Lumbar canal decompression + instrumentation, A case study

Now lets look at a case of a 33-year-old man who had Lumbar canal decompression + instrumentation done following Road Traffic Accident

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A brief rundown on what actually happened:

He was involved in a Road Traffic Accident (RTA) where he was knocked down by a moving vehicle while he was standing beside his own car.
He fell down after the hit and felt a sharp pain in his back with associated inability to move his two Lowerlimbs. There was no trauma to the head, Loss of consciousness or bleeding from craniofacial orifices. However, he sustained bruises in different part of his body and there is an history of urinary incontinence.

Following the incident, he was immediately taken to a Hospital where he a had suture done for the wound he sustained in his left knee.

Radiological investigation (MRI) carried out revealed a Listhesis of Lumbar vertebrae 2 on 3 and ??Burst fracture of L1. He later underwent surgery- Lumbar canal decompression+ instrumentation. He has been stated to need physiotherapy

His past medical history stated that:
He is not hypertensive
He is not diabetic
He is not sickle-celled
He is not asthmatic or epileptic however he has an history of peptic ulcer disease

Past surgrical history:
He hasnt undergone any surgery before this incident

Surgical history:
He had Lumber canal decompression + instrumentation.

Drug History:
Warfarin, Naproxen, Metronidazole, Vitamin C, and Rocephin.

Family and social history: He works at a bar. He is single. He neither drink alcohol nor smoke cigarette.

On observation and examination:

A young male adult, met in a supine lying position in bed, fully conscious, alert, and oriented in Time Place, and Person. He is afebrile, acyanosed, anicteric, and not in any obvious respiratory or painful distress.
Urinary catheter in situ and Intravenous line was in place on the dorsum of the Left hand.

Vital Signs:
Blood pressure- 115/82mmHg
Pulse Rate- 86bpm
Respiratory Rate- 21cpm

PCV: 35%

SEGMENTAL EXAMINATION:

Head and Neck
No Abnormality detected

Active Range of motion & Passive range of motion are full and pain-free in all planes of movement

Thorax and abdomen:

Good chest excursion
The abdomen was normal, full, and Moved with respiration

Back:

• A clean and dry wound dressing was present at the upper back.
• Surgical site wound dressing is also clean and dry with no pain on palpation around the dressing

Upper Limbs:

• Grip strength: Good bilaterally
• Muscle bulk: Preserved bilaterally
• Muscle Tone: Normotonia bilaterally
• Sensation: Intact bilaterally
• AROM & PROM: Full and pain-free in all joints bilaterally
• Spasticity: Absent bilaterally
• Gross Muscle power: Right- 5; Left- 5
• Swelling: Absent bilaterally
• Deformity: Absent bilaterally
• Tremor: Absent bilaterally
• Crepitation: Absent bilaterally

Lower Limbs: o
,-A clean and dry wound dressing around the Rt medial malleolus

• Muscle bulk: Preserved bilaterally
• Muscle Tone: Normotonia bilaterally
• Sensation: Intact bilaterally except for light skin sensation at the L2 and L3 dermatomes.
• Active Range of Motion: He could not initiate movement
• Passive Range of Motion: Full but painful in all joints
• Spasticity: Absent bilaterally
• Gross muscle power : 0 bilaterally
• Edema: Absent bilaterally
• TA Tightness: Absent bilaterally
• Clonicity: Absent bilaterally
• Deformity: Absent bilaterally
• Crepitation: Absent bilaterally
• Patella: Mobile bilaterally
• Skin: No discoloration or rashes
• Berbinski reflex- No response bilaterally

Functional assessment:

• He cannot sit, stand, or walk
• He can feed himself but is maximally dependent in other Activities of Daily living

Functional Independence Measure Score:
-Motor sub-score: 26/91
-Cognitive sub-score: 35/35
Total Functional independent measure score: 61/126

Radiological Findings
MRI revealed an Anterolisthesis of Lumbar vertebrae 2 on 3 (more than 25%). Post-surgical investigation is yet to be done.

Analysis of findings:

• He was involved in RTA
• Anterior shift of Lumbar vertebrae 2 on 3
• He had Lumbar canal decompression + instrumentation surgery
• Impaired light sensation at the L2 and L3 dermatomes
• Pain in passive movement of all joints of bilateral Lowerlimvs
• Urinary incontinence and bowel dysfunction
• Paralysis of bilateral Lowerlimbs
• He is functionally dependent

Clinical impression: Paraplegia 2⁰ to incomplete Spinal cord injury (ASIA C) following Road traffic accident

Plan of treatment:

• To await post-surgical radiological investigation
• To educate him on the condition
• To preserve the physiologic properties of muscles and joints in the bilateral Lowerlimbs
• To relieve pain in all joints of bilateral Lowerlimbs
• To improve sensation in the bilateral L2 and L3 dermatomes
• To strengthen muscles of bilateral Lowerlimbs
• To prevent complications such as Deep Vein Thrombosis, Pressure sore, and Tendon Achilles tightness
• To progressively mobilize him out of bed as his condition improves

Means of treatment

• Education/Encouragement
• Passive Mobilization to all joints of bilateral Lowerlimbs
• Tactile stimulation to muscles of Lower limbs
• Therapeutic massages to muscles of Lower limbs
• Soft tissue mobilization to all painful joints using topical Non-steroidal anti-inflammatory drugs
• Electrical Muscle stimulation to muscles of bilateral Lowerlimbs
• Encourage regular turning in bed
• Application of Thrombo-Embolic Deterent stockings
• Progressive Mobilization

The aim basically is to improve him functionally and improve his independence in his activities of daily living. This can only be achieved through physiotherapy. The means for achieving this are stated in the Means of treatment above.

Thanks for following, Sayonara 🖐️

Reference

https://emedicine.medscape.com/article/793582-overview
https://www.physio-pedia.com/Spinal_Cord_Injury
https://www.ninds.nih.gov/health-information/disorders/spinal-cord-injury