rehab rotation sci case presentation

8/13/2019 Rehab Rotation SCI Case Presentation

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REHAB ROTATION SPINAL CORD INJURY

CASE PRESENTATION

Katrina C. Morales

MD 10-0045

June 6, 2013


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IDENTIFYING DATA

JB is a 17 year old male, right handed,Filipino, Catholic, high-school student fromBulacan who was admitted to the Philippine

Orthopedic Center last March 11, 2013.

The source of information is the patienthimself with excellent reliability.

SOURCE AND RELIABILITY


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CHIEF COMPLAINT

Patient came in for referral for paralysis of

the lower extremities


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HISTORY OF PRESENT ILLNESS

11 days PTA: sudden non-radiating stabbing

pain on the lower back with a score of 5 out

of 10, undocumented intermittent fever

present with night sweats and decreasedappetite,

Aggravated by walking, relieved by rest

No relief measures done, no other constitutionalsymptoms present, returned to daily independent

activities


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5 days PTA: increased severity of non-

radiating stabbing lower back pain with a

score of 7 out of 10, aggravated by walking,

relieved by restUndocumented intermittent fever present with

night sweats and decreased appetite

Difficulty in sleeping, no bowel and bladderimpairment noted

Returned to daily independent activities

*Patient went to a hilot for the pain, but to noavail


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3 days PTA: Increased severity of a stabbing

lower back pain with a score of 9 out of 10,

radiating to both lower extremities,

aggravated by being in supine positionUndocumented intermittent fever present with

night sweats and numbness

Slight changes in bowel and bladder movementNo medications taken, no consults done


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2 days PTA: Persistence of severe lower

back pain with a score of 9 out of 10,

radiating to both lower extremities,

aggravated by being in supine positionNoted weaknessof the lower extremities,

suddenly fell on the floor and could no longer

moveNo medications taken, no consults done


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1 day PTA: Persistence of severe lower back

pain with the paralysis of the lower

extremities prompted consult at the Bulacan

Medical Center Laboratory and X-ray of the thoracic area was

doneresults not available

Spinal cord injury was suspected and was thenreferred to POC for further evaluation and

management


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REVIEW OF SYSTEMS

NOTHING PERTINENT General:(-) fever, weight gain, weight loss, weakness, fatigue

Musculo-Integumentary: (-) ashes, lumps, sores, itching, musclepains, joint pains, changes in color, joint swelling, changes in hairnails

HEENT: (-) headache, dizziness, blurring of vision, tinnitus,deafness, epistaxis, frequent colds, hoarseness, dry mouth, gumbleeding, enlarged LN

Respiratory: (-) dyspnea, hemoptysis, cough, wheezing

Cardiovascular: (-) palpitations, chest pains, syncope, orthopnea

Gastrointestinal: (-)nausea, vomiting, dysphagia, heartburn,

constipation, diarrhea, rectal bleeding, jaundice Endocrine: (-) excessive sweating, heat intolerance, polyuria,

excessive thirst, cold intolerance

Genito-urinary: (-) dysuria, sexual dysfunction, discharge

Neurological: (-) seizures, tremors


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PAST MEDICAL HISTORY

No previous illnesses, such as asthma, allergic rhinitis,known allergies to food and medicines, hypertension,diabetes mellitus, cancers Claims to have no exposure to tuberculosis or other infectious

diseases

No prior hospitalizations and surgeries done No medications used for maintenance and the like

Paternal history of hypertension No known illnesses (especially of the infectious kind) in

the family, as well as in the paternal and maternal side

FAMILY HISTORY


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IMMUNIZATION HISTORY

Unrecalled

Currently, patient eats regularly per day and hasintake of vegetables and fruits together with the riceand meat

Claims to be developmentally at par with age.

Currently, patient is more involved in doing physicalactivities (playing basketball)

NUTRITIONAL HISTORY

DEVELOPMENTAL HISTORY


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HEADSSS

Home and Environment: Lives with father and step-mother only in Bulacan (Originally from Bicol)

Education and Employment: Will be entering 2ndyear HS in the coming school year

Activities: Likes to spend time with his close friendsplaying basketball in the court of their school

Drugs: None

Sexuality: No intimate relationships with others

Substance Abuse: None Suicide/Depression: Depressionno visits from

parents, siblings and other relatives


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PERSONAL-SOCIAL HISTORY

Patient is the second in a brood of 5 18F, 17M*, 14M, 11M, 8F

Currently lives with the father and stepmother only inBulacan

Biological mother died a few years back Bungalow house with 2 bedrooms and 1 bathroom

(inside), hard to enter with wheelchair

Occasional alcoholic beverage drinker, does not smokeand use illicit drugs

There is frequent collection of waste and garbage fordisposal.

