Grand Case Report

MYELOPATHY

Presented by:
Raissa Kurniasih
NIM : 1608438257

Supervisor :
dr. Yossi Maryanti, Sp.S, M.Biomed

CLINICAL CLERKSHIP
NEUROLOGY DEPARTEMENT
FACULTY OF MEDICINE RIAU UNIVERSITYOF RIAU
ARIFIN ACHMAD GENERAL HOSPITAL
PEKANBARU
2018

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 KEMENTRIAN PENDIDIKAN DAN KEBUDAYAAN
FAKULTAS KEDOKTERAN UNIVERSITAS RIAU
SMF/ BAGIAN SARAF
Sekretariat : Gedung Kelas 03, RSUD Arifin Achmad Lantai 04
Jl. Mustika, Telp. 0761-7894000
E-mail : saraffkur@gmail.com
PEKANBARU

I. Patient’s identity
Name Mrs. R
Age 43 years old
Gender Female
Address Padang Sawah
Religion Moslem
Marital’s Status Married
Occupation Housewife
Hospital Admission Oct, 23rd 2018
Medical Record 997010

II. ANAMNESIS :
Auto and Alloanamnesis with patient’s husband (Oct, 24th 2018 on 11.00
AM)
Chief complain
Weakness on both lower extremities since 3 weeks before admitted to the
hospital
Present illness history
 Since 3 weeks before admitted to the hospital, patient complained weakness
on both lower extremities. Weakness gradually began on the left leg, then
to the right leg. Patient has difficulty to lift both lower extremities and can’t
stand by her own. The muscle weakness didn’t improve with rest and get
worsen until patient couldn’t move her legs at all. Patient also complained
can’t defecate and urinate.

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  Since 2 months before, patient complained back pain radiating to abdomen
until both legs. The pain was intermittent. The pain became severe in
activity but decrease with drug. Pain occured gradually without any
previous trauma histories before. Then, patient felt numb on both legs.
Numbness began on the left leg, then to the right leg. Numbness felt
continuously and getting worse day by day.
 Patient had fever, ups and down, accompanied by shivering. There is no
pain on her neck and no weakness on the upper limbs. Weight loss denied,
prolonged cough denied, bump on the back denied.

Past illness history

 History of malignancy (-)
 History of stroke (-)
 History of 6 months medication (-)
 Hypertension (-), Diabetes mellitus (-)

The family disease history

 History of malignancy (-)
 History of TB (-)

Socioeconomic history
 History of smoking (-)
 Dietary habit is regular

Occupation
Housewife

SUMMARY
Mrs. R, 43 years old admitted to the hospital on Oct, 23rd 2018. The patient
has complained weakness gradually on both legs 3 weeks before admission. She
also complained can’t defecate and urinate. Patient complained back pain radiating
to abdomen until both legs since about 2 months before admission. Patient also felt

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numbness began on the left leg and then to the right leg. Patient complained she had
fever, ups and down and accompanied with shivering.

III. Physical examination

A. Generalized state (Oct, 24th2018 on 11.00 AM))
Blood Pressure : 120/70 mmHg
Heart Rate : 80 bpm
Respiratory rate : 19 x/i
Temperature : 36,8°C
Weight : 55 kg Height : 160 cm BMI : 21,48 (Normoweight)

B. NEUROLOGICAL STATUS
1) Consciousness : Composmentis-cooperative
GCS : E(4)V(5)M(6)
2) Cognitive Function : Normal
3) Meningeal Sign : Negative
4) Cranial Nerves
1. Cranial nerve I (Olfactory)
Right Left Interpretation
Senseof Smell + + Normal

2. Cranial nerve II (Optic)

Right Left Interpretation
Visual Acuity Normal Normal
Visual Fields Normal Normal Normal
Colour Recognition + +

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3. Cranial nerve III (Oculomotor)
Right Left Interpretation
Ptosis (-) (-)
Pupil
Shape Isochoric Isochoric
Size Φ3mm Φ3mm
Pupillary reactions to light Normal
Direct (+) (+)
Indirect (+) (+)
Extraocular movement Normal Normal

