General Data

General Data

• 24 years old • Female• Single• Marilao, Bulacan

• Chief ComplaintWeakness of both lower extremities

History of Present Illness

1 mont

h PTA

•Intermittent, non-radiating back pain graded 4/10 between the scapular area

•Piroxicam 20mg/tab 1 tab OD relief

3 weeks PTA

•Back pain even at rest

•Piroxicam temporary relief

•Numbness of both lower extremities

•No consult done

8 days PTA

•Persistence of back pain

•Progression of numbness to abdominal area

•Sought consult at a hospital in Bulacan•Xray of

spine: Normal results

History of Present Illness

5 day

s PTA

•Persistence of symptoms accompanied by urinary straining and sensation of bladder fullness

•Difficulty in urination and defecation

2 day

s PTA

•Sought consult at USTH ERCD•Could not

ambulate•MMT 4/5

on both lower extremities

•MRI of lumbar spine requested but not done

•Discharged with unrecalled diagnosis

History of Present Illness

1 day PTA

•Upon waking up, could no longer move lower extremities

•Sought consult again at USTH ERCD•MRI of

lumbar spine: Done outside

Few hours PTA

•Came back with MRI results

ADMISSION

Past Medical History

• (+) Primary complex at 2 years old, treated for 3 months only

• No DM, HPN, asthma• No allergies• No previous surgeries

Obstetrical History• G0P0• Menarche: 12 years old• Interval: 28-30 days• Duration: 4-5 days• Amount: 3 pads per day, fully soaked• Symptoms: Occasional dysmenorrhea• LMP: November 20, 2008• PMP: October 22-25, 2008• 1st sexual contact at 18 years old• 2 sexual partners• No post coital bleeding, no dyspareunia, no family planning methods

used

Family History

• (+) HPN, asthma, PTB – father• No DM, cancer

Personal & Social History

• Non-smoker• Occasional alcohol beverage drinker

Physical Examination

• Conscious, coherent, not in distress• BP 110/70mmHg PR 85bpm RR 20cpm T37.3°C• Warm, moist skin, no active dermatoses• Pink palpebral conjunctivae, anicteric sclera• Supple neck, no palpable cervical

lymphadenopathies• Adynamic precordium, AB 5th LICS MCL, no

murmurs• Symmetrical chest expansion, clear breath sounds

Physical Examination

• Globular abdomen, NABS, bulging flanks, (+) fluid wave, (+) shifting dullness, soft, non-tender, no palpable masses

• Abdominal circumference: 87cm• DRE: No fissures/anal lesions, tight sphincteric

tone, no pararectal tenderness, smooth rectal mucosa, lower pole of masses cannot be appreciated, no blood on examining finger

Physical Examination

• External genitalia: No gross lesions• IE– Cervix firm, long, closed; – Uterus normal sized, pushed posteriorly; – (+) 6x5cm firm, slightly fixed, non-tender mass,

right, seemingly anterior to the uterus– (+) 5x4cm firm, slightly fixed, non-tender mass,

left, seemingly anterior to the uterus

Neurologic Examination• Conscious, coherent, oriented to 3 spheres• Pupils 2-3mm ERTL, (+) direct and consensual light reflex• EOMs full and equal, no visual field cuts• No gross facial asymmetry, can frown, puff cheeks, raise eyebrows• (+) gag reflex• Can turn head side to side with resistance, tongue midline on protrusion• No atrophy, no fasciculations, no spasticity• MMT 5/5 on both upper extremities; 0/5 on both lower extremities• Can do FTNT and APST with ease• DTRs ++ both upper extremities, hyperreflexia on both lower extremities• 100% sensory deficit T9 below, 20% sensory deficit T8, 30% sensory

deficit T7; intact sensory T6 and above• (+) Babinski, bilateral

SALIENT FEATURES

Course in the Ward

• Repeat CBC• leukocytosis with neutrophilic

predominance• Medications• Dexamethasone 5mg/IV q6• Omeprazole 40mg/tab 1 tab OD• Domperidone 10mg/tab q8• Mefenamic acid 500mg/tab q6

