spinal tuberculosis / pots' disease- case-presentation- ...
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SPINAL-TUBERCULOSIS-POTT-S-DISEASE- CASE-PRESENTATION-At-Shaheed-Suhrawardy-Medical-College-Hospital-Dhaka-Bangladesh (1)TRANSCRIPT
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Department Of Orthopaedics&Traumatology.SheedSuhrawardyMedical College Hospital, Dhaka-1207, Bangladesh.
Case Presentation-
From -
“A patient with gradual walking impairment”
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Presenting By- Dr. GolamMahamud Suhash,From Department of Orthopedic & Traumatology, Shaheed Suhrawardy Medical College Hospital, Dhaka-1207. Bangladesh.
Prepared By-Dr. Md Nazrul IslamMBBS, M . sc. (B M E).
“A patient with gradual walking impairment”
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PARTICULARS OF THE PATIENT
• Name- Mr. Ali Akbar• Age- 57 Years• Sex- Male• Occupation- govt.
Service Holder• Address- B-14,G-
8,Agargong• Date of Admission -
20/10/2009.
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CHIEF COMPLAINTS
• Weakness of left leg – one & half months.
• Unable to walk – one & half months.
• Evening rise of temperature – one & half months.
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HISTORYOF PRESENT ILLNESS
Mr. Ali Akber was alright – two & half months back.
Then he noticed gradual weakness of his left leg which lead him initially only to able to stand and walk for about 1-2 min. with help.
After 2-3 days, he can only able to stand only but fails to walk.
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HISTORYOF PRESENT ILLNESS(continues)
He also complains of evening rise of temperature for the same duration lasting for about 4-5 hours that relived spontaneously followed by sweating.He denied any H/O trauma, heavy weight lifting or abnormal jerking. Patient is Asthmatic, but free from Hypertension and Diabetes. His bowel and bladder habit is normal
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HISTORY OF PAST ILLNESS
• History of low back pain for last 7-8 years. History of pleural effusion – 7 years back. He is asthmatic and hypertensive but non diabetic.
• No history of exposure of TB case. • Family History- Nothing Contributory.• Socioeconomic History- Middle class
family.• Personal History-Patient is non
alcoholic/smoker.• Drug History: (At present continuing) - Tab. Diola, Tab. Bukof, Tab. Contin,
Salmolin inhaler, Anti TB ( For 6 weeks) .
• Immunization History- Patient is properly Immunized.
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PHYSICAL EXAMINATION
General Examination• Appearance – Normal.• Cooperation –
Cooperative.• Mental Status –
Intelligent.• Decubitus – Lying.• Body Build – Average.• Skin Condition – Normal.• Hair Distribution –
Normal.• Anemia – Absent• Jaundice – Absent• Cyanosis – Absent.
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General Examination( Continues)
Clubbing – AbsentTemperature - 98°FPulse – 82/ min.BP – 140/80mm/HgLymph node – • Cervical• Axillary• Inguinal • Para-aortic• Others.
General Examination
Not
Pal
pab
le
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LOCAL EXAMINATION
LOOK – Bulging in the middle
of Lumber spine. No scar mark, discharging sinus or pigmentation.
FEEL – Overlying skin is free.
Fullness of mid Lumber region with spasm. Size - about 2cm×2cm.
MOVE – Flexion Extension Lateral bending
Pain
ful
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SYSTEMIC EXAMINATION
Locomotors system:
Gait:- Unable to walk. Limb Joints :- Normal. Spinal movement: Restricted & Painful. Deformity:-Absent .
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SYSTEMIC EXAMINATION
Nervous System
Motor Assessment:ROM:SLR – Lt 30 dreg,Rt 60 dregPower of muscle: Lt-2/5,Rt-4/5Tone: Decreased at Lt lower limb.Bulk: NormalSensory: All sensory response at L5 & S1 reduced on left leg., and on right side intact.
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SYSTEMIC EXAMINATION(Continues)
Reflexes: Planter- Bilaterally Flexor. Ankle jerk : Left -
diminished Right -normal Knee jerk: Left - normal. Right- normal. Clonus: Absent.
