typical spine case just to give a vague idea about how to present a case of spine

1. Clinical case presentation - spine
Dr. Guru Prasad
DNB Orthopaedics

2. Case no .1
Dr. Guru prasad

3. Patient Details
• Name : G.Ashwin kumar
• IP Number: 817
• Age: 28 y
• Gender: male
• Residence : Hyderabad
• Profession : salesman
• DOA: 19/5/15
• DOD: 25/5/15

4. Chief complaints :
low backache since 20 days

5. History of present illness
• Patient was apparently alright 9 months
back, when he developed lower backache
• Which was insidious in onset,
• Gradually progressive
• Radiating to his right leg
• Associated with tingling sensation.

6. • Pain was dragging in nature
• Radiating from lower back to back of the thigh till the right
foot
• Pain increases with coughing and sneezing
• Patient develops pain and tingling sensation or heaviness
in both lower limbs. More so in the right after walking a
certain distance
• Pain becomes so severe that he has to take rest(sit)
immediately for a few minutes
• Then the symptoms settle down temporarily and allow him
to walk further the same distance
• Patient feels comfortable with Forward bending

7. No history of…
• Significant trauma
• Constitutional symptoms (fever, loss of
weight)
• Burning micturition
• Other joint pains
• Morning stiffness

8. • Not a known case of ...
• Diabetes
• Hypertension
• Tuberculosis
• Asthma
• Epilepsy
• Hypothyroidism

9. • Past history : no significant past history
no h/o of any hospital admissions , previous medications
• Personal history : not significant
bowel and bladder habits normal
sleep disturbed
appetite normal
no h/o allergies
Mixed diet
Known alcoholic and a smoker
• Family history : not significant

10. General examination
• Moderately built and nourished
• No pallor /icterus
/cyanosis/clubbing/lymphadenopathy/edema
• Pulse 86/min right radial
• Blood pressure 110/80 mmHg right
upperlimb

11. Spine examination
• Inspection :
no obvious deformity
no swellings
no scars or sinuses
no paraspinal muscle spasm
• Palpation :
Tenderness over the L4- L5 and L5-S1 region
Movements : extension was painful

12. Special Tests
Name Left Right
Straight leg raising test
(SLRT)
80 degrees 40 degrees
Lasegue test Negative positive
FABER test Negative Negative
Femoral stretch reflex Negative Negative

13. Neurological examination
• Higher mental function - NAD
• Cranial nerves - NAD

14. Motor system
Muscle Left Right
Hip flexors (L1 /L2) 5/5 5/5
Quadriceps (L3) 5/5 5/5
Ankle dorsiflexors(L4) 5/5 5/5
Extensor hallusis
longus(L5)
5/5 3/5
Ankle Plantar flexion(S1) 5/5 5/5
Nutrition : Bulk equal on both sides
Tone : Normal on both sides
Power :

15. Sensory system
No neuro-deficit was observed in
- Touch
- Temperature
- Pain

16. Reflexes
Reflexes Left Right
Knee jerk (L4) Brisk Brisk
Ankle jerk (S1) Brisk Brisk
Plantar reflex (S1) Flexor (down going) Flexor (down going)
No bladder dysfunction (S2 S3 S4)

17. Hip examination
• No abnormality detected
• Rotations were normal

18. Other systems
• Cardio vascular examination – NAD
• Respiratory system – NAD
• Per Abdomen – NAD

19. Differential diagnosis
Prolapsed intervertebral disc
Lumbar canal stenosis
Spondylolisthesis
Tumors

20. Diagnostic tests
Sr. Investigation 19/5/15
1 Hb 15.3gm%
2 TC 6900/cumm
3 DC 60,34,03,03,00
4 Platelet 2.6 lakhs/cmm
5 ESR 30mm
6 CUE WNL
7 RBS 93 mg%
8 B.Urea 24mg%
9 S.Creatinine 1.0mg%
10 BT 2.10
11 CT 4.20
12 Blood group B – Positive
13 HIV Non Reactive
14 HbsAg Non Reactive
15 S.Electrolytes
Na – WNL
K –
Cl -
16 TSH 1.52 microIU /ml

22. MRI

27. Diagnosis
• Prolapsed intervertebral disc L4 – L5 with
lumbar canal stenosis
• Which correlates clinically with patient
symptoms

