Prof. S.Sundar unitDr. Vikraman.G

A CASE OF PARAPLEGIA

CHRONOLOGY 0F EVENTS1/3/2008-A 40 Year old male admitted in salem medical

colege with c/o cough with mucoid expectoration,breathlessness,vomitting-2-3 months duration

H/o fever,low grade 10 days backnot associated with chills,evening rise of temperature, settled with treatment

h/o LOA/LOWNo h/o

hemoptysis,chestpain,palpitation,PND,orthopnoea,bone pain,any focal neurological deficit,headache,syncope,bowel,bladder disturbance,seizures,abdominal pain,distension

No other specific complaints PAST HISTORY- not a known

DM/SHT/CAHD/CVA/SEIZURE/PTPERSONAL HISTORY-SMOKER/ALCOHOLIC

Examination

o/e Pt. conscious, oriented, afebrile,hydration fair GRADE 1 CLUBBING PALLORno CY/PE/LA/JVP/ICT

RS- trachea in midline, no TF, chest movements decreased in right side,BS diminished in whole of Right hemithorax,VF/VR decreased in right hemithorax

Other systems-WNL

INVESTIGATIONSRBS-137mg%RFT-B.Urea-17mgs%,Sr.creat-0.9mgs

%,Na+-142meq/l,k+-4.3meq/lCHG-Hb%-8.6g%,TC-10,200cells/cumm,DC-

P60,L38,E2,platelets-1.74mgs%,ESR-25/50MP/MF negUrine WNLPLEURAL FLUID EXAMINATION-sugar-70mgs

%,proteins-2.8g%,WBC’s 160cells/cu.mm,RBC’s plenty

Mantoux-reactive,10mm

CT thorax-massive right Hydrothorax,destroyed right lung with collapse,consolidation with minimal left pleural effusion

Sputum AFB-negSputum C&S-no growth

Diagnosed as right effusion (tubercular origin) and started on ATT cat III and discharged

30/4/2008-pt re-admitted with added c/o -pain in back of chest,weakness of lower limbs-2 days

Positive sign- GRII clubbing,pallor, RS-chest movements,dullness on

percussion in right side,VF/VR,BS decreased in right side

CVS,PA- wnl

CNS HF-wnlSPINOMOTOR

RIGHT LEFT

BULK N N

TONE UL N N

LL

POWER

UL 5/5 5/5

LL 4/5 4/5

DTR UL ++ ++

LL +++ +++

ABDOMINAL ABSENT ABSENT

PLANTAR EXTENSOR EXTENSOR

CRANIAL NERVES/CEREBELLAR/EXTRAPYRMIDAL-WNL

SENSORY SYSTEM-DECREASED BELOW D6GIBBUS ,TENDERNESS D2,D3,D4

INVESTIGATIONESR-I5/40,HB%-9.5,HIV

NONREACTIVE,ECG-WNLX RAY DORSAL SPINE-NO RADIOLOGICAL

ABNORMALITY DETECTED IN SPINE

CT BRAIN-Evidence of moderately defined rounded minimally enhancing iso to hypodense lesion with surrounding white matter edema noted in right parieto occipital region and left temporal regions. No evidence of mass effect& midline shift. To consider the possibility of multiple granulomatous lesions involving right parieto occipital region & left temporal region.

Neuro opinion- multiple tuberculoma. Advice to continue ATT

DIAGNOSIS ANDMANAGEMENT

TUBERCULOSIS/PLEURAL EFFUSION/MULTIPLE TUBERCULOMA/?POTT’S SPINE/PARAPARESIS

STARTED ON CAT I ATT/STEROIDS/NSAIDS/

PT CONDITION DIDN’T IMPROVE. REFERRED TO DEPARTMENT OF MEDICINE STANLEY MEDICAL COLLEGE ON 15/6/2008 FOR FURTHER MANAGEMENT.

DEPARMENT OF MEDICINE,GSHPt. a 40 year old on ATT cat I for multiple

tuberculoma/?Pott’s spine admitted with C/o back pain 2 months,difficulty in using both lower limbs for the past 17 days. decreased sensation below coastal margin-17 days c/o bowel and bladder disturbance-4 days

c/o difficulty in using both lower limbs, insidious onset , slowly progressive,spastic and now complete inabilty to use both lower limbs

Constricting band like sensation at the level of Xiphi sternum decreased sensation below that level.

c/o breathlessness, right sided chest pain, cough

No other specific complaints

o/e pt. conscious , oriented , afebrile, hydration fair, pallor +, grade II clubbing, Dyspnoeic , tachypnoeic, accessory muscles of respiration active

