Name : Age : Race : Sex : Address ate o! admission ate o! cler&ing RN :
Nursyafqah binti Ali 25 years old Malay Female : Puchong Perdana : "#$""$2%"5 : "'$""$2%"5 "'$""$2%"5 S%%(5)*%"
CHIEF COMPLAINT A 25 years old Malay lady +resented ,ith bac& +ain 5 days +rior to admission
HISTORY OF PRESENTING ILLNESS Patien atientt ,as ,as a++ar a++aren entl tly y ,ell ,ell unti untill 5 days days +rio +riorr to admi admiss ssio ionn- she com+laint o! lo,er bac& +ain. /t ,as sudden in onset u+on ,a&ing !rom slee+. 0he +ain ,as throbbing and shooting in nature as the +ain radiated !rom the bac&- to the thigh- leg and sole o! !oot. 0he +ain ,as not relie1ed relie1ed by +ain +ain &ill &iller er or massa assage ge and and exace xacerb rbat ated ed by mo1e mo1eme ment nt.. 0he 0he +ain +ain ,as ,as associated ,ith numbness and tingling sensation o! !oot. She scored the +ain "%$"%. esides- the +ain disturbed her daily acti1ities- as she had di3culty ,al&ing and mo1ing around. She could only stand !or less than one minute due to the +ain. Pre1iously she used squatting toilet- but no, had to use sitting toilet. Most o! time- she had to hold the ,all to mo1e around- as she !elt +ain. 0he +ain also disturbed her slee+. She needed to ta&e +ain &iller frst be!ore getting slee+. Since +ain- she had absence !rom ,or& !or se1eral days. 4n !urther questioning- she had history o! motor 1ehicle accident 2 years years ago. ago. She ,as the +assenge +assengerr o! motorb motorbi& i&e e and out o! sudden sudden-- the moto motorrcycl cycle e ,as ,as s&idd s&idded ed.. She She !ell !ell on her her righ rightt side side in sitt sittin ing g +osi +ositi tion on.. o,e1er- only minor bruises ,ere noted. She denied any hea1y bleedingloss o! consciousness and !racture. She e1en can ambulate ,ell right a!ter the accident. 4ne day a!ter trauma- she started to ha1e bac& +ain- more on right side- associated ,ith numbness and tingling sensation. 0he +ain had similar nature as current +resentation but not se1ere as no,. She ,ent to &lini& &esihatan seri &embangan !or medical attention. 6ray ,as done at that time and no abnormality ,as noted. She had gi1en +ain &iller and +hysiothera+y schedule. 0he +ain ,as com+letely resol1ed a!ter 2 days and one 1isit to +hysiothera+y.
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o,e1er- since the incident- she com+laint o! intermittent bac& +ain sometimes- ,ith !requency once in three months- es+ecially during hea1y li!ting and doing hea1y ,or&s. She could bear ,ith the +ain. 4ther,ise she ,ill ta&e +ain &iller to resol1e the +ain. 0he bac& +ain ,as started to ,orsen since one month ago- as she doing +art time 7ob at #ele1en sho+. She needed to carry hea1y loads and require much ,al&ing and standing most o! time. 4ther,ise- she had history o! 0 contact- ,hich is her late uncle- one year ago. er mother8s aunt had history o! bone malignancy and died due to the malignancy. 4ther,ise- she had no history o! !e1er- cough- shortness o! breath and night s,eats. She denied any recent trauma and tra1elling. She had no constitutional sym+toms such as loss o! ,eight and loss o! a++etite.
SYSTEMIC REVIEW /t ,as unremar&able. PAST MEDICAL HISTORY She is 9)P +atient since child. 4ther,ise- no hy+ertension- diabetes mellitus or any underlying medical illness. PAST SURGICAL HISTORY No history o! surgical inter1ention be!ore DRUG HISTORY She only get allergy ,ith !ood that are contraindicated !or 9)P +atient. No &no,n drug allergy.
FAMILY HISTORY She is single- not married yet. She is the frst out o! 2 siblings. er mother had died due to breast cancer 2 years ago. er !ather and little brother are healthy. er mother8s aunt has history o! bony malignancy. 4ther,ise- no diabetes- no hy+ertension running in her !amily
SOCIAL HISTORY ;urrently- she stayed ,ith her !amily in a single storey terrace house at Puchong Perdana. She ,or&s as an administrati1e o3cer at u&it
SUMMARY
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Miss Syafqah- 25 years old Malay lady ,ith history o! trauma on right side 2 years ago +resented ,ith +rogressi1e ,orsening lo, bac& +ain- associated ,ith numbness and tingling sensation on !oot 5 days +rior to admission. She had !amily history o! bone malignancy and had recent contact ,ith 0 +erson one year ago.
