Mr. Khandre

September 1, 2022 By Dr. Sangram Rajale In Uncategorized

History :

The 60-year-old gentleman was brought to the Emergency Medical Department (EMD) after falling from a flight of stairs (approximately 5-6 stairs) on August 28, 2022. Following the fall, the patient complained of neck pain, low back pain, and decreased power in both hands. He also reported being unable to stand since the incident. Additionally, the patient experienced tingling sensations in both upper limbs and numbness in both lower limbs (left greater than right). There was a history of a possible head injury and a whiplash-type injury. However, there were no complaints of bladder involvement, vomiting, ENT (ear, nose, throat) bleed, or seizures. The patient also mentioned having constipation for the past two days.

ON EXAMINATION:

During examination, the following findings were noted :

  1. Neck Pain: Patient reported sudden onset of sharp pain in the neck region upon inquiry.
  2. Arm Weakness or Paralysis: Observation of difficulty in lifting or moving arms, particularly noticeable in hands and fingers.
  3. Sensory Changes: Patient described sensations of numbness, tingling, or “pins and needles” in hands, arms, and possibly legs during sensory testing.
  4. Loss of Coordination: Demonstrated difficulty with fine motor skills, such as buttoning a shirt or gripping objects, indicative of coordination impairment.
  5. Bowel and Bladder Dysfunction: Patient reported problems with controlling urination or defecation, including episodes of accidents or urgency.
  6. Pain: Patient expressed experiencing pain in the neck, shoulders, or arms, with varying intensity based on location.
  7. Loss of Temperature Sensation: Testing revealed challenges in detecting hot or cold stimuli, suggesting altered temperature sensation.
  8. Partial Recovery: Patient discussed gradual improvement in symptoms with ongoing rehabilitation and medical management during history taking.

MRI :

MRI findings for the patient show

  • Cervicodorsal Spondylosis:This refers to degenerative changes in the cervical and upper thoracic spine.
  • C5-C6 and C6-C7 Levels:
  1. Diffuse disc bulge and thickening of the ligamentum flavum are causing central canal stenosis, which is narrowing the space for the spinal cord.
  2. Complete effacement (loss of definition) of the anterior subarachnoid space is observed, indicating pressure on the spinal cord.
  3. There is mild indentation on the ventral (front) surface of the spinal cord, suggesting mild compression.
  4. There are posterolateral osteophytes (bony outgrowths) and degeneration of facet joints, causing severe narrowing of the neural foramina (openings for nerve roots) and compression on the nerve roots as they exit the spinal canal.
  5. Myelomalacia, which is softening or damage to the spinal cord, is seen at the C4-C5 and C5-C6 levels.
  • C3-C4 and C4-C5 Levels: Diffuse disc bulge is present, leading to partial effacement of the anterior subarachnoid space. However, there is no compression of the spinal cord at these levels. Overall, the MRI findings indicate degenerative changes in the cervical and upper thoracic spine, resulting in narrowing of the spinal canal, compression of the spinal cord and nerve roots, and associated myelomalacia at certain levels. These findings can explain the patient’s symptoms such as neck pain, tingling, and numbness in the upper and lower limbs, as well as decreased power in the hands and difficulty standing.

Operation :

The patient underwent a surgical procedure known as C4-C7 laminectomy on September 1, 2022, under general anesthesia. The operating surgeon for this procedure was Dr. Sangram Rajale. Laminectomy involves the removal of the lamina (part of the vertebral bone) to decompress the spinal cord and nerve roots, addressing issues such as central canal stenosis, spinal cord compression, and neural foraminal narrowing caused by conditions like spondylosis and disc bulges.

Condition On Discharge :

Upon discharge, the patient’s condition was as follows:

a. The patient was stable and transferred to the ward for further care.
b. There were no episodes of fever with chills throughout the hospitalization period, indicating no signs of infection.
c. The patient was able to walk with full weight-bearing using walker support starting from day 5 after the surgery, showing progress in mobility.
d. Complete suture removal was performed on day 15 post-surgery, ensuring proper wound healing.
e. The patient was discharged with a Foley catheter, which was removed after 45 days as per the treatment plan.
f. By the end of 2 months post-surgery, the patient had achieved complete recovery, indicating successful outcomes from the laminectomy procedure.