Concluded Case

Spondylodiscitis at D2 ,TB spine

9 yr old girl,fully immunuzed ,upper dorsal back pain of one month with out any back ground history of significant medical illness. Chief Complaints Presented with upper dorsal back pain .Intermittent ,movement induced pain.Mostly while lying down and getting up in the bed and while taking something from the floor, she used to get severe catching pain.Evaluated initially by the Pediatrician and then Ortho dept in one of the private hospital.For the last one week she is crying most of the time due to pain and she refused to take good also for one week. She is on diclofenac for 1week.The parents denied having fever, loss of wt or appetite till one week ago.She denied having any motor weakness.For one week she is hesitant to move much,and crying most of the time. History No significant past medical illness other than throat pain on a few occassions and diagnosed to have tonsillitis, last episode one yr ago.No significant family history other than DM in the paternal side. No contact with infectious diseases in the recent past Vitals Afebrile .HR 86/ mt.Bp90/60mmhg.Tendency to stand forward to avoid pain .No significant lymphadenopathy. Physical Examination Intact higher functions,cranial nerves.Motor system gr5/ 5 power.DTRs equal with downgoing plantars and intact sensations.She is afraid to stand straight due to pain.There is local tenderness at D2- 3,with very mild prominence if spine Investigations CBC,peripheral smear normal.ESR 64mm/ hr.Normal LFT .Normal X ray chest. MrI dorsal spine- for discussion. Diagnosis Diagnosis : MRI spine for discussion. Management On appropriate medicine after discussing with the spinal surgeon. DISCUSSION: What is the diagnosis? What abnormality in the MRI spine?

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Concluded answer

Thanks Curofy and all doctors who answered the case. MRI dorsal spine shows lysis and collapse of D2 vertebral body with associated marrow edema.Perivertebral Inflammatory changes at D- D2 disc space, signal intensity changes with end plate destruction. No epidural abscess. Impression Spondylodiscitis D2 vertebral body. * Neural foraminal narrowing with mild impingmentvof exiting nerve roots at D2-3 level. * Spinal cord appeared normal in size and spinal patterns.

All Answers

Thanks Curofy and all doctors who answered the case. MRI dorsal spine shows lysis and collapse of D2 vertebral body with associated marrow edema.Perivertebral Inflammatory changes at D- D2 disc space, signal intensity changes with end plate destruction. No epidural abscess. Impression Spondylodiscitis D2 vertebral body. * Neural foraminal narrowing with mild impingmentvof exiting nerve roots at D2-3 level. * Spinal cord appeared normal in size and spinal patterns.

Continuation . Started on ATT. Discussed the case with spinal surgeon . Plan Rept MRI after 6 weeks.
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Thanks Curofy
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pathological fracture of vertebra..this doesn't appear to be Koch's as both adjoining discs are stark normal.. trauma is high on list of dd and careful leading question might get the answer...if not, a needle guided biopsy to ascertain etiology is a must.. dd could be a connective tissue neoplasia, plasmacytoma or myeloma.. trauma seems most likely since there is a chip# of ant.edge

D2 collapse, with mild compression over thecal sac , possibility of early pott's spine, kindly do montoux also , give trial her to ATT, AND rule out other cause , mets etc , is there any history of trauma

Valuable opinion
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Looks like kochs att&steroids with bed rest.if the patient neurologically detoriates surgery.antrolateral approach.with rods&screw fixation.confirmation by sending the ?kochs tissue for hpe

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Potts spine Lost of vertebral body With compressive myelopathy at D2 ATT with spine immobilization Symptomatic pain treatment

New case

Pott's spine with involvement of D2 vertebral body causing lymphatic deformity resulting in myelopathy. Possible abscess in perivertebral space.