4. Cranial nerve IV (Trochlear)

Right Left Interpretation
Extraocular movements Normal Normal Normal

5. Cranial nerve V (Trigeminal)

Right Left Interpretation
Motoric Normal Normal
Sensory (+) (+) Normal
Corneal reflex (+) (+)

6. Cranial nerve VI (Abducens)

Right Left Interpretation
Eyes movement Normal Normal
Strabismus (-) (-) Normal
Deviation (-) (-)

7. Cranial nerve VII (Facial)

Right Left Interpretation
Tic (-) (-)
Motor:
- Frowning Normal Normal Normal
- Raised eye Normal Normal
brow

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 - Closed eyes Normal Normal
- Corners of Normal Normal
the mouth
- Nasolabial Normal Normal
fold
Sense of Taste Normal Normal
Chvostek Sign - -

8. Cranial nerve VIII (Acoustic)

Right Left Interpretation
Hearing sense Normal Normal Normal

9. Cranial nerve IX (Glossopharyngeal)

Right Left Interpretation
Pharyngeal Arch Normal Normal
Sense of Taste Normal Normal Normal
Gag Reflex + +

10. Cranial nerve X (Vagus)

Right Left Interpretation
Pharyngeal Arch Normal Normal
Normal
Dysphonia - -

11. Cranial nerve XI (Accessory)

Right Left Interpretation
Motoric Normal Normal
Normal
Trophy Eutrophy Eutrophy

12. Cranial nerve XII (Hypoglossal)

Right Left Interpretation
Motoric Normal Normal
Trophy Eutrophy Eutrophy Normal

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 Tremor - -
Disartria - -

IV. MOTORIC SYSTEM

Right Left Interpretation
Upper Extremity
Strength
Distal 5 5
Medial 5 5
Proximal 5 5
Tone Normal Normal
Trophy Eutrophy Eutrophy
Involuntary movements - -
Clonus - -
Lower Extremity Paraparesis inferior
Strength
Distal 1 1
Medial 1 1
Proximal 1 1
Tone Normal Normal
Trophy Eutrophy Eutrophy
Involuntary movements - -
Clonus - -
Body
Trophy Eutrophy Eutrophy
Involuntary movements - - Normal
Abdominal Reflex + +

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V. SENSORY SYSTEM
Right Left Interpretation
Touch ↓ on Th-4 ↓ on Th-4
Hypoesthesia
Pain ↓ on Th-4 ↓ on Th-4
on Th-4
Temperature Not identified Not identified
dermatome to
Propioseptive Negative Negative
the lower

VI. REFLEX
Right Left Interpretation
Physiologic
Biceps + +
Physiologic reflex
Triceps + +
increased
Knee +++ +++
Ankle +++ +++

Pathologic
Babinsky (-) (-)
Chaddock (-) (-) Pathological reflex(-)
HoffmanTromer (-) (-)
Oppenheim (-) (-)
Schaefer (-) (-)

VII. COORDINATION
Right Left Interpretation
Point to point movement Normal Normal
Walk heel to toe
Difficult to
Gait Difficult to Difficult to
Interpretate
Tandem asses asses
Romberg

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VIII. AUTONOM
a. Urination : Micturition (-)
b. Defecation : Defecation (-)

IX. OTHERS EXAMINATION

a. Laseque : Unlimited (>70)
b. Kernig : Unlimited (>135)
c. Patrick : -/-
d. Kontrapatrick : -/-
e. Valsava test :-
f. Brudzinski :-

X. EXAMINATION RESUME
Generalized condition
Consciousness : CM (GCS: E(4)V(5)M(6))
Blood Pressure : 120/70 mmHg
Heart Rate : 80 bpm
Respiratory Rate : 19 bpm
Temperature : 36,8°C
Cognitive Function : Normal
Meningeal sign : Negative
Cranial Nerves : Normal
Motoric : Paraparese inferior
Sensory : Hypoesthesia on Th-4 dermatome to the lower
Coordination : Difficult to interpretate
Autonomy : Micturition (-), defecation (-)
Reflex : Physiology (), Pathology (-)

