
EXAMINATION
CASE
REPORT
5
3
3
2
2
5
3
0
3
2
2
1
1
0
0
0
1
1
0
0
0
No
PHYSICAL
EXAMINATION
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
0 Absent
1 Impaired
2 Normal
NT Not testable
PHYSICAL
EXAMINATION
CASE
REPORT
REFLEXES
Physiologic Reflex
R
Biceps (+)
Triceps (+)
Achilles (+)
Patellar (+)
L
(+)
(+)
(+)
(+)
Pathologic Reflex
R
L
Hoffman/
(+) (+)
Tromner
Babinski
(+)
(+)
Chadock
(+)
(+)
Openheim
(+)
(+)
Clonus
(+)
LABORATORY
FINDINGS
WBC
Na
142 mmol/l
RBC
4,2 mmol/l
HGB
13,3 g/dl
Cl
106 mmol/l
HCT
42,5%
GOT
20 U/L
PLT
379 x 103/ul
GPT
41 U/L
PT
8,6 detik
GDS
199 mg/dl
APTT
21,9 detik
Ureum
28 mg/dl
Hbs Ag
Negatif
Kreatinin
0,33 mg/dl
RADIOLOGY
FINDINGS
Chest X-Ray AP :
Theres no any
abnormality in this
radiograph
RADIOLOGY
FINDINGS
Cercival X-Ray
AP/Lateral:
- Spondylolisthesis CV
C5-C6
- Destruction of CV C5
and C6
RADIOLOGY
FINDINGS
RADIOLOGY
FINDINGS
RADIOLOGY
FINDINGS
RADIOLOGY
FINDINGS
RESUME
Man, 30 years old, consulted by neurology
department with Weakness on four limbs suffered
since 3 months ago.
Mechanism of Trauma : The patient had a traffic
accident 4 months ago but can still do activity after
accident.
RESUME
From Physical examination at spine region theres scar at
coccygeal region. There were also muscle atrophy at four
limbs.
Motoric examination resulted motoric function 3 on bilateral
C6 and C7 levels, motoric function 2 on bilateral C8 and T1
levels.
Sensory examination resulted a hypostesia below C5 level.
Physiologic reflex increased and there were pathological
reflex.
RESUME
From Physical examination at hand region there were
muscle atrophy on thenar, hipothenar, and interosseus along
with hipostesia on hipothenar and index finger, middle
finger, ring finger, and little finger on both hands.
Finger escape sign was positive on both hands
Grip and release test was positive for both hands
Spurlings sign was negative
RESUME
Laboratory finding, White Blood Cells were 30,8 x 103 /ul
(leukocytosis)
Radiologic finding at x-ray of cervical region, there were
spondylolisthesis CV C5-C6, destruction of CV C5-C6.
MRI Cervical T1W1 without contrast, T2W1 axial and
sagittal and MR-Myelography, there were destruction of CV
C5 and C6 with narrowing of discus intervertebralis on that
levels as the picture of spondylitis and intradural abcess.
DIAGNOSIS
Physical
Examination
History
Taking
Investigation
PLANNING
CASE
REPORT
Antibiotics
Mobilization right and left lateral
decubitus
Use of decubitus bed
Decompression
Stabilization
DISCUSSION
ANATOMY
DENNIS
CLASSIFICATION
The three columns of the spine, as proposed by Francis Denis. The anterior
column (A) consists of the anterior longitudinal ligament, anterior part of the
vertebral body, and the anterior portion of the annulus fibrosis. The middle
column (B) consists of the posterior longitudinal ligament, posterior part of the
vertebral body, and posterior portion of the annulus. The posterior column (C)
consists of the bony and ligamentous posterior elements. (Modified from Denis F.
The three-column spine and its significance in the classification of acute
thoracolumbar spinal injuries. Spine 1983;8:817831.)
Kenneth A.Egol, Kenneth J.Koval, Joseph D. Open fracture in: Handbook of Fracture, Fourth edition, chapter 3.
ANATOMY
ANATOMY
ANATOMY
ANATOMY
Column vertebrae:
Bodies
Arch :
o Pedicles
o Laminae
Processes:
o Transverse
o Spinosus
Foramina
o Vertebral
o Neural
LIGAMENT
HISTORY
TAKING
INTRODUCT
ION
Myelopathy Any disease or disorder of the spinal cord
Cervical Myelopathy Results from cervical cord
compression due to a narrow cervical vertebral canal.
The constriction of the canal enclosing the cervical cord
is due to:
Congenital narrowing
Cervical spondylosis involving hypertrophy of the facet
joints and osteophyte formation
Hypertrophy of the ligamenta flava
Bulging (or prolapse) of a cervical disc
Excessive mobility, usually associated with
cervical spondylosis.
Andrew H. Kaye : Essential Neurosurgery Chapter 15 ( 3th
INTRODUCT
ION
The morphological changes within the cord include :
Degeneration and loss of nerve cells, cavitation and
proliferation of glia within the grey matter
Demyelination of the lateral and posterior columns
Wallerian degeneration in ascending tracts above and
descending tracts below the compression
Proliferation of small blood vessels with thickening of
the vessel walls
Rare involvement of the anterior columns.
ETIOLOGY
CLINICAL
FEATURES
The presenting features are pain and neurological
disturbance attributable to cervical cord involvement.
MUSCULAR
WEAKNESS
SENSORY
SYMPTOMS
PHYSICAL
FINDINGS
The supinator (brachioradialis) reflex may be of value in
localizing the level. If it is absent, but the reflex evokes
flexion of the digits and sometimes the biceps or triceps,
this is regarded as evidence of a lesion restricted to the
C6 segment (the inverted supinator reflex).
CLASSIFICA
TION
Nuricks Classification
Grade
Grade I
No difficulty in walking
Grade II
Grade III
Grade IV
Grade V
Chairbound or bedridden
orthobullets.com/spine/2031/cervical-myelopathy
CLASSIFICA
TION
Japanese
Orthopaedic
Association
Classification
orthobullets.com/spine/2031/cervical-myelopathy
RADIOLOGICAL
INVESTIGATION
RADIOLOGICAL
INVESTIGATION
MRI :
Show the exact pathological basis for the
compression
DIFFERENTIAL
DIAGNOSIS
NON OPERATIVE
TREATMENT
OPERATIVE
TREATMENT
Surgery is definitely indicated for clinically progressive
or moderate or severe myelopathy.
A further reason for advising early surgery is that any
existing neurological deficit may not improve following
an operation, due to irreversible changes within the
cervical cord
OPERATIVE
TREATMENT
The type of surgical procedure performed will depend
upon:
PROGNOSIS
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