History :
A 72-year-old man was brought to the emergency department of Best Spine Hospital in Pune Dr. Sangram Rajale with weakness in both legs since two days. He slipped and fell a month ago, which caused continuous low back pain that worsened when standing or walking.
Recently, he suddenly became weak in both legs and couldn’t walk. He also hasn’t been able to urinate for the past two days. The pain has been disturbing his sleep, and he has lost feeling below his lower back.
On examination, the patient’s leg strength is very weak:
Below the ankle: No strength in toe and foot movements on either side
Below the knee:
1. Weak knee bending (3/5 on the right, 2+/5 on the left)
2.Weak knee straightening (3/5 on the right, 2+/5 on the left)
Below the hip:
1.Weak hip bending (3/5 on both sides)
2.Weak hip movements inward and outward (2+/5 on both sides)
MRI :
The patient had a fracture in the L1 vertebra, which had lost about 50% of its height and is pressing against the spinal cord, causing a significant narrowing of the spinal canal to 0.5 cm.
There is also swelling in the spinal cord from the D11 to L1 levels, indicated by abnormal signals in imaging.
Operation :
A spinal surgery was performed on March 5, 2024, by Spine Injury Doctor in Pune Dr. Sangram Rajale to stabilize and fuse the spine from the D11 to L3 vertebrae.
Condition On Discharge :
a. After surgery, the patient showed remarkable improvement in Leg Strength.
Full strength (5/5) in toe and foot movements on both sides.
Improved ankle strength: Dorsiflexion at 5/5 and plantar flexion at 3/5 (right) and 5/5 (left).
Full strength (5/5) in knee bending and straightening on both sides.
Full strength (5/5) in all hip movements on both sides.
Sensations: Equal and intact on both sides.