Name : SK.Maibali Age : 24yrs Sex : Male occupation: labourer Residence : suryapet Date of admission : 8/5/17 IP no :
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3 Name : SK.Maibali Age : 24yrs Sex : Male occupation: labourer Residence : suryapet Date of admission : 8/5/17 IP no :
4 CHIEF COMPLAINTS : Complains of pain in the middle &lower 1/3 rd junction of back since 8yrs Complains of stiffness of back since 6yrs. Complains of deformity of spine since 5yrs.
5 HISTORY OF PRESENTING ILLNESS : PAIN: Backache is insidious in onset, persistent, progressive in nature & radiating to buttocks. More during night times. Aggravated on taking rest & deep inspiration. Relieved on performing some activity. STIFFNESS: Pain in the spine is associated with early morning stiffness lasting for longer duration. patient has difficulty in lying on bed.
6 DEFORMITY: Patient complaints of loss of normal posture of spine with forward bending & difficulty in extension of back.deformity is insidious & has progressed to the present state. Associated with improper gaze.
7 Associated with tingling sensation. Not Associated with weight loss & fever. No significant pulmonary symptoms. No h/o HTN/DM. No bowel &bladder disturbances. No extra-skeletal manifestations.
8 Past history : Not significant Personal history : Not significant Family history : Not significant.
9
10 CLINICAL PICTURE
11 GENERAL EXAMINATION : Patient is moderately built,well nourished,conscious & coherent. Oriented to time,place &person. Temp : Afebrile Pulse : 78 bpm BP : 120/80mm hg RR : 14cpm
12 LOCAL EXAMINATION : ATTITUDE:stooped posture with loss of lumbar lordosis. visible deformity kyphosis(dorso-lumbar region). Prominent lumbar spinous processes. Increased thoracic kyphosis and loss of lumbar lordosis. No scars/sinuses. (Rt) (Lt) SLRT 70 degrees 70 degrees EHL 5/5 5/5 FHL 5/5 5/5 KNEE-flexion 5/5 5/5 extension 5/5 5/5 SENSATIONS Normal Normal. Hip movements are normal,no deformity. Cervical spine movements are normal.
13 Special tests Occiput-wall distance- 6cm Finger to floor distance- increased Modified schober test-unable to do flexion. FABER TEST-pain at sacroiliac region Genslen s test-positive
14 PRE OP RADIOGRAPH
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16 RADIOGRAPH A plain radiograph of dorsolumbar spine & pelvis with both hips showing squarring of thoracic &lumbar vertebrae with loss of anterior cocavity. loss of lumbar lordosis. Early changes leading to bamboo spine. Facet joint erosion. Ankylosis of bilateral sacroiliac joints. cobbs angle-36 degrees. plumb line is passing in front (anterior)of sacrum.
17 MAGNETIC RESONANCE IMAGING Features-1)kyphosis deformity of spine. 2)E/O bony ankylosis involving all facet joints. 3)E/O bony ankylosis of bilateral S.I joints. 4)L5-S1 facet joint shows edematous changes. F/S/O advanced Ankylosing Spondylitis kyphotic deformity of dorsolumbar spine. No active lesions except around L5- S1 facet joint.
18 COMPUTED TOMOGRAPHY Ossification of Anterior longitudinal ligament,supraspinatus,i nterspinous ligaments & facet joints.
19 BLOOD INVESTIGATIONS : Serum electrolytes : sodium ~ potassium ~ chloride ~ Arterial blood gases : PH ~ 7.36 PO2 ~ 189 PCO2~32.8 HCO3~19.3
20 COMPLETE BLOOD PICTURE : Hb ~11.4g/dl TLC ~1200 Neutrophils ~51 Lymphocytes ~3 peripheral smear normocytic/normochromic bleeding time -2min clotting time - 4min blood grouping B positive
21 HIV negative HBS AG negative HCV negative. blood urea -13 serum creatinine RBS -137mg/dl LFT total bilirubin mg/dl direct bilirubin mg/dl
22 ECG No changes 2D ECHO normal
23 CLINICAL DIAGNOSIS A 24 yr old male with seronegative Ankylosing spondylitis with Dorsolumbar kyphosis with no neurological deficit.
24 PLAN OF TREATMENT : L3 pedicle substraction osteotomy with L1,L2,L4,L5 pedicle screw fixation & posterolateral spine fusion.
25 POST OP XRAYS
26 PRE OP XRAY POST OP XRAY
27 POST OP CLINICAL PICTURE
28 Contd..
29 IMMEDIATE POST OP Patient developed immediate post operative foot drop &EHL weakness which recovered from 0/5 to 3/5 at the time of discharge. During surgery lumbar lordosis is created to compensate for thoracic kyphosis. Saggital balance is improved. Patient was able to lie comfortable on the bed. Patient was advised extension brace for support of back.
30 FOLLOW UP Patient recovered from foot drop. He is able to lie comfortable on bed. He is able to do his daily activities. Symptoms got relieved.
31 THANK YOU
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