There is no history of recent travel.


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FUNCTIONAL INDEPENDENCE MEASURE (FIM)

Uponadmission,patient wasgraded withan FIM score

of 68.*In cases where there is arelatively low score or measure inthe assessment made, the patientwould either need more supportand aid in regaining back hisfunctionality, or on another note itwould mean that he has a poorerprognosis after the disease if ithas not been addressed.

3

3

3

33

3

2

2

33

3

2

0

7

7

7

7

7

C

33

35

68

B

B


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Awake, alert, not in cardiorespiratory distress

GENERAL APPEARANCE

HR: 75 beats / minute Blood Pressure: 100 / 70 mmHg

RR: 16 breaths/minute Body Temperature: Not taken

VITAL SIGNS

ANTHROPOMETRICS

Weight: 45 kg BMI: 17.6 kg/m2(underweight)Height: 160 cm


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PHYSICAL EXAMINATION

Head and Neck: head is normocephalic; no facial tenderness, no

palpable lymph nodes; thyroid is not palpable and there are no bruits

Eyes:anicteric sclerae, pale conjunctiva, no signs of hemorrhage and

(+) red-orange reflex, pupils were equally round and reactive to light

Nose:nasal septum positioned midline, pink nasal mucosal and nosigns of inflammation, nasal discharges and obstructions

Cardiovascular: adynamic precordium, point of maximal impulse at the

5thintercostal space at the left midclavicular line; no heaves, lifts, thrills;

no murmurs

Chest and Lungs: no visible skin lesions and no tenderness, symmetricchest expansion, no additional breath sounds, equal resonance on all

lung fields

Abdomen: flat abdomen with the umbilicus at midline, normoactive

bowel sounds (3 bowel sounds per minute); tympanitic abdomen, liver

span not measured


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Integumentary:

Skin dry and warm to touch, normal skin turgor and

capillary refill time, no pressure sores

Nails

there were no signs of clubbing, no signs ofcyanosis, pink nail beds

Hair and Scalp full, black hair with no signs of masses

and infestations

Back and Spine: (-) deformities, tenderness Rectum (DRE/Sacral) : (-) no anal tags/fissures,

palpable masses; empty rectal vault; (+)

bulbocavernosus reflex, (-) perianal sensation


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Extremities: full and equal pulses, no cyanosis or

edema

ROM: Full ROM on R and L Upper Extremities, active;

Full ROM on R and L Upper Extremities, passive MMT: C5 to T1 5 / 5 for both R and L; L2 to S1 0 / 5

for both R and L

Sensory: C2 to T6 2 / 2 for light touch and pin prick for

both R and L; T7 to T8

1 / 2 for light touch and pin prickfor both R and L; T9 to S4-5 0 / 2 for light touch and pin

prick for both R and L

DTRs: Normoreflexive on R and L Upper Extremities;

Areflexive on R and L Lower Extremities


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DIAGNOSTICS PRIOR TO ADMISSION

Thoracolumbar X-ray

AP: No fractures/dislocations, intact vertebral

body height, intervertebral disc space,

interpedicular distance LAT: No fractures/dislocations, intact vertebral

body height, intervertebral disc space

Chest X-ray: No infiltrates seen, heart notenlarged, diagphragmatic sulci intact,

trachea at midline


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ASSESSMENT

Problem list:

Paralysis of the lower extremities (sensation and

motor affected)

Pain management

Rehabilitation exercises (restrengthening,

retraining/adjustment)


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DIAGNOSIS

SCI Complete Sensory Level T8Secondary to possible Transverse Myelitis

AIS A


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TRANSVERSE MYELITIS

PAINis the primary presenting symptom oftransverse myelitis in approximately one-third toone-half of all patients. The pain may be localized in the lower back or

may consist of sharp, shooting sensations thatradiate down the legs or arms or around thetorso.

Bladder and bowel problems may involve

increased frequency of the urge to urinate orhave bowel movements, incontinence, difficultyvoiding, the sensation of incomplete evacuation,and constipation..


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TRANSVERSE MYELITIS

TM has a conservatively estimated incidence ofbetween 1 and 8 new cases per million per year, orapproximately 1400 new cases each year. (US)

Although this disease affects people of all ages, with

a range of six months to 88 years, there are bimodalpeaks between the ages of 10 to 19 years and 30to 39 years.

In addition, approximately 25% of cases are inchildren.

There is no gender or familial association with TM. In 75-90% of cases TM is monophasic, yet a small

percentage experience recurrent diseaseespecially if there is a predisposing underlying

illness.