On Admission

Course in the Ward

• Paracetamol + Tramadol q6• Gabapentin 300mg/cap 1cap ODHS

2nd HD

• Referred to Rehab Med• Spinal orthosis• Bedside physiotherapy

3rd HD

• Referred to Gynecologic Oncology service

4th HD

Course in the Ward

• Progression of sensory deficit from T6 to T4• Weakness of RUE grip to 3/5• Dexamethasone 5mg/IV q6• Referrals• Neurosurgery• Medicine Oncology• Radiation Oncology

• Laboratory Tests• B-HCG• AFB• CA 125-5

5th HD

• Emergent radiotherapy

6th HD

Course in the Ward

• Scheduled for barium enema

8th HD

• Neurologic status was stable• Laboratory tests• Urinalysis

• Ciprofloxacin 500mg/cap, 1cap BID

10th HD

• Improvement on grip and sensory level to T6• On day 8 RT• Problem: decubitus ulcer Gr 1-2• Calmoseptin cream on affected area

14th HD

Course in the Ward

• UGI series with small intestinal series

15th HD

• Pelvic laparotomy• Repeat Hgb, Hct

18th HD

• Cefoxitin shifted to Cefuroxime 500mg/cap, 1 cap q8

21st HD

• (+) feel defecation and passage of flatus• (-) feel bladder fullness• (+) crackles on both lung fields

• Nebulization, hooked to O2 3-4LPM• Repeat CXR• Repeat CBC

24th HD

Course in the Ward

• Laboratory Tests• CBC with peripheral smear• PT, aPTT• FDP, D-dimer

25th HD

• (+) cough with greenish sputum• Febrile• Cefuroxime shifted to Levofloxacin 750mg/tab OD• Sputum G&S

26th HD

• Persistent fever and chills• Repeat urinalysis

27th HD

Course in the Ward

• Hypotensive, tachycardic, tachypneic• Levophed drip

• Advised transfer to MICU, relatives did not consent• Blood C&S requested• Imepinem 500mg/IV q6• ABG

• Compensated metabolic acidosis with more than adequate oxygenation

• Repeat CXR• Consolidation on both lower lung fields

• 4 ‘u’ platelet concentrate transfused

25th HD

Course in the Ward

• Altered sensorium (GCS 8)• Intubated, hooked to mechanical ventilation• Hypotensive at BP 70/40• Dopamine and dobutamine drip

• Continued to deteriorate• Relatives instituted DNR order

1:35 p.m.

• Cardiopulmonary arrest• Expired

12:05am

Laboratories & Ancillaries

D1 D5 D18 D24 D27 D28

Hgb 124 125 116 96 115 105

Hct 0.37 0.37 0.34 0.28 0.33 0.31

RBC 4.98 4.79 3.8 4.3 3.96

MCV 75 77.8 73.2 77.2 77.8

MCH 25 26.1 25.1 26.8 26.5

MCHC 33 33.5 34.3 34.7 34

Plt 311 384 20 80 20

WBC 14.2 16.3 4.5 3.9 1.5

Seg 0.89 0.91 0.41 0.26 0.85

Lympho 0.07 0.09 0.59 0.72 0.01

Eos 0.01 - - - -

Mono 0.03 - - 0.01 0.01

Bands - - - 0.01 0.10

Meta 0.03

nRBC 2

D1 D2 D14 D23 D25

Na 138 131 141

K 4.2 3.9 3.5

Crea 0.72 0.68

D25

PT 11.1

NC 12

INR 0.9

aPTT 27.3

NC 36.9

D-dimer 690

FDP 10

D1 D10 D28

Color Slightly yellow Light yellow Yellow

Transparency Slightly turbid Turbid Turbid

pH 7 8 6

SG 1.005 1.015 1.020

Albumin Negative Negative +

Glucose Negative Negative Negative

RBC 0-1 6-8 3-6

Pus cells 2-5 1-3 0-2

Squamous cells ++ Few

Bacteria ++ ++++ ++++

A. Urate ++

A. Phosphate +++

Triple Phosphate +

• Peripheral Smear (D25): hypochromic RBC with anisocytosis, no abnormal WBC seen

