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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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HISTORY OF PRESENT ILLNESS
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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HISTORY OF PRESENT ILLNESS
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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HISTORY OF PRESENT ILLNESS
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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HISTORY OF PRESENT ILLNESS
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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PHYSICAL EXAMINATION
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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PHYSICAL EXAMINATION
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