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    Add as FriendSpinal Tuberculosis Potts Disease Case

    by: Dr. Md Nazrul

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    1 : Department Of Orthopaedics&Traumatology. SheedSuhrawardyMedical College Hospital, Dhaka-1207, Bangladesh. Case Presentation- From - “A patient with gradual walking impairment”
    2 : Presenting By- Dr. GolamMahamud Suhash, From Department of Orthopedic & Traumatology, Shaheed Suhrawardy Medical College Hospital, Dhaka-1207. Bangladesh. Prepared By- Dr. Md Nazrul Islam MBBS, M . sc. (B M E). “A patient with gradual walking impairment”
    3 : PARTICULARS OF THE PATIENT Name- Mr. Ali Akbar Age- 57 Years Sex- Male Occupation- govt. Service Holder Address- B-14,G-8,Agargong Date of Admission -20/10/2009.
    4 : CHIEF COMPLAINTS Weakness of left leg – one & half months. Unable to walk – one & half months. Evening rise of temperature – one & half months.
    5 : HISTORY OF PRESENT ILLNESS Mr. Ali Akber was alright – two & half months back. Then he noticed gradual weakness of his left leg which lead him initially only to able to stand and walk for about 1-2 min. with help. After 2-3 days, he can only able to stand only but fails to walk.
    6 : HISTORY OF PRESENT ILLNESS (continues) He also complains of evening rise of temperature for the same duration lasting for about 4-5 hours that relived spontaneously followed by sweating. He denied any H/O trauma, heavy weight lifting or abnormal jerking. Patient is Asthmatic, but free from Hypertension and Diabetes. His bowel and bladder habit is normal
    7 : HISTORY OF PAST ILLNESS History of low back pain for last 7-8 years. History of pleural effusion – 7 years back. He is asthmatic and hypertensive but non diabetic. No history of exposure of TB case. Family History- Nothing Contributory. Socioeconomic History- Middle class family. Personal History-Patient is non alcoholic/smoker. Drug History: (At present continuing) - Tab. Diola, Tab. Bukof, Tab. Contin, Salmolin inhaler, Anti TB ( For 6 weeks) . Immunization History- Patient is properly Immunized.
    8 : PHYSICAL EXAMINATION General Examination Appearance – Normal. Cooperation –Cooperative. Mental Status – Intelligent. Decubitus – Lying. Body Build – Average. Skin Condition – Normal. Hair Distribution – Normal. Anemia – Absent Jaundice – Absent Cyanosis – Absent.
    9 : General Examination ( Continues) Clubbing – Absent Temperature - 98°F Pulse – 82/ min. BP – 140/80mm/Hg Lymph node – Cervical Axillary Inguinal Para-aortic Others. General Examination Not Palpable
    10 : LOCAL EXAMINATION LOOK – Bulging in the middle of Lumber spine. No scar mark, discharging sinus or pigmentation. FEEL – Overlying skin is free. Fullness of mid Lumber region with spasm. Size - about 2cm×2cm. MOVE – Flexion Extension Lateral bending Painful
    11 : SYSTEMIC EXAMINATION Locomotors system: Gait:- Unable to walk. Limb Joints :- Normal. Spinal movement: Restricted & Painful. Deformity:-Absent .
    12 : SYSTEMIC EXAMINATION Nervous System Motor Assessment: ROM:SLR – Lt 30 dreg, Rt 60 dreg Power of muscle: Lt-2/5,Rt-4/5 Tone: Decreased at Lt lower limb. Bulk: Normal Sensory: All sensory response at L5 & S1 reduced on left leg., and on right side intact.
    13 : SYSTEMIC EXAMINATION(Continues) Reflexes: Planter- Bilaterally Flexor. Ankle jerk : Left - diminished Right -normal Knee jerk: Left - normal. Right- normal. Clonus: Absent.
    14 : SYSTEMIC EXAMINATION(Continues) Patient has been suffering from asthma over the past few years, but continues to keep well by proper medical management. Respiratory System:
