1. INTERESTING CASE OF BACK ACHE DR.ANIRUDH J SHETTY PROF.DR.G.ELANGOVAN’S UNIT

2. 24 year old female came with the complaints of pain in the lower back radiating to the right lower limb -5 days

3. Patient was apparently normal 5 days back when she developed severe pain which radiated from the lower back uptill the right malleoli . Pain was sharp,constant,stabbing,electric shock like pain which was distributed in the region below the right buttock .Aggravated on walking ,change in posture,sneezing

4. Patient specifically c/o of the pain in the lumbosacral region. Patient also c/o not being able to appreciate hot or cold water on the lateral side of right feet or feel her clothing h/o urge incontinence + h/o bowel incontinence +

5. No h/o headache ,vomiting,blurring of vision No h/o any cranial nerve involvement No h/o fever or night sweats No h/o involvement or weakness of the upper limb No h/o seizures No h/o trauma

6. No h/o any involuntary movements Past h/o – not a k/c/o DM/HTN/Tb/Seizure disorder Personal h/o - attained menarche at 14 yrs h/o menorrhagia +

7. O/E – Pt conscious oriented afebrile hydration fair severe pallor(+) no icterus,clubbing,cyanosis,LAN sternal tenderness+

8. B.P – 110/70 mmHg P.R – 88/min JVP not elevated

9. CNS – Higher mental functions – normal UL – Tone n power (N) LL - RT LT BULK N N TONE DECREASED N

10. RT LT POWER HIP 4- 5 KNEE 4- 5 ANKLE 4- 5 EHL WEAK N

11. DTR RT LT KNEE + ++ ANKLE ABSENT + BICEPS ++ ++ TRICEPS ++ ++

12. SUPERFICIAL REFLEXES CORNEAL REFLEX – (+) CONJUCTIVAL REFLEX – (+) ANAL REFLEX- ABSENT PLANTAR R L MUTE FLEXOR

13. CRANIAL NERVES – NORMAL SENSORY SYSTEM LOSS OF ALL MODALITIES OF SENSATION OVER LATERAL ASPECT OF RT FOOT LOSS OF SENSATION OVER THE PERIANAL REGION

14. AUTONOMIC INVOLVEMENT URGE INCONTINENCE + BOWEL INCONTINENCE + NO CEREBELLAR SIGNS NO MENINGEAL SIGNS

15. CVS – S1S2 + No murmurs RS – NVBS + no added sounds P/A – Soft hepatomegaly + no spleenomegaly

16. IMPRESSION : COMPRESSIVE TYPE OF MYELORADICULOPATHY MOTOR LEVEL : L1 SENSORY LEVEL:BELOW L-5 REFLEX LEVEL : L-5 AUTONOMIC INVOLVEMENT : S2,3,4

17. 2 PACKED CELLS T.TRAMADOL INJ.RANTAC INJ CEFTRIAXONE I.V FLUIDS T.PARA TREATMENT

18. INVESTIGATIONS CBC Hb-4.2 TC-17000 DC-P22,L76,E2 PLATLET-30000 RFT RBS-96 UREA - 26 CREAT-0.6 SODIUM- 140 K+ -4.2

19. LFT T.B-0.8 D.B-0.2 SAP-88 SGOT- 30 SGPT-40 ALBUMIN-4gm ECG- WNL CHEST X RAY- WNL USG ABDOMEN LIVER SPAN-15.2 CM SPLEEN- 12.1 CM

20. RBC’S :severe microcytichypochromic RBC’s Anisopoikilocytosisseen.few target cells seen WBC’S : Leukocytosis observed. Lymphocyte predominence more than 10% blasts seen. PLATLETS: Severe thrombocytopenia seen. IMPRESSION: To r/o acute leukemia P/S STUDY

24. PREVERTEBRAL AND PARAVERTEBRAL SOFT TISSUE LESIONS WITH INTRASPINAL EXTENSION AT D-11,D-12,L5 TO S3 VERTEBRAL LEVEL. S/0 METASTATIC DEPOSITS MRI REPORT

25. Hb-6.2 PCV- 25% TC-25,000 DC-BLAST 80% ?AML Haematology GH

32. Hypercellular marrow Abnormal premyelocytes and myelocytes seen. Myeloblast 40% Vacoulated blast (+) Erythroid progenitors reduced Occasional megakayocytes seen. Impression – AML Type 4 with dysplasia BONE MARROW REPORT

33. 2 PACKED CELLS 2 PLATLETS CYTOSINE ARBINOSIDE 150 mg od 7 days ADRIAMYCIN 30 mg od 3 days ETOPOSIDE 100mg od 3 days INJ DEXA 8 mg iv bd InjTramadol 1gm iv hs RADIOTHERAPY – Total dose of 180cGY in 10 fractions TREATMENT

35. Compression of the spinal cord from metastatic cancer located outside the spinal cord,subarachnoid space and duramater. METASTATIC EPIDURAL SPINAL CORD COMPRESSION

36. Metastatic epidural spinal cord compression (MESCC) is a devastating complication of cancer . It is estimated to develop in approximately 5% to 14% of all cancer patients. Although most patients with MESCC have limited survival, up to one third will survive beyond 1 year. METASTATIC EPIDURAL SPINAL CORD COMPRESSION

37. If left untreated, virtually 100% of these patients would become paraplegic; therefore, it is considered a true medical emergency and immediate intervention is required. Thus, it is essential to consider aggressive therapy to preserve or improve the quality of life and prevent paraplegia.

