Clinical case-6

A 55-year old woman came to her physician with sensory alteration in the right gluteal (buttock) region and in the intergluteal (natal) cleft. Examination also demonstrated low-grade weakness of the muscles of the foot and subtle weakness of the extensor hallucis longus, extensor digitorum longus, and fibularis tertius on the right. The patient also complained of some mild pain symptoms posteriorly in the right gluteal region.

A lesion was postulated in the left sacrum.

Pain in the right sacroiliac region could easily be attributed to the sacroiliac joint, which is often very sensitive to pain. The weakness of the intrinsic muscles of the foot and the extensor hallucis longus, extensor digitorum longus, and the fibularis tertius muscles raises the possibility of an abnormality affecting the nerves exiting the sacrum and possibly the lumbosacral junction. The altered sensation around the gluteal region toward the anus would also support these anatomical localizing features.

An X-ray was obtained of the pelvis.

The X-ray appeared on first inspection unremarkable. However the patient underwent further investigation, including CT and MRI, which demonstrated a large destructive lesion involving the whole of the left sacrum extending into the anterior sacral foramina at the S1, S2 and S3 levels. Interestingly, plain radiographs of the sacrum may often appear normal on first inspection, and further imaging should always be sought in patients with a suspected sacral abnormality.

The lesion was expansile and lytic.

Most bony metastasis are typically nonexpansile. They may well erode the bone producing lytic type of lesions or may become very sclerotic (prostate metastases and breast metastases). From time to time we see a mixed pattern of lytic and sclerotic.

There are a number of uncommon instances in which certain metastases are expansile and lytic. These typically occur in renal metastases and may be seen in multiple myeloma. The anatomical importance of these specific tumors is that they often expand and impinge upon other structures. The expansile nature of this patient's tumor within the sacrum was the cause for compression of the sacral nerve roots, producing her symptoms.

The patient underwent a course of radiotherapy, had the renal tumor excised, and is currently undergoing a course of chemoimmuno therapy.

Clinical case-5

A 72-year-old fit and healthy man was brought to the emergency department with severe back pain beginning at the level of the shoulder blades and extending to the mid lumbar region. The pain was of relatively acute onset and was continuous. The patient was able to walk to the gurney as he entered the ambulance; however, at the emergency department the patient complained of inability to use both legs.

The attending physician examined the back thoroughly and found no significant abnormality. He noted that there was reduced sensation in both legs, and there was virtually no power in extensor or flexor groups. The patient was tachycardic, which was believed to be due to pain, and the blood pressure obtained in the ambulance measured 120/80 mm Hg. It was noted that the patient's current blood pressure was 80/40 mm Hg; however; the patient did not complain of typical clinical symptoms of hypotension.

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On first inspection, it is difficult to "add up" these clinical symptoms and signs. In essence we have a progressive paraplegia associated with severe back pain and an anomaly in blood pressure measurements, which are not compatible with the clinical state of the patient.

It was deduced that the blood pressure measurements were obtained in different arms, and both were reassessed.

The blood pressure measurements were true. In the right arm the blood pressure measured 120/80 mm Hg and in the left arm the blood pressure measured 80/40 mm Hg. This would imply a deficiency of blood to the left arm.

The patient was transferred from the emergency department to the CT scanner, and a scan was performed that included the chest, abdomen, and pelvis.

The CT scan demonstrated a dissecting thoracic aortic aneurysm. Aortic dissection occurs when the tunica intima and part of the tunica media of the wall of the aorta become separated from the remainder of the tunica media and the tunica adventitia of the aorta wall. This produces a false lumen. Blood passes not only in the true aortic lumen but also through a small hole into the wall of the aorta and into the false lumen. It often re-enters the true aortic lumen inferiorly. This produces two channels through which blood may flow. The process of the aortic dissection produces considerable pain for the patient and is usually of rapid onset. Typically the pain is felt between the shoulder blades and radiating into the back, and although the pain is not from the back musculature or the vertebral column, careful consideration of other structures other than the back should always be sought.

The difference in the blood pressure between the two arms indicates the level at which the dissection has begun. The "point of entry" is proximal to the left subclavian artery. At this level a small flap has been created, which limits the blood flow to the left upper limb, giving the low blood pressure recording. The brachiocephalic trunk has not been affected by the aortic dissection, and hence blood flow remains appropriate to the right upper limb.

The paraplegia was caused by ischemia to the spinal cord.

The blood supply to the spinal cord is from a single anterior spinal artery and two posterior spinal arteries. These arteries are fed via segmental spinal arteries at every vertebral level. There are a number of reinforcing arteries (segmental medullary arteries) along the length of the spinal cord-the largest of which is the artery of Adamkiewicz. This artery of Adamkiewicz, a segmental medullary artery, typically arises from the lower thoracic or upper lumbar region, and unfortunately during this patient's aortic dissection, the origin of this vessel was disrupted. This produces acute spinal cord ischemia and has produced the paraplegia in the patient.

Unfortunately, the dissection extended, the aorta ruptured, and the patient succumbed.