XI. WORKING DIAGNOSIS :

CLINICAL DIAGNOSIS :
- Paraparese inferior with UMN type
- Hypoesthesia from Th-4 dermatome to lower

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 - Autonomic dysfunction
TOPICAL DIAGNOSIS : 4th thoracal spinal cord segments
ETIOLOGIC DIAGNOSIS : Thoracic myelopathy ec susp. Spinal
cord tumor
DIFFERENTIAL DIAGNOSIS : Susp. Spondilitis TB

XII. ADJUNCT EXAMINATION :

o Blood routine
o Blood chemistry
o Electrolytes
o Chest X-ray
o Thoracal spine X-ray
o MRI thoracal spine
o Lumbar puncture

LABORATORIUM FINDING :
1. Blood Routine (Oct, 23rd 2018)
Haemoglobin : 11,7 gr/dl
Haematocrit : 36,5 %
Leucocytes : 20.360 /mm3
Platelet : 182.000 /uL

2. Blood Chemistry (Oct, 23rd 2018)

Glucose : 100 mg/dl (<200 mg/dl)

Ureum : 34 mg/dl (15 – 41)
Creatinin : 0,5 mg/dl ( 0,55 – 1,30)
SGOT : 39 U/L (15 – 37)
SGPT : 24 U/L (12 – 78)

3. Electrolyte (Oct, 23rd 2018)

Na+ : 141 mmol/L (135-145)
K+ : 3,6 mmol/L (3,5-5,5)

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 Cl : 107 mmol/L (97-107)

4. Chest X-ray (Sept 14th 2018)

Interpretation :

Within normal limits

5. MRI (Oct, 26th 2018)

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 Interpretation :

Spondylitis VTh 1-3 with abcess paravertebral susp. ec TB

FINAL DIAGNOSE
- Thoracic myelopathy ec Spondilitis TB

MANAGEMENT :
 IVFD Ringer Lactate (30cc/kgBW/day)  20 dpm
 Corticosteroid : Metilprednisolon 3x125 mg IV
 Analgetic : Ketorolac 2x30 mg IV
 Neuroprotector : Mecobalamin 3x500 mg IV
 Gastric protector : Ranitidin 2x125 mg IV

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FOLLOW UP
1. October, 25th 2018
S : Weakness on extremities (+), numbness (+), back pain (+), fever (-),
constipation
O : GCS E(4)V(5)M(6)
Blood Pressure : 130/70 mmHg
Heart Rate : 85 bpm, reguler
Respiratory Rate : 20 tpm
Temperature : 37,2°C
Cognitive Function : Normal
Neck Stiffness : Not found
Cranial Nerves : Within normal limits
Motoric : Paraparese inferior with UMN type
5 5
1 1
Sensory : Hypoesthesia on Th-4 dermatome to lower
Coordination : Not testable
Autonom : Micturition (+) with cateter, Defecation (-)
Reflex : Physiologic reflex ()
Pathologic reflex (-)
A : Thoracic myelopathy ec susp. Spinal cord tumor
P :
 IVFD RL 20 dpm  Plan: MRI Thoracal
 Metilprednisolon 3x125 mg  Consul to surgeon  BNO 3
IV position and consul to interna
 Mecobalamin 3x500 mg IV  IVFD Ciprofloxacin 2x400
 Ketorolac 2x30 mg IV mg, IVFD Metronidazol
 Ranitidin 2x125 mg IV 3x500 mg, omeprazole 2x40
 MST 3x10 mg mg IV
 Dulcolax sup

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2. October, 26th 2018
S : Weakness on extremities (+), numbness (+), back pain (+), constipation,
fever (-)
O : GCS E(4)V(5)M(6)
Blood Pressure : 120/70 mmHg
Heart Rate : 82 bpm, reguler
Respiratory Rate : 20 tpm
Temperature : 37,4°C
Cognitive Function : Normal
Neck Stiffness : Not found
Cranial Nerves : Within normal limits
Motoric : Paraparese inferior with UMN type
5 5
1 1
Sensory : Hypoesthesia on Th-4 dermatome to lower
Coordination : NT
Autonom : Micturition (+) with cateter, Defecation (-)
Reflex : Physiologic reflex ()
Pathologic reflex (-)
MRI Thoracal : Spondylitis VTh 1-3 with abcess paravertebral susp. ec TB
A : Thoracic myelopathy ec Spondilitis TB
P :
 IVFD RL 20 dpm  Dulcolax supp
 Metilprednisolon 3x125 mg  Omeprazol 2x40 mg IV
IV  IVFD Ciprofloxacin 2x400
 Mecobalamin 3x500 mg IV mg
 Ketorolac 2x30 mg IV  IVFD Metronidazole 3x500
 Ranitidin 2x125 mg IV mg
 MST 3x10 mg  Consul to Med Rehab