38. Physically, MESCC occurs in one of three ways: (1) continued growth and expansion of vertebral bone metastasis into the epidural space. (2) destruction of vertebral cortical bone, causing vertebral body collapse with displacement of bony fragments into the epidural space. (3) neural foramina extension into the epidural space by a paraspinalmass. PATHOPHYSIOLOGY

40. Although multifactorial, the most significant damage caused by MESCC appears to be vascular in nature. The epidural tumor causes epidural venous plexus compression, which leads to spinal cord edema. The increased vascular permeability and edema lead to increased pressure on the small arterioles. Capillary blood flow diminishes as the disease progresses, leading to white matter ischemia. Prolonged ischemia eventually results in infarction and permanent cord damage.

41. Back pain is the most common presenting symptom (88% to96%) weakness (76% to 86%), sensory deficits (51% to 80%) autonomic dysfunction (40% to 64%) CLINICAL PRESENTATION

42. The most common level of the MESCC involvement is : thoracic spine (59% to 78%), lumbar (16% to 33%) cervical spine (4% to 15%)

43. Breast cancer(29 %) Lung cancer (17%) Prostate cancer(14%) Sarcomas Melanomas Lymphoma and leukemia TUMOURS CAUSING MESCC

44. MRI is the standard modality for imaging of the central nervous system in cancer patients. It has a very high sensitivity (93%), specificity (97%), and accuracy (95%) in diagnosing MESCC Since patients can have synchronous, multifocal MESCC, an MRI of the entire spine should be performed promptly in anyone suspected of having MESCC DIAGNOSIS

45. In terms of predicting ambulatory outcome, one of the most important factors is the rapidity of symptom onset. Other important prognostic factors include radiosensitive histology (eg, multiple myeloma, germ-cell tumors, lymphomas, and small-cell carcinoma) and pretherapy ambulatory function. PROGNOSIS

46. CORTICOSTEROIDS Corticosteroids must be started as soon as possible in anyone suspected of having MESCC even before radiographic diagnosis, because they can be discontinued rapidly with a negative diagnosis. They decrease cord edema, and they serve as an effective bridge to definitive therapy THERAPY

47. Based on several studies, an IV loading dose of 10 mg dexamethasone followed by a maintenance dose of 4 to 6 mg (IV or orally) every 6 to 8 hours should be sufficient for most patients. Furthermore, patients should be started on a proton-pump inhibitor for GI prophylaxis.

48. Palliative radiotherapy has long been the standard of care in the treatment of patients with MESCC. Although multiple fractionation schedules have been reported in the literature, a total of 30 Gy in 10 fractions is the one most frequently employed RADIOTHERAPY

49. back pain relief maintenance of ambulation bladder function improvement Motor function improvement

50. Upfront chemotherapy (with a planned consolidative radiation) may be considered in select, newly diagnosed patients with excellent neurological status and very chemosensitive tumors

51. Radiation alone has been the standard treatment for MESCC, although results with radiation alone are disappointing. There are several reasons for this: SURGERY

52. (1) some tumors (eg, renal cell, sarcoma, and melanoma) are not radiosensitive; (2) even in radiosensitive tumors, it may take several days to deliver a radiation dose large enough to cause a response during which time the spinal cord damage may continue

53. (3) the most commonly used radiation dose and schedule (30 Gy in 10 fractions) is insufficient to provide long-term local control of gross tumor (except for radiosensitive tumors), so tumor may regrow to cause a recurrence of MESCC even after initial clinical response

54. For years laminectomy and postoperative radiotherapy were frequently combined. Recently, many have advocated the use of direct decompressive and maximal- debulking surgery with intraoperative stabilization of the spine (in appropriate cases) followed by postoperative radiation therapy

55. Recently, many have advocated the use of direct decompressive and maximal- debulking surgery with intraoperative stabilization of the spine (in appropriate cases) followed by postoperative radiation therapy. Since over 85% of spinal metastases arise anterior to the spinal cord, direct attempts at anterior spinal decompression seems logical.

56. The advantages of direct decompressive surgery include removal of the tumor with a resultant decrease in tumor burden that allows for more effective postoperative radiotherapy. immediate relief of the cord compression and immediate stabilization of the spinal column, which can be achieved by the same operation.

57. THANK YOU