• D5: AFP – 2.67 ng/mL (0-7) Beta HCG – 0 mIU/mL (non-pregnant: 0-2.9) CA 125 – 297.6 U/mL (0-35)

• Sputum GS (D26): g(+) cocci singly in pairs and in clusters: ++ g(-) bacilli: +++ g(+) yeast-like cells: few PMNs: >25/lpf Squamous epithelial cells: >25/lpf

MRI of the Whole Spine

• Epidural soft tissue mass at level of C7-T8 producing severe compression of the spinal cord

• Paravertebral soft tissue densities observed at level of lower cervical, mid and lower thoracic, lower lumbar and sacrum

• Patchy areas of abnormal marrow signals seen in vertebrae, iliac bone, and femoral heads

MRI of the Whole Spine

• Solid soft tissue masses demonstrated, largest measuring 5.1 x 5.6 in transverse and vertical dimensions

• Visualized portion of stomach thickened• Cervical alignment straightened, unremarkable

craniocervical junction, visualized brain shown no abnormality, normal alignment of thoracic and lumbar spine, conus medullaris ends at L1

• No abnormal enhancement in the pelvis and spine

Transvaginal Sonography

• Normal sized uterus• Proliferative endometrium• Adnexal masses, bilateral; consider ovarian

newgrowths• Minimal ascites

Single-contrast barium enema• No significant findings

Upper GI series with small intestinal series• Unremarkable UGIS with

small intestinal follow through

Differential Diagnosis

Cauda Equina Syndrome• Cauda equina (CE) – formed by nerve roots caudal

to the level of spinal cord termination• Cauda equina syndrome (CES) – results from

mechanical compression of cauda– Nerve root lesion (peripheral nerve injury)– Irreversible– Presents with the following:

• Back pain• Unilateral or usually bilateral sciatica• Saddle sensory disturbances• Bladder and bowel dysfunction• Variable lower extremity motor and sensory loss

Intramedullary Spinal Cord Abscess

• Mechanisms of infection:– Hematogenous spread from an extraspinal focus of infection– Contiguous spread from an adjacent focus of infection– Direct inoculation (i.e., penetrating trauma, post-

neurosurgery)– Cryptogenic mechanisms (i.e., no documented extraspinal

focus of infection)• Fever• Radiculopathic pain• Neurologic deficit

Spinal Epidural Abscess

• Hematogenous spread with seeding of epidural space is the suspected source of infection

• The expanding suppurative infection can compress the spinal cord

• Produces motor and sensory dysfunction• Depending on location it can ultimately lead to

paralysis and even death• Staphylococcus aureus: most common

pathogen

Pott’s Disease

• Also known as tuberculous spondylitis• Back pain is the earliest and most common symptom• Almost all have some spine deformity• The basic lesion is a combination of osteolyelitis and

arthritis that usually involved more than one vertebra

• Progressive bone destruction leads to vertebral collapse

• Abscesses, granulation tissue or direct extension of lesion can compress spinal cord

Amyotrophic Lateral Sclerosis• Familial (autosomal dominant) and sporadic forms (90-95%

of cases)• Motor axons die by Wallerian degeneration, large motor

neurons are affected to a greater extent• Death of the anterior horn cell body, leading to

degeneration• F>M (2.1:1.5)• Peak age at onset occurs from 55-75 years (mean: 62)• Muscle weakness usually is asymmetric• Signs of mixed upper and lower motor neuron involvement• In patients with bulbar involvement, speech may be

impaired

Multiple Myeloma

• Spinal cord compression is one of the most severe adverse effects

• As many as 20% develop spinal cord compression

• Symptoms include: back pain, weakness, paralysis in the legs, numbness, dysythesias in the legs

