1. Case conference Presendted by R3 李偉群 Supervisor: VS 鄭錦昌 CGMH JIAI 2008/12

2. Patient data 69 y/o female, housewife DM, HTN history under medication control Denied betel nut Denied alcohol Denied smoking Allergy: NKA

3. Chief complaint Low back pain with bilateral legs weakness for 10+ days after falling down

4. History summary Falling down on 2008/10/30 at bathroom Progressive low back pain with bilateral legs weakness since then After using Chinese herb, LBP relieved but legs weakness progressed, disability since 11/12 Difficult urine voiding for one day 11/13 at our ER: ICP more than 1000c.c.

5. Physical examination Knocking pain of back(+) over iliac crest level Muscle power of lower limbs Right Left –hip flexion(L2) 4 4 –knee extension(L3) 4 4 –ankle dorsiflexion(L4) 4 4 –big toe dorsiflexion(L5) 4- 4 –plantar flextion(S1) 4- 4 –walk on heels can’t can’t –walk on toes can’t can’t

6. Physical examination Sensation:soreness(+) over left lateral calf (L5 dermatone) Reflex: –ankle jerk: right(+), left (++) –knee jerk : right(+), left(++) Babinski sign: right(-), left (-) SLRT : right 90 (-), left 90 (-) FABER test: bilateral (-)

7. Lab of ER (11/13) CBC/DC: WBC 10500 –band 2% seg 94% Glucose: 597 BUN/Cr: 35/4.8 GFR: 9 Na: 131.8 K: 3.84 CRP: 57

8. 11/13 L-spine

9. What’s your impression?

10. 11/13 Myelography

11. 11/13 MRI - T12

14. 11/13 MRI - L4/L5

17. Impression T12 burst fracture with spinal stenosis L4 compression fracture combined with L4-5 herniated disc Acute renal failure due to urine retention, r/o cauda eqina dyndrome Diabetes mellitus Hypertension

18. Course & treatment Pain control, legs MP monitor On foley -> renal function recovery LBP(local tender over iliac crest level) and paresthesia (left calf soreness), urine retention persist, no stool incontinence, no paddle anesthesia

19. Examination 11/17 Urodynamic study –Incomplete relaxing sphincter –Acontractile detrusor with urine retention 11/19 NCV/EMG –Bilateral tibia neuropathy and left L5/S1 radiculopathy with denervative change

20. What’s your diagnosis? How to manage?

21. 11/22 OP record Osteoporosis and ligament hypertrophy at L4- 5 and T12 L1 level Laminectomy T12, lower L4, L5 Check bilateral L5, S1 root Dural adhesion with flavum ligament and some tophi intraligament T12 burst fracture & L4 compression fracture --> open vertebroplasty with PMMA L4-5 posterolateral fusion

22. 11/27 post-OP

23. 12/12 Latest follow up Bilateral legs muscle power full, ambulation well Left calf paresthesia improved Lower back pain improved Urine retention persist, no improvement

24. Discussion D/D of low back pain? Diagnosis of compression fracture? The effect of vertebroplasty? Surgical management for cauda equina syndrome- timing V.S. prognosis

25. Low back pain Traumatic –Fracture: compression, burst… –Dislocations –Herniated discs –Ligament tears Atraumatic: degenerative disc disease, degenerative spinal stenosis, inflamatory arthritis, spondylolysis or spondylolisthesis, tumor, infection

26. Diagnosis of compression fracture Osteoporotic vertebral fracture –Wedge fracture –Biconcave deformity –Compression fracture Radiographic findings –Anterior wedging with vertebral collapse –Vertebral end-plate irregularity –General demineralization

27. Compression fracture Stable: pure flexion injuries Unstable (may involve middle column) –Severe compression (>50% height) –Significant fracture kyphosis (>30º) –Rotational component to the injury –Multiple levels compression fracture

28. Vertebroplasty Improve vertebral height of 47% compression fracture patients Vertebroplasty group V.S. conservative therapy: lower pain scores at 24 hours and six weeks, no difference at 12 and 24 months Dublin AB et al, AJNR 2005 Diamond TH et al, Med J Aust.2006

29. Cauda Equina Syndrome: OP Timing V.S. Prognosis Acute onset (10/31): poorer prognosis, especially for the return of bladder function Bladder function: most seriously affected function preoperatively and postoperatively The prognosis for return of motor function was good, 90% regained normal no correlation of OP time with return of function JP Kostuik et al, JBJS 1986

30. Cauda Equina Syndrome: OP timing V.S. Prognosis 7/8 patients had complete recovery of bladder function No distinct correlation between timing of operation and results Even late surgery due to delayed presentation, significant improvement in the bladder function can still be expected Raj. D, Acta Orthop Belg.,2008

31. Cauda Equina Syndrome: OP Timing V.S. Prognosis meta-analyses of observational cohort studies, evidence level III 5 breakpoints: 12, 24, 36, 48, or 72 hours supports early surgery for CES DeLong WB et al, J Neurosurg Spine. 2008

32. Return to our patient Bilateral legs weakness --> T12 burst fracture with spinal stenosis --> decompression and vertebroplasty LBP and urine retention --> cauda equina syndrome from L4/5 disc herniation, worsened by further L4 compression fracture --> decompression and vertebroplasty

33. Thanks for your attention!!