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3. October, 27th 2018
S : Weakness on extremities (+), numbness (+), back pain (+), constipation,
fever (-)
O : GCS E(4)V(5)M(6)
Blood Pressure : 110/80 mmHg
Heart Rate : 82 bpm, reguler
Respiratory Rate : 19 tpm
Temperature : 37,2°C
Cognitive Function : Normal
Neck Stiffness : Not found
Cranial Nerves : Within normal limits
Motoric : Paraparese inferior with UMN type
5 5
1 1
Sensory : Hypoesthesia on Th-4 dermatome to lower
Coordination : NT
Autonom : Micturition (+) with cateter, Defecation (-)
Reflex : Physiologic reflex ()
Pathologic reflex (-)
A : Thoracic myelopathy ec Spondilitis TB
P :
 IVFD RL 20 dpm  Dulcolax supp
 Metilprednisolon 3x125 mg  Omeprazole 2x40 mg IV
IV  IVFD Ciprofloxacin 2x400
 Mecobalamin 3x500 mg IV mg
 Ketorolac 2x30 mg IV  IVFD Metronidazole 3x500
 Ranitidin 2x125 mg IV mg
 MST 3x10 mg  Consul to spine consultant

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 DISCUSSION

1. Myelopathy
1.1 Definition
The term myelopathy describes pathologic conditions that cause spinal cord,
meningeal or perimeningeal space damage or dysfunction. Traumatic injuries,
vascular diseases, infections and inflammatory or autoimmune processes may affect
the spinal cord due to its confinement in a very small space. Spinal cord injuries
usually have devastating consequences such as quadriplegia, paraplegia and severe
sensory deficits.1

1. 2 Etiology
There are cases where the etiology is never identified, and they are classified
as idiopathic myelopathy. In 2001, De Seze et al. found that 43% of acute
myelopathies were secondary to multiple sclerosis; 16.5% were due to a systemic
disease; 14% to a spinal cord infarct; 6% to an infectious disease; 4% were
secondary to radiation; and 16.5% were idiopathic. Moore et al. found that in cases
of non-traumatic injury, 23.6% were due to cervical spondylolysis; 17.8% to
multiple sclerosis; 16.4% to a neoplastic lesion; 4.1% to motor neuron disease; and
18.6% were idiopathic or of unknown etiology.1

1.3 Classification
Based on the Sicard and Forstier classification that divides the disease into
compressive and non-compressive.
1.3.1 Compressive myelopathies
Compressive diseases of the spinal cord are divided into acute and chronic,
including degenerative changes, trauma, tumor infiltration, vascular malformations,
infections with abscess formation, and syringomyelia. Compressive disease is the
main cause of myelopathy in older patients. It has a chronic course and usually does
not recur. Kelley et al. found that none of the patients with compressive myelopathy
improved with intravenous corticosteroids, while patients with inflammatory

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myelopathies did improve, invalidating the hypothesis of traumatic inflammatory
demyelination.2
1.3.2 Non-compressive myelopathies
Once compression is ruled out as the etiology of myelopathy, the clinical
history is analyzed in depth and a careful clinical examination is performed in order
to look for an inflammatory cause. The diagnosis of an inflammatory myelopathy
requires evidence of spinal cord inflammation. At the present time, MRI and
cerebrospinal fluid (CSF) analysis are the only tools available for determining the
presence of inflammation. There needs to be gadolinium enhancement of the spinal
cord, pleocytosis in the CSF or a high immunoglobulin G index in the CSF, with a
time course ranging between four hours and four weeks. If none of these findings
are present at the time of onset of symptoms, MRI and lumbar taps must be repeated
two to seven days later.2

