Spondylolisthesis with Osteoporosis

Patient Details

IP Number: 716

Age: 34 y

Gender: Female

Weight: 49 kg

Unit: Orthopaedics II

DOA: 25/3/14

DOD: 31/3/14

Reason for Admission:c/o lower backache since 2 months

Patient was apparently normal 8 monthsback, when she developed lowerbackache, which was insidious in onset,gradually progressive, non radiating,digging type and not associated withtingling sensation.

Pmhx: NS

Fhx: NS

Diet: Vegetarian

Appetite: Normal

Bowel & Bladder: Normal

Sleep: Normal

Allergies: NKA

Spondylolisthesis with Osteoporosis

DAY 1PULSE: 82 bpm BP: 120/80 mmHg

o/e:

Spine

Inspection: no visible spinal deformity

no scars, swelling

Palpation: spinous tenderness + over L4

and L5 spinous processes

paraspinal spasm +

no paraspinal tenderness

B/L SI joint tenderness +

SLR Examination

Right Left

SLR 45° 30°

LF + +

PF + +

FHL 5/5 5/5

EHL 5/5 5/5

Reflex Examination

Right Left

Knee + +

Ankle + +

Plantar

Adv: Hb, BC, CT, PT-INR, Blood Urea, Serum Creatinine, Urine Routine, X-ray

Referred for Physiotherapy

Treatment Chart

Current Drugs Dose Route Freq

Calcitriol + Calcium Carbonate + Zinc

0.25 mcg+ 500 mg + 7.5 mg

PO 1-0-0

Nimesulide + Tizanidine

100 mg + 2 mg PO 1-0-1

Pyridoxine + Folic Acid + Alpha Lipoic

acid

PO 0-0-1

DAY 2

BP: 130/70 mmHg

Case reviewed

GC fair

Vitals stable

CST

Laboratory InvestigationsHematologyHb 11.1 gm/dl (13.5 ± 2)

WBC 7,500 cells/cu.mm (4000-11,000)

DLC N 68%

E 03%

B 00%

L 26%

M 03%

PLT 2.39 l/cu.mm (1.5-5)

ESR 48 mm/hr (0-20)

Biochemistry

RBS 94 mg/dl (70-150)

Urea 23 mg/dl (19-43)

Secr 0.8 mg/dl (0.6-1.5)

Urine Analysis

Pus cells 2-4

Electrolytes

Na 132 mEq/L (133-144)

K 4.1 mEq/L (3-5.5)

Cl 102 mEq/L (95-105)

X-RAY Report

Lumbar X-ray shows first degree spondylolisthesis with gross

osteoporosis

Treatment Chart

Current Drugs Dose Route Freq

Calcitriol + Calcium Carbonate + Zinc

0.25 mcg+ 500 mg + 7.5 mg

PO 1-0-0

Nimesulide + Tizanidine

100 mg + 2 mg PO 1-0-1

Pyridoxine + Folic Acid + Alpha Lipoic

acid

PO 0-0-1

DAY 3BP: 100/70 mmHg

Case reviewed

GC fair

Vitals stable

CST

Treatment Chart

Current Drugs Dose Route Freq

Calcitriol + Calcium Carbonate + Zinc

0.25 mcg+ 500 mg + 7.5 mg

PO 1-0-0

Nimesulide + Tizanidine

100 mg + 2 mg PO 1-0-1

Pyridoxine + Folic Acid + Alpha Lipoic

acid

PO 0-0-1

DAY 4

BP: 100/62 mmHg

Case reviewed

GC fair

Vitals stable

Pre-operative instructions:

Posted for epidural steroid tomorrow

Drugs Dose Route Freq

Alprazolam 0.5 mg PO HS

Ranitidine 150 mg PO HS

Treatment Chart

Current Drugs Dose Route Freq

Calcitriol + Calcium Carbonate + Zinc

0.25 mcg+ 500 mg + 7.5 mg

PO 1-0-0

Nimesulide + Tizanidine

100 mg + 2 mg PO 1-0-1

Pyridoxine + Folic Acid + Alpha Lipoic

acid

PO 0-0-1

DAY 5

BP: 110/60 mmHg

Operative Procedure:

Injection Methylprednisolone 80 mg + 6cc 0.25% bupivacaine

Treatment Chart

Current Drugs Dose Route Freq

Calcitriol + Calcium Carbonate + Zinc

0.25 mcg+ 500 mg + 7.5 mg

PO 1-0-0

Nimesulide + Tizanidine

100 mg + 2 mg PO 1-0-1

Pyridoxine + Folic Acid + Alpha Lipoic

acid

PO 0-0-1

DAY 6

BP: 110/60 mmHg

Post epidural 80% pain relief

GC fair

Vitals stable

CST

Treatment Chart

Current Drugs Dose Route Freq

Calcitriol + Calcium Carbonate + Zinc

0.25 mcg+ 500 mg + 7.5 mg

PO 1-0-0

Nimesulide + Tizanidine

100 mg + 2 mg PO 1-0-1

Pyridoxine + Folic Acid + Alpha Lipoic

acid

PO 0-0-1

DAY 7

BP: 110/60 mmHg

Case reviewed

GC fair

Vitals stable

Adv: Discharge

Discharge Medications

Current Drugs Dose Route Freq

Calcium Carbonate+ Vitamin D3

625 mg + 125 IU

PO 1-0-0

Nimesulide + Tizanidine

100 mg + 2 mg PO SOS

Pyridoxine + Folic Acid + Alpha Lipoic

acid

PO 0-0-1

Pharmaceutical

Care Plan

Subjective Evidence

• Low backache since 2 months

Objective Evidence

• Spinal examination

• X-ray

• Elevated ESR

Final Diagnosis

Spondylolisthesis with gross osteoporosis

Goals of TherapyFor Spondylolisthesis• To relieve the back pain (associated with an irritated

nerve)

• Restoring spinal flexibility and improving range ofmotion

• Stopping the progression of slippage

For Osteoporosis• To decrease pain

• To prevent bone loss

• To prevent fractures

• To help the patient to return to the highest level of function and independence possible, while improving the overall quality of life

Goals Achieved

• 80% pain reduction was observed by day 6

Specific Treatment Options

For Spondylolisthesis

• Conservative treatment

NSAIDS

Epidural steroid

injections

Brace

Physical therapy

For Osteoporosis

• Non pharmacological therapy

Calcium

Vitamin D

Exercise

Monitoring Parameters

Disease Specific

X-ray

BMD

Drug Specific

Serum calcium level

Kidney Stones

LFTs

Problems Identified

• BMD was not performed

• Serum calcium and phosphorous levels were not determined

• Use of nimesulide

Patient Counseling about

DiseaseSpondylolisthesis Osteoporosis

Medication Counseling

Lifestyle Modifications

• Vit K• Mg• Phytoestrogen• Protein