    15 : SYSTEMIC EXAMINATION(Continues) Cardiovascular System : NAD. GI System : NAD. Genito-Urinary System : NAD. Other Systems:
    16 : Salient feature Mr. Ali Akbor aged 57 admitted on 20/10/09 with the complaints of Weakness of left leg – Two & half months, Evening rise of temperature – and half months, Unable to walk – one & half months. He had no H/O trauma, heavy weight lifting or abnormal jerking. His bowel and bladder habit is normal. Muscle power at left side is 2/5, reduced sensation at L5 & S1. ROM:SLR – Lt. 30 dreg, Rt. 60 deg. Tone: Decreased at Lt lower limb. Ankle jerk is diminished.
    17 : DIFFERENTIAL DIAGNOSIS Pyogenic Infection ProlapseIntervertebralDisc (PLID) Primary Bone Tumor Secondary Bone Tumor. Pot's disease.
    18 : INVESTIGATION CBC - Hb%: 12 gm/dl ESR : 120mm/1sthour Total Count of WBC:11000/cmm Differential Count of WBC: N-62% L- 35% E-02% M-01% RBS : 13.6mg/dl General
    19 : INVESTIGATION ( Continues) GENERAL Urine for R/M/E: RBC : nil/HPF Pus cell : 01-03/HPF Epithelial cell: 2-3/HPF S. Creatinine :1.2mg/dl Chest X-ray :Normal ECG : Normal ECG finding USG of whole abdomen: No itraabdominallymphadenopathy.
    20 : Specific investigation MT: 18mm Anti TB IgG, IgM, IgA: Positive X-ray L-S- spine both view: Disc space between L4 & L5 and L5&S1 is reduced with destruction of adjacent end plate. No obvious Para vertebral soft tissue swelling is noted.
    21 : SPECIFIC INVESTIGATION MRI: Tubercular spondylitis at L4 &L5 level with peri-vertebral mass. Vertebral posterior bulging causing indentation of thecal sac. Disc space between L5 & S1 is reduced. Rt. Para-vertebral abscess .
    22 : DIAGNOSIS - (Pot's Disease). Spinal Tuberculosis
    23 : Management Objective of Treatment- To eradicate or at least arrest the disease. To prevent or correct deformity. To prevent or treat the major complication.
    24 : For this patient the choice of Treatment is Operative (Clearance & Spinal fixation) adjunctive to Chemotherapy. (Chemotherapy include – Initially four drugs combination (Rifampicin + INH + Ethambutol + Pyrazinamide) – 2 months. Followed by- Two drugs combination- Rifampicin + INH ) for 12 to 14 months.) Management (Cont.)
    25 : Conservative Management failure. Progressive Neurological deficit. Persistent neurological deficit. Progressive enlargement of abscess. Decompression of large abscess. Indication for operation Management (Cont.)
    26 : Drainage of abscess. Decompression and scraping of infected lesion. Decompression with bone graft. In presence of deformity- Correction of deformity and stabilization by internal fixation and fusion. Management (Cont.) Types of Surgery-
    27 : Management (Cont.)
    28 : Management (Cont.)
    29 : Management (Cont.)
    30 : Management (Cont.)
    31 : Other treatment modalities Medical Management- Continuous bed rest with chemotherapy. Ambulant with chemotherapy Ambulant, Chemotherapy with spinal brace. Operative treatment- Naked eye per-operative appearance - Para-vertebral abscess which is to be drained. With courtesy : Dr. Sk. Abbas uddin Ahmed. Management (Cont.)
    32 : Cautious movement. Continue medical treatment according to prescription. 3 months interval follow up. Management (Cont.)
    33 : Special thanks are due to – Dr. (Associate Professor) Sheikh Abbas Uddin Ahmed, & Dr. Subir Hossain for their nice co-operation. Orthopedics & Traumatology Department, Shaheed Suhrawardy Medical College and Hospital, Dhaka- 1207, Bangladesh. Thank you very much For Patience.

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