2. Spinal Cord Tumor

2.1 Definition
Spinal tumors are neoplasm located in the spinal cord. Tumors of the spinal
cord is divided as primary tumors and secondary tumors. The primary tumor is a
tumor originating from the spinal cord, while secondary tumors are the mestastase
of tumors in other body parts.3

2.2 Epidemiology
The number of spinal cord tumor patients in Indonesia is not known with
certainly. The number of cases of spinal cord tumors in the United States reaches
15% of the total number of tumors that occur in the central nervous system with an
estimated incidence of 0.5-2.5 cases per 100.000 population per year. The number
of male sufferers are almost the same as women with the range of age between 30
to 50 years. The spread of 25% tumors are located in the cervical segments, 55% in
the thoracal segments and 20% in the lumbosacral segments.4,5

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2.3 Etiology
Causes of primary spinal cord tumors until now has not known for certain.
Some possible causes and are still in the research stage is a virus, a genetic disorder,
and chemicals that are carcinogenic. As for the secondary tumor (metastasis) is
caused by cancer cells that spread from other parts of the body via the bloodstream
which then penetrate the vascular wall, attached to the normal spinal cord tissue and
form a new tumor tissue in the area.4

2.4 Classification
Based on the origin and nature of the cells, the tumor in the spinal cord
tumors can be divided into primary and secondary tumors. Primary tumors can be
benign or malignant, while secondary tumors are always malignant because it is the
metastasis of malignant process in other places such as lung cancer, breast, prostate,
kidney, thyroid or lymphoma. Primary tumors are malignant astrocytomas example,
neuroblastoma, and kordoma, while benign example neurinoma and glioma.4,6,7
Based on its location, a tumor of the spinal cord can be divided into two
groups, there are tumor intradural and extradural. Intradural tumor in which it is
itself subdivided into intramedular and extramedullary tumors.8

Figure 1. (A) Intradural-intramedullar tumor, (B) Intradural-extramedullar tumor

and (C) Extradural tumor8

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2.5 Clinical Manifestation
a. Extradural Tumors
Most of the tumors are metastatic, which cause compression of the spinal
cord and are located in the thoracic segments. Radicular pain can be an initial
symptom in 30% patients but then after a few days, weeks or months followed by
symptoms of myelopathy. Pain is usually more than one root, which initially
disappears with rest, but the longer it will become more persistent, so it can be the
main symptom eventough there are symptoms associated with the primary tumor.
Pain in the metastatic tumor can occur spontaneously and often increases with mild
percussion of the vertebrae, such pain is better known as vertebral pain.
Metastatics tumor extradural malignancy has the following characteristics:9
a) Most spinal tumors (>80%) are malignant metastases mainly from the
lungs, breast, kidney, prostate, colon, thyroid, melanoma, lymphoma or
sarcoma.
b) The first involved is the vertebral body. Predilection for the location of
metastatic lung, breast and colon tumors is the thoracic region, whereas
prostate, testicular and ovarian tumors usually go to the lumbosacral
region.
c) Symptoms of spinal cord compression mostly occur at the thoracic level,
because of the small diameter of the canal (approximately only 1 cm)
d) Symptoms due to spinal metastases begin with local pain that is sharp
and sometimes radiates (radicular) and is more intense at emphasis or
palpation.
b. Intradural-Extramedular Tumor
This tumor is grow in the root and causes progressive chronic radicular pain.
It is ± 70% of intradural tumors, and the most common type is neurinoma in men
and meningioma in women.
a) Neurinoma (Schwannoma)
Has the following characteristics:
 Derived from the dorsal root
 It occurs ± 30% of extramedullar tumors