Vitals- stableCVS-WNLRS- trachea in midline, diminished respiratory

movements in right hemi thorax, chest expansion 2 cm only on left side, BBS in right side with VF/VR in right side dull on percussion

PA-WNL

RIGHT

CNS HF-wnlSPINOMOTOR

RIGHT LEFT

BULK N N

TONE UL N N

LL

POWER

UL 5/5 5/5

LL 0/5 0/5

DTR UL ++ ++

LL +++ +++

ABDOMINAL ABSENT ABSENT

PLANTAR EXTENSOR EXTENSOR

CRANIAL NERVES/CEREBELLAR/EXTRAPYRMIDAL-WNL

SENSORY SYSTEM-DECREASED BELOW D6GIBBUS ,TENDERNESS D2,D3,D4BOWEL/BLADDER INCONTINENCE PRESENT,

BLADDER SENSATION LOST

INVESTIGATIONSRBS-87MG%,BLOOD UREA-20MG%,SR. CREAT-

0.8MG%,SR.NA+-142MEQ/L,K+-4.1MEQ/LCHG HB%-9.6MG%,ESR-20/45MM,PLT CT-1.4

L,WBC-10,400 CELLS/CU.MM, DC-P62L36E2CXR HOMOGENOUS OPACITY ON RIGHT SIDEUSG ABDOMEN- CONSOLIDATION RIGHT LUNGECG-WNLLFT- WNL (SAP-67 IU/L)

MRI SPINE WITH SCREENING OF BRAIN-METASTASIS IN D3D4 CAUSING SIGNIFICANT CORD COMPRESSION, SMALL METASTASIS IN D8D9

MULPIPLE LARGE METASTASIS BRAINMASS RIGHT LUNG(?SARCOME/?CARCINOMA)

ULTRASOUND GUIDED TRANSTHORACIC NEEDLE ASPIRATION- CLUSTERS OF SMALL ROUND CELLS WITH DARK STAINING NUCLEUS AND INCONSPICUOUS NUCLEOLI. FEW AREAS SHOW DYSCOHESIVE CELLS S/O SMALL CELL CARCINOMA.

DIAGNOSISSMALL CELL CARCINOMA- STAGE IVPARA PLEGIA DUE TO COMPRESSIVE

MYELOPATHY D4 LEVEL EXTRADURALEXTRAMEDULARY-SENSORY LEVEL D6/MOTOR LEVEL D6 SECONDARIES SPINE AND SECONDARIES BRAIN

Small cell carcinoma

The current classification of subtypes of small cell lung cancer are:

small cell carcinoma mixed small cell/large cell carcinoma combined small cell carcinoma (small cell

lung cancer combined with neoplastic squamous and/or glandular components)

Standard:

1. Combination chemotherapy with one of the following regimens and chest irradiation (with or without PCI given to patients with complete responses):

The following regimens produce similar survival outcomes: EC: etoposide + cisplatin + 4000-4500 cGy chest radiation therapy ECV: etoposide + cisplatin + vincristine + 4500 cGy chest radiation

therapy2. Combination chemotherapy (with or without PCI in patients with complete responses), especially in patients with impaired pulmonary function or poor performance status. 3. Surgical resection followed by chemotherapy or chemotherapy plus chest radiation therapy (with or without PCI in patients with complete responses) for patients in highly selected cases.

TREATMENT-LIMITED STAGE DISEASE

TREATMENT-EXTENSIVE STAGE DISEASE

Standard:

1. Combination chemotherapy with one of the following regimens with or without PCI given to patients with complete responses:

The following regimens produce similar survival outcomes: CAV: cyclophosphamide + doxorubicin + vincristine CAE: cyclophosphamide + doxorubicin + etoposide EP or EC: etoposide + cisplatin or carboplatin ICE: ifosfamide + carboplatin + etoposide

Other regimens appear to produce similar survival outcomes but have been studied less extensively or are in less common use, including:

cyclophosphamide + methotrexate + lomustine cyclophosphamide + methotrexate + lomustine + vincristine cyclophosphamide + doxorubicin + etoposide + vincristine CEV: cyclophosphamide + etoposide + vincristine single-agent etoposide

2. Radiation therapy to sites of metastatic disease unlikely to be immediately palliated by chemotherapy, especially brain, epidural, and bone metastases.