PHYSICAL EXAMINATION
9enerally- +atient ,as alert and conscious. She couldn8t lie com!ortably as she had +ain on her lo,er bac&. She +re!erred to lie laterally- either right or le!t side to be com!ortable. o,e1er- she8s not in res+iratory distress. Not cachexic loo&ing. ;a+illary refllary time ,as less than 2 second. No con7uncti1a +allor and good oral hygience. No central cyanosis noted. ydration status ,as adequate. =ital signs ,ere: Res+iratory rate : 2% breaths +er minute Pulse rate : #* b+m 0em+erature : (#.%o; >a!ebrile? lood +ressure : ""#$)@ mmg >normotensi1e?
Spine Examination xamination ,as done in standing and lying +osition. o,e1er- it ,as restricted in standing +osition as +atient ,as ha1ing +ain to stand. 4n ins+ection- there ,as no shoulder asymmetry and +el1ic ,as not tilted but she could only stand !or a ,hile as she8s ha1ing +ain. /ns+ection o! bac& re1ealed there ,as no surgical scar- no s&in changes- no 1isible s,elling or no scoliosis noted. 0here ,as also no muscle ,asting. From lateral side- there ,as no gibbus- no excessi1e lumbar lordosis obser1ed. /ns+ection !rom anterior- there ,as no de!ormity o! the chest- and no abnormal +rotrusion o! the abdomen. 4ther,ise- there ,as no muscle ,asting o! the quadrice+s and no de!ormity o! the lo,er limbs. 4n gait examination- there ,as +resence o! antalgic gait on her right side. Pal+ation o! the s+ine re1ealed tenderness o1er lumbar region- B5 area and sacroiliac 7oint. 0he s+ine ,as centrally aligned. Ste+oC ,as absence. 0here ,ere also no tem+erature changes and no +aras+inal muscle s+asm. For range o! mo1ement- !or,ard Dexion- acti1e mo1ement ,as !rom % o to "5o- ,hich ,as limited >normally % o E '%o?- and it ,as same ,ith +assi1e mo1ement. Schober8s test couldn8t be a++reciated as the +atient ,as ha1ing 3
+ain. 4ther mo1ement such as extension- lateral and medial rotation could not be done due to the +ain. S+ecial test- SLR ,as +ositi1e !or the right lo,er limb ,here the +atient com+laint o! shooting +ain at "% degree. Patient had +ositi1e FAR8s sign on her right lo,er limb- ,hereas her le!t lo,er limb is normal.
Neurological Examination 4n ins+ection o! lo,er limb- there ,as no surgical scar- no s,elling- no muscle ,asting- no !asciculation or limb length discre+ancy ,as noted. No clonus ,as noted. 4n +al+ation- tone ,as normal bilaterally. Po,er o! Dexors and extensors grou+ muscle ,as normal bilaterally. 0here ,as +resence o! an&le and &nee reDex !or both sides. Abdomen reDex ,as also intact. abins&i ,as negati1e. o,e1er- there ,as reduced sensation and reduced in +in+ric& touch on S" area o! right !oot. ut- le!t side re1ealed normal sensation. ;oordination and +ro+rioce+tion ,ere intact. All +ulses ,ere !elt bilaterally. Anal sensation ,as intact. 4ther examination ,as unremar&able.
SUMMARY Miss Syafqah- 25 years old Malay lady ,ith history o! trauma on right side 2 years ago +resented ,ith +rogressi1e ,orsening lo, bac& +ainassociated ,ith numbness and tingling sensation on !oot 5 days +rior to admission. Physical examination re1ealed +resence o! antalgic gait and +atient lied uncom!ortably due to +ain. S+ine examination sho,ed tenderness on B5S" area- together at right sacroiliac 7oint. 0here ,as reduced sensation on right side o! S" area. Be!t lo,er limb re1ealed normal fnding
PROVISIONAL DIAGNOSIS Prola+se inter1ertebral disc at lumbar area- B5 ,ith ner1e root com+ression Points !or : chronic bac& +ain- since 2 years ago disturbance in daily acti1ities history o! trauma and !all history o! hea1y li!ting ,ithin +ast one month tenderness o1er lumbar area and sacroiliac 7oint • • • • •
DIFFERENTIAL DIAGNOSIS 4
Points for history o! tuberculosis contact one year ago
S+ine tuberculosis
Pyogenic in!ection o! s+ine
Points against no +rolonged cough- no night s,eat- no loss o! ,eight or a++etite no tachy+nea- no !e1er- no muscle s+asm
bac& +ain- restriction o! mo1ement- tenderness o! 1ertebrae
Mechanical bac& +ain
•
one malignancy
•
history o! hea1y li!tingtenderness o! lumbar area- recurrent e+isode Family history o! bone malignancy
•
•
history o! traumanot relie1ed by massage No constitutional sym+toms such as loss o! ,eight- loss o! a++etite
INVESTIGATION Renal profle 4b7ecti1e :0o loo& !or the le1el o! serum creatinine and urea !or renal !unctionand any electrolytes imbalance.
