Case conference

Presendted by R3 李偉群Supervisor: VS 鄭錦昌

CGMH JIAI 2008/12

Patient data

• 69 y/o female, housewife

• DM, HTN history under medication control

• Denied betel nut

• Denied alcohol

• Denied smoking

• Allergy: NKA

Chief complaint

• Low back pain with bilateral legs weakness for 10+ days after falling down

History summary

• Falling down on 2008/10/30 at bathroom• Progressive low back pain with bilateral legs

weakness since then• After using Chinese herb, LBP relieved but

legs weakness progressed, disability since 11/12

• Difficult urine voiding for one day• 11/13 at our ER: ICP more than 1000c.c.

Physical examination

• Knocking pain of back(+) over iliac crest level• Muscle power of lower limbs Right Left

– hip flexion(L2) 4 4 – knee extension(L3) 4 4– ankle dorsiflexion(L4) 4 4– big toe dorsiflexion(L5) 4- 4 – plantar flextion(S1) 4- 4– walk on heels can’t can’t – walk on toes can’t can’t

Physical examination

• Sensation:soreness(+) over left lateral calf (L5 dermatone)

• Reflex: – ankle jerk: right(+) , left (++) – knee jerk : right(+) , left(++)

• Babinski sign: right(-) , left (-)• SLRT : right 90 (-), left 90 (-)• FABER test: bilateral (-)

Lab of ER (11/13)

• CBC/DC: WBC 10500– band 2% seg 94%

• Glucose: 597

• BUN/Cr: 35/4.8 GFR: 9

• Na: 131.8 K: 3.84

• CRP: 57

11/13 L-spine

What’s your impression?

11/13 Myelography

11/13 MRI - T12

11/13 MRI - T12

11/13 MRI - T12

11/13 MRI - L4/L5

11/13 MRI - L4/L5

11/13 MRI - L4/L5

Impression

• T12 burst fracture with spinal stenosis

• L4 compression fracture combined with L4-5 herniated disc

• Acute renal failure due to urine retention, r/o cauda eqina dyndrome

• Diabetes mellitus

• Hypertension

Course & treatment

• Pain control, legs MP monitor

• On foley -> renal function recovery

• LBP(local tender over iliac crest level) and paresthesia (left calf soreness), urine retention persist, no stool incontinence, no paddle anesthesia

Examination

• 11/17 Urodynamic study – Incomplete relaxing sphincter– Acontractile detrusor with

urine retention

• 11/19 NCV/EMG– Bilateral tibia neuropathy and

left L5/S1 radiculopathy with denervative change

What’s your diagnosis?How to manage?

11/22 OP record

• Osteoporosis and ligament hypertrophy at L4-5 and T12 L1 level

• Laminectomy T12, lower L4, L5• Check bilateral L5, S1 root• Dural adhesion with flavum ligament and

some tophi intraligament• T12 burst fracture & L4 compression fracture

--> open vertebroplasty with PMMA• L4-5 posterolateral fusion

11/27 post-OP

12/12 Latest follow up

• Bilateral legs muscle power full, ambulation well

• Left calf paresthesia improved

• Lower back pain improved

• Urine retention persist, no improvement

Discussion

• D/D of low back pain? Diagnosis of compression fracture?

• The effect of vertebroplasty?

• Surgical management for cauda equina syndrome- timing V.S. prognosis

Low back pain

• Traumatic– Fracture: compression, burst…– Dislocations– Herniated discs– Ligament tears

• Atraumatic: degenerative disc disease, degenerative spinal stenosis, inflamatory arthritis, spondylolysis or spondylolisthesis, tumor, infection

Diagnosis of compression fracture

• Osteoporotic vertebral fracture– Wedge fracture– Biconcave deformity– Compression fracture

• Radiographic findings– Anterior wedging with vertebral collapse– Vertebral end-plate irregularity– General demineralization

Compression fracture

• Stable: pure flexion injuries• Unstable (may involve middle

column)– Severe compression (>50% height)– Significant fracture kyphosis (>30º)– Rotational component to the injury– Multiple levels compression fracture

Vertebroplasty

• Improve vertebral height of 47% compression fracture patients

• Vertebroplasty group V.S. conservative therapy: lower pain scores at 24 hours and six weeks, no difference at 12 and 24 months

Dublin AB et al, AJNR 2005

Diamond TH et al, Med J Aust.2006

Cauda Equina Syndrome: OP Timing V.S. Prognosis

• Acute onset (10/31): poorer prognosis, especially for the return of bladder function

• Bladder function: most seriously affected function preoperatively and postoperatively

• The prognosis for return of motor function was good, 90% regained normal

• no correlation of OP time with return of function

JP Kostuik et al, JBJS 1986

Cauda Equina Syndrome: OP timing V.S. Prognosis

• 7/8 patients had complete recovery of bladder function

• No distinct correlation between timing of operation and results

• Even late surgery due to delayed presentation, significant improvement in the bladder function can still be expected

Raj. D, Acta Orthop Belg.,2008

Cauda Equina Syndrome:OP Timing V.S. Prognosis

• meta-analyses of observational cohort studies, evidence level III

• 5 breakpoints: 12, 24, 36, 48, or 72 hours

• supports early surgery for CES

DeLong WB et al, J Neurosurg Spine. 2008

Return to our patient

• Bilateral legs weakness --> T12 burst fracture with spinal stenosis --> decompression and vertebroplasty

• LBP and urine retention --> cauda equina syndrome from L4/5 disc herniation, worsened by further L4 compression fracture --> decompression and vertebroplasty

Thanks for your attention!!