SPINAL CORD COMPRESSION AND CANCEROncological emergencyOccurs in 5-10% of patientswith cancerLung cancer is the most common cancerLung,breast and prostrate are the main

offendersLymphomas,melanoma,renal cell

carcinoma and genito urianary cancers are few others

Thoracic spine (commonest-70%)Lumbosacral(20%)Cervical spine (10%)The most common initial symptom is localized

back painPatient with cancer developing back pain

should be evaluated as quickly as possible.Early treatment-better prognosisUpto 75%patients who are ambulatory remain

ambulatory. But only 5-10% of patients with paraplegia recover walking capacity.

Radiological findingsErosion of pedicles(the winking owl sign) is

the earliest findingOthers include increased inter pedicular

distance,vertebral destruction,lytic or sclerotic lesions, scaolloped vertebral bodies and vertebral body collapse.(though not specific)

Normal appearance on plain films does not exclude the diagnosis of cancer

Paraplegia with unknown primarySimple work up1.Chest radiography2.Mammography3.PSA4.Abdominal CT

MANAGEMENTRadiation plus glucocorticoids is the initial

treatment of choiceIndications for surgical intervention1.Unknown aetiology2.Failure of radiation therapy3.Radioresistant tumours(melanoma,renal

cell carcinoma)4.Pathological fracture dislocation5.Rapidly evolving neurological symptoms

At present laminectomy is used only for tissue diagnosis

As most cases involve anterior or anterolateral extradural disease, resection of anterior vertebral body with the tumour followed by spinal stabilisation has better results.

Chemotherapy is used for chemosensitive tumours with prior radiation and not fit for surgery.

Prostrate cancer patients can be given hormonal therapy if not given earlier in addition to forementioned forms

Percutaneous vertebroplasty, the injection of acrylic cement mat benefit

Treatment of spinal epidural metastasis improves patient survival and functional state

Osama O. Zaidat, MD and Robert L. Ruff, MD PhD From the Neurology Service and Rehabilitation and Spinal Cord Injury and Dysfunction Care Line, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, and Department of Neurology, Case Western Reserve University, Cleveland, OH.

Objectives: To determine factors affecting the success of radiation therapy (RT) of spinal epidural metastases and patient survival after RT.

Design/Methods: One hundred thirty-nine male veterans with an initial spinal epidural metastases treated with dexamethasone and RT were evaluated prospectively. Patients were followed until death.

Results: At presentation, 84 patients could walk. After RT, 119 patients walked. The likelihood of regaining ambulation increased if treatment began <12 hours after loss of ambulation and if patients had bladder and bowel function and sacral sensory sparing. Treatment reduced pain levels, and ambulatory patients had less pain compared with nonambulatory patients. Median length of survival was 104 weeks for ambulatory patients and 6 weeks for nonambulatory patients. Mean interval between loss of ambulation and death was 4.0 ± 0.5 weeks. Recurrent spinal epidural

metastases occurred in 8.63% of patients.

Conclusions: Patients who walked after treatment lived longer, were ambulatory for most of their remaining life, had less pain, and had a lower incidence of depression.

Causes of Misdiagnosis and Mistreatment of Spinal Tuberculosis With Radiotherapy in Nonendemic Areas: A Pitfall in Diagnosis and Treatment: Hazards of Radiotherapy on the Tuberculous Lesion. Case Report Spine. 30(11):E300-E304, June 1, 2005.Jutte, Paul C. MD *; van Altena, Richard MD +; Pras, Elisabeth MD, PhD ++; Thijn, Cees J.P. MD, PhD [S]

Abstract: Study Design. Report of initially misdiagnosed and mistreated cases.

Objectives. To report a previously undescribed misdiagnosis and subsequent mistreatment with radiation for tuberculosis of the spine and to promote awareness for tuberculosis in nonendemic areas.

Summary of Background Data. It is not seldom that radiation therapy is provided for suspected malignant spinal lesions without histologic confirmation. Literature is not available on harmful effects of radiation therapy for tuberculosis of the spine.

Methods. Clinical case analysis for initial misdiagnosis and mistreatment, analysis of subsequent clinical course.

Results. Two patients received radiotherapy on spinal lesions of suspected malignant origin. In both patients, the lesions were of tuberculous origin and the lesions increased during radiotherapy. In Case 2, the paraplegia did not heal.

Conclusion. In cases of a spinal lesion of unknown origin, tuberculosis should always be considered. Adequate biopsy for cultures and histology is mandatory. Radiotherapy locally aggravates tuberculous spinal lesions.

ACKNOWLEDGEMENTSDR SUKUMAR,INTERVENTIONAL

RADIOLOGIST,SGEDEPT. OF PATHOLOGYPATIENT AND HIS FAMILY

THANK U