FIRM III – ORTHOPAEDIC
GRANDROUND PRESENTATION
BY
DR. ONDIGO
DR. SAULA
TOPIC: SPINAL METASTASIS
NAME : LWK
AGE : 58 YEARS
SEX : FEMALE
RESIDENCE : GITHUNGURI
D.O.A. : 18.09.2010
WARD : 6A
IP NO. : 0949850
CHIEF COMPLAINT
• Back pain
• Weakness of the left lower limb x 3 Years
HISTORY OF PRESENTING ILLNESS
Back pain
• Onset Jan. 2007
• Gradual
• Low back
• Sharp and Occasionally spasmodic
• Episodes last 30 minutes
• Radiates to left lower limb
• Severe on bending
• Relieved by diclofenac
Weakness of left lower limb
• Initial numbness
• 2008 involved in RTA
• walking with use of crutches
• Unable to stand straight
• Urine and stool incontinence
Associated
• Weight loss
• Poor appetite
• No history of
– Cough
– Night sweats
– Contact with TB patient
• 2009 Jan severe episode pv bleeding
• No blood in stool
• No history of breast swellings
Treatment
• 2008 May – anti TB at Kiambu District Hospital
August – TB spine diagnosed at KNH.
• 2009 Jan – Completed anti TB
– EUA of uterus done
– Abdominal u/s normal.
• 2009 June – Mammography done at Nairobi
hospital - normal.
• Followed up in SOPC Kiambu District Hospital
• Jan 2010 – referred to KNH
PMHX
1979 – RTA
- Splenectomy
1994 – Diabetes : diabenese
2008- Hypertension – inderol
- nifedipine
OBSTETRIC AND GYNECOLOGY
HISTORY
• Para 5 + 0
• Last delivery 1984
• 5 years post menopausal
• No use of contraceptive pills
FAMILY AND SOCIAL HISTORY
• Married
• Sales lady with Pfizer
• Mother was a diabetic
REVIEW OF SYSTEMS
RESPIRATORY
• No cough, difficulty in breathing, chest pains or
wheezing.
CVS
No dyspnea, palpations
GASTROINTESTINAL
No abdominal distension, masses or Para rectal
bleeding.
MUSCULOSKELETAL
• Generalized bone pains.
EXAMINATION
(i) General
• Fair general condition
• Not pale, jaundiced
• No lymphadenopathy, no oedema
• Vital signs
– RR 20/min Temp. 37.2oC
– PR 72/min Bp 170/100 mmHg
(ii) Back
• Walking with crutches
• Scoliosis to the left –
• loss of lumber Lordosis
• No gibbus
• Tenderness over T12, L1, L2
• Limited forward flexion
• Straight leg raising test positive
(iii) Lower Limbs
Left Rt.
Muscle bulky Normal Normal
Tone Normal Normal
Power4 5
Reflexes Ankle jerk Reduced Normal
Anal Reduced Reduced
Reduced anal sphincter tone
iv. Other systems
• CNS
• CVS Normal
• PA
DIAGNOSIS
RECURRENT TB SPINE
DDX – Spinal metastasis
- Spondylosis
- Chronic Spinal osteomyelitis
PLAN
• Admitted
• Investigations
(a) Laboratory
(I) Haemogramme + ESR
• WBC 11.3 x 109/L
N – 67%
L – 28% M 2.5% B 1.5%
E – 1%
RBC 4.37 x 1012/L – Normocytic normochronic
Hb 13.6 gm/dl
MCV 90 fl/L
Platelets 395 x 109/L
ESR 50mm/hr
(11)Liver function tests
• Total proteins 79.g/dl
• Albumin 46.4g/dl
• Globulin 22.6g
• AST 21 iu/L
• Alp 225 iu/L
• Bilirubin
T 11.8 ummol/L
D 2.8 ummol/L
• PTI 78%
(III) Urea creatinine and electrolytes
Urea 9.1 mmol/L
Creatinine 124 mmol/L
Sodium 140 mmol/L
Potassium 4.5 mmol/L
(IV) Serum . Calcium 2.48 mmol/L
Phosphate 1.0 mmol/L
(V) Urinalysis
- sugar +++
- No Bj proteins
(VI) Serum electrophoresis
- Normal protein electrophoretic pattern
(VII)Mantoux – 8mm
(VIII) Stool for occult blood – negative.
(b) Radiological
(i) Plain X-ras
Thoracolumber - Collapsed L1.
- Skull, cervical, pelvic normal
(ii) Abdominal ultrasound normal
TREATMENT
1. Bed rest
2. Analgesics Tramol and declofenac
3. Nifedipine
4. Enalapril
5. Tegrettol
6. Insulin
7. Lumbar corset
8. Planned for decompression and biopsy
Pre-operative investigations
(i) Electrolytes
Na+ 133 mmol/L
K+ 4.5 mmol/L
Urea 6.5 mmol/L
Creatinine 120 Ummol/L
(ii) Hb 12.g%
(iii) Group and crossmatch 2 units
1.10.2010
Surgery
• Incision – left posterolacteral with excision
of part of 12th rib.
• Finding – firm mass on L1
- Origin of ileopsoas divided
- Mass accessed and excised
- Under water seal drainage fixed
Post operative treatment
• Zinacef
• Pethidine and latter diclofenac
• Nifedipine
• Enalapril
• Tegrettol
• Insulin
• Chest tube removed on 5th day after check X-ray
• Lumber corset.
Histology
• Metastatic Papillary Carcinoma
PLAN
• Thyroid function test.
• Thyroid u/s
• Thoracic inlet X-ray
• Thyroid scan
• Radiotherapy
• Physiotherapy