MORNING REPORT

CERVICAL MYELOPATHY REZKI ARGHA NAULI C 111 10 290Advisor:dr. FAHRONI CAHYONO WINATAdr. ALFA JANUAR KRISTASupervisor:dr. Karya Triko Subiakto, Sp.OT(K)Spine

IDENTITYName:Mr. A.B.Age:65 years old / MaleAdmission:February 9th, 2015 Registration :70 05 97Status:JKNAUTOANAMNESIS

Suffered since 21 days before admitted to Wahidin General Hospital24 days ago, patient suddenly felt weakness of his lower extremities, but could still walk with assistance. Patient went to Daya Hospital and had been given physiotherapy but no improvement. 21 days ago, patient couldnt walk anymore and couldnt move both of leg. Patient admitted to Daya Hospital for 10 days and after that referred to Ibnu Sina Hospital and underwent MRI cervical examination.Chief Complain : Cannot move both of lower extremityPatient also complained pain at his neck since 5 weeks ago, dullness pain, intermittent, not referred, duration 5 10 minutes, worsen when activity and better when rest, worse at night (-)Patient could not sense defecation and urination.History of fever 4 weeks ago for 3 daysHistory of chronic cough (-), history of weight loss (-), history of tumour (-) , history of family member with tumour (-)history of hypertension (+), diabetes mellitus (-)

GENERAL STATUS

Conscious / Well-nourishedVital Signs:Blood pressure: 150/100 mmHgPulse rate: 90 x/minRespiratory rate: 20 x/minTemperature : 37 0C

LOCAL STATUS Vertebra RegionLook:Decubitus Ulcer Grade I at parasacralis dextra, multiple, 4 x 3 cm, Deformity (-), swelling (-), hematoma (-)Feel:Tenderness (+) at vertebrae cervical, Step Off (-)

43311No0000NT00NTNT43311000000

22222222222222222222

0 Absent1 Impaired2 NormalNT Not testable

Any anal sensationN22222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222REFLEXPhysiologic ReflexPathologic ReflexRLRLBiceps(N)(N)Hoffman Trommer(+)(+)Triceps(N)(N)Chadock(+)(+)Achilles(-)(-)Openheim(+)(+)Patellar(-)(-)Babinski(+)(+)RECTAL TOUCHERSphincter tone was looseMucous was smoothAmpula recti is filled with faecesProstat gland is difficult to evaluate due to faecesGloves : blood (-), slime (-), feces (+)Bulbocavernosus reflex (+)

CLINICAL FINDINGS

RADIOLOGY FINDINGS(Cervical AP/Lateral)

Thorax

Pelvic

MRI

LABORATORY FINDINGS

WBC: 11.200 /ulRBC: 3.590.000/ulHGB: 11,1 g/dlHCT : 34 %PLT: 189.000/ulCT: 700BT: 300

Albumin: 2,7 g/dLSGOT: 31 U/dLSGPT: 29 U/dLUreum: 20 mg/dLCreatinine: 0,90 mg/dLRBG: 113 g/dLHBsAg: Non-reactiveDIAGNOSISServical MyelopathyDecubital ulcer grade IHipoalbuminemia21MANAGEMENTIVFD RLAntibioticPlan for surgery : CorpectomyDISCUSSION33 Vertebrae:7 Cervical (lordosis)12 Thoracic (kyphosis)5 Lumbar (lordosis)5 Sacral fused (kyphosis)4 Coccygeal (fused)

Source: Netters Concise Orthopaedic Anatomy, 2nd ed.THE SPINE24Root exit spinal column via intervertebral foramen

C1-7 : exit above their vertebraC8-L5 : exit below their vertebra (C7 exit above C7 vertebra and C8 exit below C7 vertebra)Medula spinalis end at L1 (Conus Medullaris)Lumbar and sacral nerve form cauda equina in spinal canal before exitSource: Netters Concise Orthopaedic Anatomy, 2nd ed.

THE SPINE25What is cervical myelopathy?

Myelopathy is the manifestation that caused by cervical spinal cord compression.

Vincent J D. Evaluation of cervical spine disorder, Spine Secret Plus, 2nd Edition 2012PATOGENESIS Trauma resulting vertebra spinal cord compression The process of inflammation , for example myelitis urgent spinal cord tumors Vascular diseases , such as vascular myelopathy Congenital due to spinal canal stenosis Degenerative diseases , such as spondylosis or herniated intervertebral discs resulting in spinal cord compression

PATOLOGICAL PROCESSThe underlying cause of the condition is compression of the long tracts in the spinal cord. The normal diameter of the cervical spinal canal is between 17 mm and 18 mm. When this diameter falls below 12 mm to 14 mm for any reason this is likely to cause stenosis and myelopathic symptoms. The average diameter of the spinal cord in the cervical spine is 10 mm. The common pathological processes underlying cervical myelopathy are outlined below:Disc HerniationCongenitalSpondylosisPost traumatic myelopathyOssification of the posterior longitudinal ligament (OPLL)Myelopathy due to tumour expansion

DIAGNOSISHISTORY TAKINGSholahuddin R. Cervical myelopathy Orthopeadi Spine UI10-20% 1st notice leg symptoms.

1/3 notice electric shock sensations on extending neck indicating an early stage to disease.NEUROLOGIC EVALUATION PHYSICAL EXAMINATIONS

Jon C. Thompson Spine Netter's Concise Orthopaedic Anatomy, 2010

PHYSICAL EXAMINATIONSJon C. Thompson Spine Netter's Concise Orthopaedic Anatomy, 2010NEUROLOGIC EVALUATION

PHYSICAL EXAMINATIONSJon C. Thompson Spine Netter's Concise Orthopaedic Anatomy, 2010Hoffmanns signFinger escape sign (finger adduction test)Grip-and-release testInverted radial reflexScapulohumeral reflex

Babinskis testClonusLhermittes signUPPER EXTREMITIESLOWER EXTREMITIESPHYSICAL EXAMINATIONSVincent J D. Evaluation of cervical spine disorder, Spine Secret Plus, 2nd Edition 2012SPECIAL TESTTHANK YOU