• Frequent complication: pathological function

Non-Pharmacologic Management

Rehabilitation

• Spinal Orthotics – stabilize patients spine and decrease spinal pain by limiting motion

• Prophylactic fixation of upper extremity lesions to aid mobility and weight bearing

Psychologic Interventions

• Patient preparation• Patient may complain of issues such as loss of

independence• Emotional support• Family participation

Pharmacologic Management

Symptomatic Therapy

• Constipation, spinal instability, pain, and psychological and social distress

• Constipation arises in these patients from autonomic dysfunction, inactivity, and opioids

• Must be treated aggressively because the pain of cord compression increases with a Valsalva maneuver, such as straining at stool

• Osmotic agents, such as polyethylene glycol 3350 (MiraLax), are often needed in addition to stool softeners and stimulants to promote regular, soft stools

• Control of pain: opioids and adjuvants for nerve and bone pain

• Corticosteroids are effective adjuvants• NSAIDs for those unable to take

corticosteroids

Corticosteroids• Used most commonly in patients that develop

spinal cord compression with neurologic deficits• Glucocorticoids with antioxidant or antioxidant-like

activity (such as methylprednisolone) – Reduce the release of total free fatty acids (including

arachidonic acid) and prostanoids and prevent lipid hydrolysis and peroxidation, thereby reducing injury from traumatic spinal cord injury

• Dexamethasone I– Inhibits PGE2 and VEGF production and activity and, as a

consequence, decreases ischemic edema, which is partially mediated by increased levels of PGE2 and VEGF

• Studies in animal models indicate a dose-dependent response of vasogenic edema to corticosteroids, even without radiation therapy

• High doses of corticosteroids – better than low doses in reversing edema and improving neurologic

function • Loading dose of 10 to 100 mg is administered, followed by a 16- to

96-mg/day maintenance dose• High doses have been recommended (100 mg loading dose followed

by 24 mg every 6 hours × 3 days) to quickly restore ambulation, although may increase the incidence of serious adverse effects

• Adverse effects of steroids – insomnia, increased appetite, edema, hyperglycemia, leukocytosis,

increased risk of infection, and gastrointestinal bleeding

21-aminosteroids

e.g. U-74006F • 21-aminosteroids that lack glucocorticoid or

mineralocorticoid activity• These potent inhibitors of lipid peroxidation

for the acute treatment of central nervous system trauma and ischemia

• Inhibit the release of free arachidonic acid from injured cells

Analgesics

• Opioid and non-opioid• Mild pain– Nonsteroidal anti-inflammatory drugs (NSAIDs) and

acetaminophen are – Acetaminophen-preferred in patients with

thrombocytopenia, renal dysfunction, those receiving nephrotoxic agents, or at risk for gastrointestinal bleeds

– In patients with liver dysfunction, NSAIDs are preferred for mild pain

Analgesics

• Moderate to severe pain– Opioid analgesics– begin with low doses of immediate release agents

(typically 5-15 mg per os morphine or 2-4 mg intravenous morphine)

– Reassess patient every 1 to 2 hours for effect– After 24 hours of pain control on a short-acting

regimen, patients should be converted to a long-acting agent (morphine, oxycodone, fentanyl, or methadone).

“ Radiation therapy is also the standard of care. Radiotherapy is delivered to the site of disease and to one or two levels above and below. It is typically given as 3,000 cGy in 10 300-Gy fractions. With this regimen, 50% of patients are able to walk again, Dr. Wen noted”

management of spinal cord compression, journal of supportive oncology, volume 6, 2008

Prognosis

• Dependent upon histology• Better outcome with early diagnosis and

treatment • Permanent disability is likely

Prognosis

• Radiotherapy + Glucocorticoids up to 75% of patients treated when

ambulatory remain ambulatory only 10% of patients with paraplegia recover

walking capacity

Prognosis

• Surgery a randomized trial show that patients who

underwent surgery followed by radiotherapy retained the ability to walk significantly longer than those treated with radiotherapy alone