Clinical case-4

A 25-year-old woman complained of increasing lumbar back pain. Over the ensuing weeks she was noted to have an enlarging lump in the right groin, which was mildly tender to touch. On direct questioning, the patient also complained of a productive cough with sputum containing mucus and blood, and she had a mild temperature.

The chest radiograph revealed a cavitating apical lung mass, which explains the pulmonary history.

Given the age of the patient a primary lung cancer is unlikely. The hemoptysis (coughing up blood in the sputum) and the rest of the history suggest the patient has a lung infection. Given the chest radiographic findings of a cavity in the apex of the lung, a diagnosis of tuberculosis (TB) was made. This was confirmed by bronchoscopy and aspiration of pus, which was cultured.

During the patient's pulmonary infection, the tuberculous bacillus had spread via the blood to vertebra LI. The bone destruction began in the cancellous bone of the vertebral body close to the intervertebral discs. This disease progressed and eroded into the intervertebral disc, which became infected. The disc was destroyed, and the infected disc material extruded around the disc anteriorly and passed into the psoas muscle sheath. This is not an uncommon finding for a tuberculous infection of the lumbar portion of the vertebral column.

As the infection progressed, the pus spread within the psoas muscle sheath beneath the inguinal ligament to produce a hard mass in the groin. This is a typical finding for a psoas abscess.

Fortunately for the patient, there was no evidence of any damage within the vertebral canal.

The patient underwent a radiologically guided drainage of the psoas abscess and was treated for over 6 months with a long-term antibiotic regimen. She made an excellent recovery with no further symptoms, although the cavities within the lungs remain. It healed with sclerosis.

Clinical case-3

A 45-year-old man was involved in a serious car accident. On examination he had a severe injury to the cervical region of his vertebral column with damage to the spinal cord. In fact, his breathing became erratic and stopped.

If the cervical spinal cord injury is above the level of C5, breathing is likely to stop. The phrenic nerve takes origin from C3, C4, and C5 and supplies the diaphragm. Breathing may not cease immediately if the lesion is just below C5, but does so as the cord becomes edematous and damage progresses superiorly. In addition, some respiratory and ventilatory exchange may occur by using neck muscles plus the sternocleidomastoid and trapezius muscles, which are innervated by the accessory nerve [XI].

The patient was unable to sense or move his upper and lower limbs.

The patient has paralysis of the upper and lower limbs and is therefore quadriplegic. If breathing is unaffected, the lesion is below the level of C5 or at the level of C5. The nerve supply to the upper limbs is via the brachial plexus, which begins at the C5 level. The site of the spinal cord injury is at or above the C5 level.

It is important to remember that although the cord has been transected in the cervical region, the cord below this level is intact. Reflex activity may therefore occur below the injury, but communication with the brain is lost.

Clinical Case-2

A 50-year-old woman visited her local family practitioner with severe lower back pain radiating into her right buttock.

Low back pain is a common problem in family practice.

Of the many common causes of low back pain some need to be identified early to commence appropriate treatment. The common causes include an anular disc tear, a disc prolapse that impinges directly on a nerve root, spinal stenosis, and mechanical zygapophysial joint pain. Overall, the main causes can be distilled into three central groups: mechanical back pain, degenerative joint disease, and neuronal compression.

Sciatica and lumbago are not the same. Lumbago is a generic term referring to low back pain. Sciatica is a name given to pain in the area of distribution of the sciatic nerve (L4 to S3), which is commonly felt in the buttock and over the posterolateral aspects of the leg.

Clinical Case 1-

A young man sought medical care because of central abdominal pain that was diffuse and colicky. After some hours, the pain began to localize in the right iliac fossa and became constant. He was referred to an abdominal surgeon, who removed a grossly inflamed appendix. The patient made an uneventful recovery.

When the appendix becomes inflamed, the visceral sensory fibers are stimulated. These fibers enter the spinal cord with the sympathetic fibers at spinal cord level T10. The pain is referred to the dermatome of T10, which is in the umbilical region (Fig. see above). The pain is diffuse, not focal; every time a peristaltic wave passes through the ileocecal region, the pain recurs. This intermittent type of pain is referred to as colic.

In the later stages of the disease, the appendix contacts and irritates the parietal peritoneum in the right iliac fossa, which is innervated by somatic sensory nerves. This produces a constant focal pain, which predominates over the colicky pain that the patient felt some hours previously. The patient no longer interprets the referred pain from the T10 dermatome.

Although this is a typical history for appendicitis, it should always be borne in mind that the patient's symptoms and signs may vary. The appendix is situated in a retrocecal position in approximately 70% of patients; therefore it may never contact the parietal peritoneum anteriorly in the right iliac fossa. It is also possible that the appendix is long and may directly contact other structures. As a consequence, the patient may have other symptoms (e.g., the appendix may contact the ureter, and the patient may then develop urological symptoms).

Although appendicitis is common, other disorders, for example of the bowel and pelvis, may produce similar symptoms.