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SYSTEMIC EXAMINATION(Continues)
Patient has been suffering from asthma over the past few years, but continues to keep well by proper medical management.
Respiratory System:
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SYSTEMIC EXAMINATION(Continues)
•Cardiovascular System : NAD.
•GI System : NAD.•Genito-Urinary System : NAD.
Other Systems:
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Salient feature
Mr. Ali Akbor aged 57 admitted on 20/10/09 with the complaints of Weakness of left leg – Two & half months, Evening rise of temperature – and half months, Unable to walk – one & half months.He had no H/O trauma, heavy weight lifting or abnormal jerking. His bowel and bladder habit is normal. Muscle power at left side is 2/5, reduced sensation at L5 & S1. ROM:SLR – Lt. 30 dreg, Rt. 60 deg. Tone: Decreased at Lt lower limb. Ankle jerk is diminished.
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DIFFERENTIAL DIAGNOSIS
• Pyogenic Infection• ProlapseIntervertebralD
isc (PLID)• Primary Bone Tumor• Secondary Bone Tumor.• Pot's disease.
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INVESTIGATION
CBC - Hb%: 12 gm/dlESR : 120mm/1sthourTotal Count of WBC:11000/cmmDifferential Count of WBC:
N-62%L- 35%E-02%M-01%
RBS : 13.6mg/dl
General
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INVESTIGATION( Continues)GENERAL
Urine for R/M/E:RBC : nil/HPFPus cell : 01-03/HPFEpithelial cell:
2-3/HPFS. Creatinine :1.2mg/dlChest X-ray :NormalECG : Normal ECG
findingUSG of whole abdomen:
No itraabdominallymphadenopathy.
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Specific investigation
MT: 18mm Anti TB IgG, IgM, IgA:
Positive
X-ray L-S- spine both view:
Disc space between L4 & L5 and L5&S1 is reduced with destruction of adjacent end plate. No obvious Para vertebral soft tissue swelling is noted.
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SPECIFIC INVESTIGATION
MRI:
Tubercular spondylitis at L4 &L5 level with peri-vertebral mass.Vertebral posterior bulging causing indentation of thecal sac.Disc space between L5 & S1 is reduced.Rt. Para-vertebral abscess .
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DIAGNOSIS -
(Pot's Disease).
Spinal Tuberculosis
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Management Objective of Treatment-
• To eradicate or at least arrest the disease.
• To prevent or correct deformity.
• To prevent or treat the major complication.
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For this patient the choice of Treatment is Operative(Clearance & Spinal fixation) adjunctive to Chemotherapy.
(Chemotherapy include –
Initially four drugs combination(Rifampicin + INH + Ethambutol + Pyrazinamide) – 2 months.
Followed by- Two drugs combination-Rifampicin + INH ) for 12 to 14 months.)
Management(Cont.)
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•Conservative Management failure.
•Progressive Neurological deficit.•Persistent neurological deficit.•Progressive enlargement of
abscess.•Decompression of large abscess.
Indication for operation
Management(Cont.)
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Drainage of abscess.Decompression and scraping of infected lesion.Decompression with bone graft.In presence of deformity- Correction of deformity and stabilization by internal fixation and fusion.
Management(Cont.)
Types of Surgery-
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Management(Cont.)
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Management(Cont.)
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Management(Cont.)
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Management(Cont.)
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Other treatment modalities
Medical Management-• Continuous bed rest with
chemotherapy.• Ambulant with chemotherapy• Ambulant, Chemotherapy with
spinal brace.Operative treatment-• Naked eye per-operative
appearance - Para-vertebral abscess which
is to be drained. With courtesy : Dr. Sk. Abbas uddin Ahmed.
Management(Cont.)
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Cautious movement. Continue medical treatment according to prescription. 3 months interval follow up.
Management(Cont.)
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Special thanks are due to –
Dr. (Associate Professor)Sheikh Abbas Uddin Ahmed,
&Dr. Subir Hossain for their nice co-operation.
Orthopedics & Traumatology Department, Shaheed Suhrawardy Medical College and Hospital, Dhaka- 1207, Bangladesh.
Thank you very much For Patience.