rea Sodium Potassium ;hloride ;reatinine /m+ression :
Resl!s *.* mmol$B "() mmol$B *. mmol$B % "%5 mmol$B 55 mmol$B All +arameters ,ere normal.
Nor"al ran#e >".# E @.(? >"(5 E "*5? >(.5 E 5.%? >'@ E "%@? >5( '#?
Ur$nal%s$s &'e"e( • •
lood ilirubin
: Negati1e : Negati1e 5
robilinogen : 2G Hetone : Negati1e Protein : "G Nitrite : Nil 9lucose : Negati1e + : 5.% S.9 : ".%(% Beucocyte : Negati1e /m+ression : normal fnding • • • • • • •
I"a#$n# Pla$n X)ra% o' l"*o)sa+ral re#$on &AP , la!eral -$e.s( Reasons to loo& !or e1idence 0 s+ine and other associated +athology to rule out other causes >e.g.- malignancy? Result no abnormality fnding no destruction on disc s+ace no so!ttissue shado,s on +ara1ertebral area no loss o! lumbar lordosis no ob1ious !racture seen ;omment normal fnding no e1idence o! +robable 0 s+ine bone malignancy has been ruled out as there is destruction o! the inter1ening disc O!/er $n-es!$#a!$ons I .ol0 l$1e !o 0o Full blood count reason : in!ection- due to leu&ocytosis or +reo+ assessment Bi1er +rofle Reason : to rule out secondary bone tumor through increased albumin$globulin ratio Mantoux test and S+utum !or acid!ast bacilli >AF? Reason : to diagnose 0 in!ection ;Reacti1e Protein >;RP? Reason : /! it is raised- it indicates acute inDammation
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FINAL DIAGNOSIS Prola+se inter1ertebral disc at lumbar area- B5 ,ith ner1e root com+ression
TREATMENT • • • • • • •
Analgesic ;.celebrex 2%% mg - 0 P;M " g I/- ; tramal 5% mg 0S /1 ranitidine 5% mg 0S 0 e+risone 5% mg 0S !or 2$52 0 neurobion MR/ scheduled on next month 0o come again >0;A? ($52 a!ter MR/ M; !or a ,ee&
DISCUSSION ac& +ain is a 1ague +resentation that com+rises a ,ide range o! causes. 0hey are +robably due to in!ection- degenerati1e- traumaticmalignancy- or congenital. 1en the causes maybe localiJed cause such as mechanical bac& +ain or muscle s+asm itsel!. 0he +atho+hysiology behind this sym+tom can be either due to com+ression to the s+inal cord- ner1e root- or the 1ertebral ligament Regarding to this case- Ms Syafqah started to ex+erience sudden lo, bac& +ain accom+anied ,ith numbness and tingling sensation. 0he question to be as&ed is- is it caused by !ra"a to the s+ine ,hich then the !racture !ragment com+ressing the ner1e root- or is it due to $n'e+!$on- +articularly tuberculosis or is it due !"or gro,th that com+ressing the ner1e roots or is it due to +rola+sed inter1ertebral disc > PID?- ,hich then com+ressing the ner1e rootK 0here!ore- here ,here history and +hysical examination come and +lay its role. From the history- Ms- Syafqah claims that during the recent attac&- she could barely ,al& due to the +ain. She denied on !all or in7ury to the bac&. y ha1ing this- ,e can already rule out !racture o! the s+ine. 0y+ically in !racture case- the +atient ,ill ha1e +ain 7ust !ollo,ing an incident- and associated ,ith s,elling at the !racture site- loss o! !unction- and can8t mobiliJe. 4ther than that- she also denies ha1ing any !e1er- night s,eats- or chronic cough in recent +eriod. 0his may gi1e us an idea that tuberculosis in!ection is less li&ely. For malignancy- the +atient loo&ed ,ell- doesn8t ha1e any loss o! a++etite or ,eight. Pyogenic in!ection also can be ruled out as there ,as no !e1er. ere- +rola+sed inter1ertebral disc >P/? is one o! the +ossible diagnoses ,hich can lead to the com+ression the ner1e roots. From the history- +atient ,as +resented ,ith lo, bac& +ain together ,ith numbness and tingling sensation. ut no emergency case ,as noted as she denied any 7