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TRANSVERSE MYELITIS

CONSIDERATION: POST-INFECTIOUS Immune system mechanisms, rather than active

viral or bacterial infections, appear to play animportant role in causing damage to spinal

nerves Stimulation of the immune system in response to

infection indicates that an autoimmune reactionmay be responsible.

In autoimmune diseases, the immune system, which

normally protects the body from foreign organisms,mistakenly attacks the bodys own tissue,causing inflammation and, in some cases,damage to myelin within the spinal cord.


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DIFFERENTIAL DIAGNOSIS

Rule In Rule Out

Spinal Cord

Compression

Pain, weakness on the lower

extremity

Similar in presentation

No deformities seen in the

initial radiographic findings

Multiple Sclerosis Similar in initial presentation

Involve autoimmune

responses to myelin in the

spinal cord, "demyelinating"

disorders*TM may be a presentation of MS

Occurs multiple times all of

a sudden (repeat attacks)

this is only the first

episode

PottsDisease Presence of undocumentedfever with night sweats

Pain

No gibbus deformityNo history of exposure to

TB

Arterial or Venous

Ischemia (blockage)

Sudden onset of weakness

Similar presentation

No history of diseases that

have prothrombotic risk

factors


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DIFFERENTIAL DIAGNOSIS


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DIAGNOSTICS

MRI to determine any soft tissue inflammation

If an MRI is not possible CT of the spine with or

without myelography

Blood tests for SLE, HIV, VitB12 def.,NMO-IgG

Spinal Tap look for increased leukocytes,

factors, exclude infections, disease markers

*If none of these tests suggests a specific cause, the patient is

presumed to have idiopathic transverse myelitis.


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DIAGNOSTICS

SHOULD BE NOTED: Diagnosis of Exclusion


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ALGORITHM


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ALGORITHM


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MANAGEMENT

NOeffective cure currently exists for people withtransverse myelitis.

Treatments are designed to manage and alleviatesymptoms and largely depend upon the severity of

neurological involvement. Therapy generally begins when the patient first

experiences symptoms.

Physicians often prescribe corticosteroid therapy

during the first few weeks of illness to decreaseinflammation.

IMPT: Keep the body functioning while hoping for thenervous system to recover


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MANAGEMENT

Patients with acute symptoms, such as

paralysis, are most often treated in a hospital

or in a rehabilitation facility where a

specialized medical team can prevent ortreat problems that afflict paralyzed patients.

Later, if patients begin to recover limb

control, physical therapy begins to helpimprove muscle strength, coordination,

and range of motion.


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MANAGEMENT

For Acute Cases: Injection of steroids

Plasmapharesis

IV Immunoglobulin therapyRehabilitation

Physical Therapy Increase their strength and endurance, improve

coordination, reduce spasticity and muscle wasting inparalyzed limbs, and regain greater control overbladder and bowel function through various exercises


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MANAGEMENT

RehabilitationOccupational Therapy

Help individuals learn new ways to maintain or rebuildtheir independence by participating in meaningful,self-directed, goal-oriented, everyday tasks(occupations), goal is to function at the lightest levelpossible

Vocational Therapy

Vocational therapists identify potential employers,assist in job searches, and act as mediators betweenemployees and employers to secure reasonableworkplace accommodations.


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CLINICAL COURSE/PROGNOSIS

Recovery from TM may be absent, partial or

complete and generally begins within 1 to 3

months after acute treatment.

Significant recovery is UNLIKELY, if NOIMPROVEMENT OCCURS BY 3 MONTHS.

Patient has shown improvement in

independence in months 2-3 of the disease


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CLINICAL COURSE/PROGNOSIS

Subsequent to the initial attack,

approximately:

1/3 of individuals recover with little or only minor

symptoms 1/3 are left with a moderate degree of permanent

disability

1/3 have virtually no recovery and are leftseverely functionally disabled (use of

wheelchairs, dependent on others)

Most show good to fair recovery.


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CONSIDERATIONS FOR PATIENTS

INDICATORS OF LESS COMPLETE

RECOVERY:

Rapid progression of clinical symptoms

Presence of back pain

Presence of spinal shock

Para-clinical evidence, such as absent central

conduction on evoked potential testingPresence of 14-3-3 protein in the cerebrospinal

fluid (CSF) during the acute phase


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CONTEXTUAL ANALYSIS

Patient is an adolescent, is unable to

participate in activities that he used to enjoy

(ex. Playing basketball, going to school)

Important for the patient to have the supportfrom his family in the process of rehabilitation

rehab rotation sci case presentation

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