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  2/3 cases have a major complaint of radicular pain, usually on one
side and felt within a few months to years, while advanced
symptoms are pyramidal tract sign
 39% of the location is in the thoracic segments.
b) Meningioma
Meningioma has the following characteristics:
 ± 80% are located in the thoracic region and ±60% in the middle-
aged woman
 Slow growth
 In 25% of cases there is radicular pain, but more often with
symptoms of the pyramidal tract below the lesion, and the nature of
radicular pain is usually bilateral with a shorter duration of
symptoms.
c. Intradural-Intramedular Tumor
a) Ependymomas are associated with the following:
 Mean age at presentation of 43 years
 Slight female predominance
 Pain localized to the spine (65%)
 Pain worse at night or upon awakening
 Dysesthetic pain (burning pain)
 Long history of symptoms
 Myxopapillary variant (mean age of presentation of 21 years old,
slight male predominance)
b) Astrocytomas are associated with the following:
 Equal male and female prevalence
 Pain localized to spine
 Pain worse at night or upon awakening
 Paresthesias (abnormal sensation)
c) Hemangioblastomas are associated with the following:
 Onset of symptoms by the fourth decade of life, 80% symptomatic
by age 40 years

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  Familial disorder (ie, von Hippel-Lindau syndrome) present in a
third of patients
 Decreased posterior column sensation
 Back pain localized over lesion.10
General symptoms due compression, among others:
• Pain
Compression of a tumor may stimulate neural pathways-pathways found in
the spinal cord and cause pain that seemed to come from various parts of the body
(diffuse pain). This pain is usually sedentary, sometimes gain weight and feels like
a burn.
• Sensory changes
Most patients with spinal cord tumors experience a loss of sensation.
Usually numbness and loss of skin sensitivity to temperature.
• Motor problem
Initial symptoms may include muscle weakness, spasticity, and the inability
to hold urine or defecate. If untreated can worsen symptoms including muscle
atrophy and paralysis. In fact, in some people can develop into ataxia. Parts of the
body that cause the symptoms vary depending on the location of tumors along the
spinal cord. In general, the symptoms appear on the body level with the location of
the tumor or below the location of the tumor. For example, the tumor in the spinal
cord (thoracal segment) can cause chest pain that spreads to the front (girdleshape
pattern) and increased pain when coughing, sneezing, or bending. Tumors that grow
on cervical segment can cause pain that can be felt up to the arm, while tumors that
grow in the lumbosacral segment can trigger back pain or pain in legs.11

2.6 Diagnosis
In addition to history and physical examination, diagnosis of tumors of the
spinal cord can be enforced with the help of investigations like the one below.
a. Laboratory
Spinal fluid (CSF) may show increased protein and xantokhrom, and
sometimes found the cell malignancies. In taking and obtain spinal fluid of patients

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with spinal cord tumors should be careful because the blocks can be partially
transformed into a complete block of spinal fluid and cause complete paralysis.
b. Plain Photo vertebrae
Plain entire spine 67-85% abnormal. Discovered the possibility of erosion
of the pedicle (defects resembling "owl eyes" on the lumbosacral spine AP) or
dilation, pathological compression fractures, vertebral body scalloping, sclerosis,
changes in osteoblastic (perhaps myeloma, prostate Ca, Hodgkin, and usually Ca
breast).
c. CT-scan
CT scans can provide information on the location of the tumor, even
sometimes provide information on the type of tumor. This examination can also
help doctors detect the presence of edema, hemorrhage and other related
circumstances. CT scans can also help doctors evaluate the therapeutic results and
see the progression of tumors.
d. MRI
This examination can distinguish between healthy tissue and tissue
abnormalities accurately. MRI can also show images of tumor that is located near
the bone is more obvious than the CT-scan.11

2.7 Management
Management for the most part either intramedular and extramedullary
tumors is by surgery. The aim is to remove the tumor completely with the rescue of
neurological function optimally. Most intradural-extramedullary tumors can be
resected completely with a neurological disorder that minimal or no postoperative.
Tumors that have a pattern of rapid growth and aggressive histologically and not
totally eliminated through surgery can be treated with radiation therapy post
operation.4,6
Therapies for the spinal cord tumors are:4,12
a. Steroid : dexamethason 100 mg (reducing pain in 85% of cases, it may also
result in improved neurological).
b. Management based on evaluation of radiographic

