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CPC 1:
Degenerative Spine
Disease
GRAND MENTOR :
ZAMYN ZUKI BIN
DATO DR HAJI
TAN SRI DATO
HAJI MOHD
ZUKI
MENTOR
PREPARED BY
N0
TITLE
PAGE
ACKNOWLEDGEMENT
INTRODUCTION
CASE STUDY
CLINICAL HISTORY & EXAMINATION
INVESTIGATIONS
DISCUSSION
CONCLUSION
REFERENCES
ACKNOWLEDGEMENT
First of all, I would like to take this opportunity to express my gratitude and
sincere thanks to my grand mentor Dato Dr. Haji Zamyn Zuki for being a wonderful
Grand Mentor and a constant pillar of encouragement and for the never ending
support and guidance. He is a great teacher and good inspiration to us throughout my
2 months Ortholife training in this department so far. All his dedication and effort had
pushed me to strive further and unravel my own potential.
INTRODUCTION
Spinal stenosis is a condition characterized by a progressive narrowing of the
spinal canal, the vertical tube formed by the vertebrae that houses the 31 nerves of the
spinal cord.
The symptoms of congenital spinal stenosis depend on which portions of the
nerves are being compressedSpinal stenosis is often results from aging, but it can also
CASE STUDY
CHIEF COMPLAINT :
The subject of my study is a 59 years old Indian woman with co- morbids of
dyslipidemia, hypertension, schizophrenia since 2001 and history of endometrial with
hysterectomy done followed by radiotherapy. She presented to ED HSB on 8/10/15
with complaints of generalised weakness over upper and lower limbs since 2 weeks
PHYSICAL EXAMINATION :
Patient GCS full, warm peripheries, CRT < 2 secs, good pulse volume,
hemodynamically stable unsupported and saturating well under room air.
4
4
4
4
4
4
4
4
4
4
There is impaired sensation (numbness) from upper abdomen downwards (T4 S1)
Muscle tone are hypotonia over bilateral upper limbs but appears normal over lower
limbs
Barbnski signs are equivocal bilaterally.
On per rectal examination, anal tone is lax, with impacted stool, deep and superficial
sensation intact. Bulbocarvenosus reflex present.
INVESTIGATIONS
1) Hematological
Preoperative result on
Full Blood Count (FBC)
2) Radiological
Xray thoracolumbar at Hospital Teluk Intan on /10/15
Magnetic Resonance Imaging (MRI) Whole Spine on done on 9/10/15 to rule out
cauda equine syndrome with spine metastatsis.
The findings are as below :
Right
5
5
4
5
3
Left
5
5
4
4
4
L2
L3
L4
L5
S1
4
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
Hence she is discharge with TCA after 2 months with LMS cream, planned for
continuous physiotherapy at teluk intan and keep the soft collar.