history o! anal and bo,el incontinence. 0his su++orts the diagnosis o! P/. o,e1er- P/ is a MR/ diagnosis- as P/ can only be diagnosed 7ust !rom the history and +hysical examination. MR/ ,as being scheduled in this +atient. Pro+la+se inter1ertebral disc >P/? is a condition ,here the gelatinous nucleus +ul+osus o! the disc squeeJes through the fbres o! the annulus fbrosus and buldges +osteriorly or +osterolaterally beneath the +osterior ligament causing +ressure on one o! the ner1e roots. 0he +atho+hysiology beneath it is mainly due to nucleus degeneration associated ,ith ,ea&ening o! the annulus fbrosus- !ollo,s ,ith nucleus dis+lacement- and then stage o! fbrosis ,here the extruded nucleus ,ill become fbrosed. P/ commonly aCect young adults- +articularly age bet,een 2% to *% years old- and usually aCect lo,er lumbar and sacral region- ,hich is bet,een B* E B5 >in younger +atient? and B5 E S" >in older +atient?. From the history ,ise- the s+ecifc sym+tom !or P/ is ,hen +atient com+laining about aggra1ated lo, bac& +ain ,hen straining or doing any acti1ity that can increase intraabdominal +ressure such as coughing- sneeJing- +assing motion- or li!ting hea1y things. From the +hysical examination as+ect- there is no s+ecifc sign !or P/- e1en !or straight leg raising test >SBR?. /t is because SBR ,ill be +ositi1e not only in P/- but also in any condition that can cause com+ression to the sciatic ner1e. o,e1er- in +hysical examination o! P/ case- ,hat is im+ortant !or us to loo& out is that either the +atient ha1ing any associated motor and sensory de!ect. y doing this- it can gi1es us an idea about ,hich le1el is aCected- be!ore ,e confrm it by MR/.
/n this case- Miss Syafqah has com+lained that the lo, bac& +ain is ,orsened ,hen she tries to li!t hea1y things. 0his is the ty+ical +resentation o! +rola+se inter1ertebral disc. 0his is already su++ort the diagnosis o! P/. From the +hysical examination- it re1eals that there ,as tenderness o1er B5 area. Ner1e root ,as also in1ol1ed as there ,as reduced sensation at S". A+art !rom that- SBR test also is also +ositi1e !or right lo,er limbs- ,hich +ro1ed that there is com+ression o! the sciatic ner1e. For in1estigation- P/ only can be confrmed by MR/ scan. 0he other in1estigations that are usually done is mainly to rule out other diCerential diagnosis- and is also !or +reo+erational assessment !or +atient ,ho ,ill undergo surgery. P/ can be treated either by conser1ati1ely- or later- i! conser1ati1e !ailed- o+erati1e treatment ,ill come a+art. For conser1ati1e management- it is di1ided it into non+harmacological and +harmacological treatment. For non+harmacological treatment- it includes bed rest ,here the aim is mainly to reduce mo1ement o! the s+ine ,hich can ,orsen the +roblem- massage thera+y- and ,arm +ac&. For +harmacological as+ect o! conser1ati1e treatment- it is mainly to relie1e the +ain. 0he drugs that usually used is such as tramadol >o+iods?- ibu+ro!en >NSA/s grou+?- or celecoxib >;462 s+ecifc inhibitors?. 0hose drugs are ta&en orally in tablet 8
!orm. 0here is sometimes ,here these analgesic tablets cannot relie1e the +ain. 0hen- ,e can gi1e intra1enous in7ection o! glucocorticoids >egL triamcinolone? to relie1e the +ain. For o+erati1e treatment- the aims areL "? to relie1e ner1e com+ression es+ecially in emergency cases- 2? relie1e the bac& +ain- and (? restoration to normal !unction. 0he +rinci+al method !or o+erati1e treatment !or P/ is decom+ression and i! necessary- do stabiliJation8. 0here are se1eral surgical o+tions can be done- such as discectomy- laminectomy- or artifcial disc re+lacement. Post o+erati1e rehabilitation +rogram is needed. /t is im+ortant !or the +atient to be taught about +hysiothera+y. ;onsultation on li!estyle modifcation such as sto+ hea1y li!ting should be ad1ised and change to a more reasonable light duty.
REFERENCES 23 A+ley8s System o! 4rtho+aedics and 0rauma ># th edition?. A. 9raham A+ley and Bouis Solomon 43 ;linical examination- Ronald Mc Rae- ;hurchill Bi1ingstone 53 htt+:$$,,,.emedicine.medsca+e.com
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