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 • If there is no epidural mass: ambulatory primary tumor (eg with
systemic chemotherapy); Local radiation therapy at the bony lesions;
analgesics for pain.
• If there is an epidural lesions, perform surgery or radiation (typically
3000-4000 cGy at 10x care with the introduction of two levels above
and below the lesion); Radiation is usually as effective as laminectomy
with fewer complications.
c. Emergency Management (surgery / radiation) is based on the degree of the
block and the speed of deterioration :4,13
• if >80% complete block or worsening rapidly: the management as soon
as possible (when taking care of the radiation, dexamethason continue
the next day with 24 mg IV every 6 hours for 2 days, then lowered
(tappering) for radiation, for 2 weeks.
• if <80% block: routine maintenance (for radiation, continue
dexamethason 4 mg for 6 hours, lowered (tappering) during treatment
as tolerated.
d. Radiation
Radiation therapy is recommended for intramedular tumor that can’t be
removed completely.4,7

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THE BASIC OF DIAGNOSIS

1. Basic clinical diagnose

According to anamnesis and physical examination, we have found this
patient has paraparesis inferior (UMN Type), hypoesthesia from Th-4 dermatome
to the lower and autonomic dysfunction (abnormal urination and defecation). The
several important things above mean that there is damaging on complete spinal cord
because of the involvement not of all the tracts.

2. Basic topic diagnose

Based on anamnesis there are weakness on both legs and numbness in
patient’s lower extremities but from the examination of sensory system, we found
hypoesthesia from Th-4 dermatome to the lower. Based on the dermatomes, we
found that the level of disorder is 4th thoracal spinal cord segments.

3. Basic etiological diagnose

Basic etiological diagnose of this patient lead to spinal cord tumor because
based on anamnesis and physical examination, we have found symptoms like
localized back pain, numbness on lower extremities, weakness on lower extremities
and autonomic dysfunction (abnormal urination and defecation). These symptoms
were gradually occur. This classic features suitable to spinal cord tumor which is a
chronic progressive disease.

4. Basic differential diagnosis

Spondilitis TB is chosen as the differential diagnose because it almost have
the same manifestation, such as motor disturbance and numbness. On this patient,
she also had history of fever. To establish the diagnosis, some adjunct examination
are needed.

5. Basic Workup
- Laboratory : to know the risk factors whether the infection exis and
knowing the general condition of the patient for therapeutic purpose.
- Chest X-ray : to find the etiologic for this case whether the infection exist.

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 - Thoracal spine X-ray : to find the abnormality at thoracal vertebrae.
- Thoracal MRI : to find the etiologic for this case at apinal cord area or
vertebrae.
- Lumbar puncture : to find the etiologic for this case whether the infection
exist.

6. Basic final diagnose

The final diagnose of this patient is spondylitis TB. This diagnose is
considered by history taking, general and neurological examination and adjunct
examination. From history taking, we have found symptoms like localized back
pain, numbness on lower extremities, weakness on lower extremities, history of
fever, and autonomic dysfuction (abnormal urination and defecation). From
physical examination there was paraparesis inferior with UMN type, hypoesthesia
on Th-4 dermatome to lower. From adjunct examination we found there was
increased of leucocyte and from MRI’s result there is spondylitis ec suspect TB.

7. Basic treatment

a. The aim of IVFD Ringer Lactate 20 dpm is to maintain the euvolemic

condition
b. The aim of Metilprednisolon 3x125 mg per IV to provide relief for inflamed
areas of the body.
c. The aim of Mecobalamin 3 x 500 mg as a neurotropic
d. The aim of Ketorolac 2x30 mg per IV as an analgetic
e. The aim of Ranitidine 125 mg/12 hours per IV to preventing side effects
from the use of methylprednisolone in the stomach in the form of peptic
ulcer

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1. Sanchez AMG, Posada LMG, Toscano CAO, Lopez AL. Diagnostic

approach to myelopathies. Rev cColomb Radiol. 2011; 22 (3). p. 1-21

2. Ghezzi A, Baldini SM, Zaffaroni M. Differential diagnosis of acute

myelopathies. Neurol Sci. 2001; 22 (Suppl 2). p. S60-4.

3. Hakim A.A. 2006. Permasalahan serta Penanggulangan Tumor Otak dan

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