25 year old male with D9, D10, D11, D12 laminectemy and L1, L2, PSF (post spinal fusion) with grade 4 bedsore
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Here is a case i have seen:
Pt alleged to have sustained injury to mid back area due to fall from height during work. Pt c/o pain mid back area since the incident. Pt also c/o loss of sensations and unable to move his lowerlimbs since the incident. Pain aggrevates on moving on bed and relieves on rest.
No micturition / defecation occured since the incident,so bowel and bladder movements are abnormal.
No h/o any head injury/loss of consciousness /seizures /ent bleed.
Pt is not a k/c/o HTN/DM
No h/o any previous surgeries
Fooleys insitu at the time of presentation to hospital.
O/e:
Pt is c/c/c
Afebrile on touch
BP:130/70
PR:82bpm
Cvs:s1s2 heard, no murmurs
Rs:nvbs,b/l air entry+
O/E of LS spine:
Skin:normal
Mid line tenderness:present at t10-t11 area
Sensations lost
Distal pulse:present
Reports:
Lft:
TB:0.76
DB:0.14
ALP:99
RBS:112
APTT:32
Rft:
urea:83
Creat:1.0
Uric acid:4.8
Na:138
K:3.9
Cl:100
Cbp:
Hb:10.2
TC:7,700
Neutrophils:87
Lymphocytes :05
Plt:40,000
ESR:35
PT:16
INR:1.11
APTT:32
BT:2min 30 sec
CT:5min 30 sec
BGT:A+ve
Serology:negative
Cue:
Alb:nil
Sugar:nil
Rbc:3-4
Blood urea:22
ct dorsolumbar spine:
Provisional diagnosis :D12 wedge compression fracture with subluxation and compression of spinal cord with paraplegia and bowel and bladder involvement
Treatment:
D9D10-D11,L1L2 PSF +D12 laminectemy +posterior spinal fusion
Surgery was done on 29/09/2020
Post op x ray:
Pt was on following drugs after surgery:
Tab hifenac p sos
Tab shelcal lt od for 1 month
Tab neurokind lc od for 1 month
Syp cromaffin plus 15ml h/s
Passive movements of all joints
Tab trigantin 100mg h/s for 1 month
On POD 19:
O/e: noticed bed sore over the sacral region
Daily ASD was done
Air water bed
Neosporin powder for L/A
Frequent change of diapers, if toiled
On POD 26:
C/o Fever spike
C/o swelling of right thigh
Temp:101.2°
Reports:
Treatment:
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