31. Treatment plan
• Laminectomy with discectomy was done on
20 /5/15

32. Anaesthesia
• General anaesthesia
• Prone position

39. Post operative X ray

40. Day - 1
• Patient got relief from the pain
• Advised lumbo - sacral corset belt

41. Day - 2
• Patient was doing well
• Drain removal was done
• Patient was made to sit

42. Day - 3
• Patient was made to walk with walker support

43. Day – 4
• Patient discharged and called on 10th day for
suture removal
• Physiotherapy started after 2 weeks

45. Case no 2
Dr. Guru prasad

46. Patient Details
• Name : P. Madhu babu
• IP Number: 674
• Age: 34 y
• Gender: male
• Residence : Hyderabad
• Profession : businessman
• DOA: 09/5/15
• DOD: 14/5/15

47. Chief complaints
• low backache since 15 days

48. History of present illness
• Patient was apparently alright 2 years back,
when he developed lower backache,

49. • Pain was dragging in nature
• Radiating from lower back to back of the thigh
till the left foot
• Increased with sitting , rising from a seat,
standing and walking a few metres which led
to restriction of his activities
• Pain was also more while lying on his back
• Patient was comfortable lying prone

50. No history of…
• Significant trauma
• Constitutional symptoms (fever, loss of
weight)
• Burning micturition
• Other joint pains
• Morning stiffness
• Tingling and numbness

51. • Not a known case of ...
• Diabetes
• Hypertension
• Tuberculosis
• Asthma
• Epilepsy
• Hypothyroidism

52. • Past history : no significant past history
no h/o of any hospital admissions , previous
medications
• Personal history : not significant
bowel and bladder habits normal
sleep disturbed
appetite normal
no h/o allergies
Mixed diet
Non alcoholic non smoker
• Family history : not significant

53. General examination
• Moderately built and nourished
• No pallor /icterus
/cyanosis/clubbing/lymphadenopathy/edema
• Pulse : 84/min
• Blood pressure : 130/70 mmHg

54. Spine examination
• Inspection :
lumbar spine curvature convexity
towards right
no swellings
no scars or sinuses
paraspinal muscle spasm
• Palpation :
Tenderness over the L4- L5 and L5-S1 region
Paraspinal muscle spasm

55. Special Tests
Name Right Left
Straight leg raising test
(SLRT)
50 degrees 30 degrees
Lasegue test Negative positive
FABER test Negative Negative
Femoral stretch reflex Negative Negative

56. Neurological examination
• Higher mental function - NAD
• Cranial nerves - NAD

57. Motor system
Muscle Right Left
Hip flexors (L1 /L2) 5/5 5/5
Quadriceps (L3) 5/5 5/5
Ankle dorsiflexors(L4) 5/5 5/5
Extensor hallusis
longus(L5)
5/5 3/5
Ankle Plantar flexion(S1) 5/5 5/5
Nutrition : Bulk equal on both sides
Tone : Normal on both sides
Power :

58. Sensory system
No neuro-deficit was observed in
- Touch
- Temperature
- Pain

59. Reflexes
Reflexes Right Left
Knee jerk (L4) Brisk Brisk
Ankle jerk (S1) Brisk Brisk
Plantar reflex (S1) Flexor (down going) Flexor (down going)
No bladder dysfunction (S2 S3 S4)

60. Hip examination
• No abnormality detected
• Rotations were normal

61. Other systems
• Cardio vascular examination – NAD
• Respiratory system – NAD
• Per Abdomen – NAD

62. Differential diagnosis
prolapsed intervertebral disc
spondylolisthesis
Lumbar canal stenosis
spondyloarthropathy
Tumours

63. Diagnostic tests
Sr. Investigation 9/5/15
1 Hb 17.8gm%
2 TC 9500/cumm
3 DC 68,26,03,03,00
4 Platelet 2.8 lakhs/cmm
5 ESR 20mm
6 CUE WNL
7 RBS 99 mg%
8 B.Urea 22mg%
9 S.Creatinine 0.8mg%
10 BT 2.15
11 CT 4.10
12 Blood group O Positive
13 HIV Non Reactive
14 HbsAg Non Reactive
15 S.Electrolytes
Na – WNL
K –
Cl -
16 TSH 3.07 microIU /ml

64. X ray

65. MRI

67. Diagnosis
• Prolapsed intervertebral disc L4 - L5 more so
in the left side
• Which correlates clinically with patient
symptoms

69. Treatment plan
• Laminotomy with micro-discectomy at L4-L5
level was done on 10 /5/15

72. Anaesthesia
• General anaesthesia
• Prone position

79. Post operative x ray

80. Day - 1
• Patient got immediate relief from the pain
• Advised lumbo - sacral corset belt

81. Day - 2
• Patient was doing well
• Drain removal was done
• Patient was made to sit

82. Day - 3
• Patient was made to walk with walker support
With lumbo sacral corset belt

83. Day – 4
• Patient discharged and called on 10th day for
suture removal

84. • Thank you…!