Abnormalty in MRI:The cervical spine has been traditionally divided into an upper segment and a lower segment comprising C3-C7. There is diversity of opinion regarding the initial imaging of a patient suspected of having a cervical spine injury. The lateral radiograph is the single most important component in the radiographic assessment of the acutely injured cervical spine. The lateral view of the upper cervical spine and lower part of the skull is an important area in evaluating vertical subluxation of the odontoid process into the foramen magnum. The most common level of the cervical spine to be involved by cervical spondylosis is the C5/C6 disc space level, and this is most commonly seen in middle-aged people and beyond. Certain conditions that affect the craniocervical junction and cervical spine are clinically relevant to anaesthetists. Cervical spine injuries occur in 2%-5% of blunt trauma patients and of these 7%-14% are unstable. Common Causes of Upper Back Pain CVEarly Treatments for Upper Back Pain When the upper back becomes painful, it is mostly likely due to an injury that has resulted in muscular irritation or joint dysfunction. Some of the more common causes of upper back pain are: Poor posture. Living a sedentary lifestyle or routinely sitting for long periods with poor posture can cause structural changes in the back and neck. The muscles can become deconditioned and weak, and thus not hold the spine in neutral alignment as easily as before. As the head and shoulders hunch forward, more pressure is placed on the spine’s bones, discs, muscles, ligaments, and other soft tissues. If a person leans to one side more often, such as while driving or working at a computer, that could also cause an imbalance in the upper back that leads to pain. Back Pain See Good Posture Helps Reduce Back Pain Improper lifting technique. Lifting a heavy object without keeping the spine aligned can put undue stress on the upper back. In particular, lifting or holding a heavy object above the head, especially more toward the left or right as opposed to centered, can leave the shoulder and upper back susceptible to injury. Lifting an object that is too heavy can also cause upper back pain. See Avoid Back Injury with the Right Lifting Techniques Overuse. Putting the upper back through more work than usual, such as by spending a day helping a friend move into a new apartment or painting a ceiling (working above the head), could cause muscle strains, ligament sprains, and inflammation in the upper back. See Intercostal Muscle Strain Symptoms and Diagnosis Accident or collision. Trauma from a vehicular accident (car or bike crash), a fall from height (down steps or from a ladder), or sports collision (football, hockey, etc.) can cause upper back pain by injuring spinal bones, discs, muscles, ligaments, nerves, and/or other soft tissues. Sometimes there can be a combination of causes, such as from both overuse and improper lifting technique. Over-the-counter (OTC) medications. Various pain medications are available at stores for purchase without a doctor’s prescription. Most of these OTC medications work by reducing inflammation in the body or preventing pain signals from reaching the brain. Common OTC medications that may help reduce upper back pain include aspirin (e.g. Bayer or Bufferin), ibuprofen (e.g. Advil or Motrin), naproxen (e.g. Aleve or Naprosyn), and acetaminophen (e.g. Tylenol). Even though these medications do not require a prescription, it is important to read and follow the directions on the label to avoid serious side effects. See Medications for Back Pain and Neck Pain Massage. Many people find that a massage can provide relief from back pain. Even if the effects are temporary, a good massage can help loosen tight muscles and get more blood flowing to the painful area. A few options for massaging the upper back include self-massage with a foam roller or ball, having a willing friend or family member provide a massage, or seeking out a professional. Sometimes trial and error is needed to find which treatment or combination of treatments work best for a specific type of upper back pain. Nonsurgical Medical Care for Upper Back Pain Some of the more common medical treatments for upper back pain include: Physical therapy. A physiatrist, physical therapist, or other qualified medical professional can design a physical therapy program to meet the patient’s specific needs. Most physical therapy programs for upper back pain focus on strengthening and stretching the upper back’s muscles, as well as neck muscles above and core muscles below. Physical therapy starts gradually and typically progresses over a period of a few weeks or months, at which point the patient can switch to a maintenance program at home. See Physical Therapy Benefits For Back Pain Prescription pain medications. For debilitating pain or severe flare-ups, short-term use of prescription medications may be advised. Common examples include prescription-strength nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, which work by preventing pain signals from reaching the brain; and muscle relaxants, which typically work as a sedative for the neuromuscular system. See Opioid Pain Medications Injections. Several spinal injection options are available to block spinal pain. For example, an epidural steroid injection typically delivers a steroid medication in or near the pain source to reduce pain. Injections tend to provide varying amounts of short-term relief and are not considered a good long-term solution. See Injections for Neck and Back Pain Relief Cognitive behavioral therapy. A therapist can teach new and better ways to think about challenges. For example, a patient might be able to increase his or her ability to follow a doctor’s treatment plan by becoming more aware of negative thoughts and instead focusing on the positives. Commonly, more than one treatment is needed to help manage upper back pain. For example, medications might be needed when the pain first starts, but over time the medications might be phased out in favor of physical therapy or other treatments to manage ongoing chronic pain. Alternative Treatments Alternative treatments, commonly referred to as complementary and alternative medicine (CAM), are gaining in popularity. While alternative treatments tend to have less scientific backing than traditional medical treatments, that is not to say they are ineffective. Many people have reported experiencing at least some pain relief from these treatments. Some examples of alternative treatments include: Manual manipulation. A chiropractor, physiatrist, or other qualified medical professional makes spinal adjustments by using hand thrusts and other maneuvers. Manual manipulation (also known as chiropractic manipulation) helps loosen stiff or misaligned joints and may reduce pain. See Understanding Spinal Manipulation Acupuncture. Depending on the specific pain symptoms, an acupuncturist places thin needles in strategic locations of the body to theoretically alter energy flows, ease tension, and reduce pain. See Acupuncture: An Ancient Electrotherapy. Various electrotherapy treatments aim to alleviate pain by sending small electrical pulses to the painful area. The most common type of electrotherapy is a transcutaneous electrical nerve stimulator (TENS). A TENS unit typically uses small adhesive pads to place electrodes at multiple locations on or near the painful region, such as the upper back. Using an adjustable knob, the TENS unit sends electrical current to the electrodes that may cause a soothing, tingling sensation and reduce the perception of pain. Mindful meditation. Sometimes referred to as mindfulness-based stress reduction, this flexible approach typically involves learning meditation and breathing techniques, as well as practicing yoga. Research has found value in mindfulness-based stress reduction, including one study that found it to be as effectiv knowe as cognitive behavioral therapy for improving a patient’s ability to deal with chronic back pain.

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