• 목록
• 게시판 리스트 옵션
  • 수정
  • 삭제

F/62

C.C.> Back pain with radiating pain to both lower extremities
& weakness of both lower extremities

BHx> 6주전 빙판에서 slip down 후 상기 증상 발생.
10일전 혼자 일어서려다 양다리 통증 악화되면서 주저앉음.
이후 증상 호전 없어 응급실 거쳐 입원함.

P/E> SLR 70/60 Patrick -/- FST +/+
Motor : Hip flexor 5-/5-
extensor 5-/5-
abductor 4+/3
adductor 5-/5-
Quadriceps 5-/4+
Hamstrings 5-/4+
TA 5-/4+
EPH, EDL 3/3
Gastrocnemius 5/5
FHL, FDL 3/3
Sensory : L1-L2 100/100
Circulation : DPA ++/++ PTA ++/++
DTR : K/J ±/± A/J ±/±
Babinski -/- Ankle Clonus -/-
Midline tenderness (+) : T12 level
Paravertebral tenderness (+) : T12 level
Defecation & Urination : controllable
Perianal sense : intact
Anal tone & sphincter power : slightly decreased

X-ray> L-S spine AP/Lat
- T12 bursting fracture
- L2 compression fracture

MRI> L-spine MRI
- T12 bursting fracture with cord compression
- L2 compression fracture (old comp. Fx가 있었고,
여기에 이번의 충격으로 새로운 comp. 가 추가된 것으로 보임)
- L4-5 HIVD, spinal stenosis

Impression> 1.Bursting fracture with cord compression T12
2.Compression fracture, L2
3.HIVD & spinal stenosis, L4-5

Treatment> Op. was done;
1.Anterior decompression by vertebral corpectomy, T12
with stabilization with Kaneda instrument & Mesh cage
2.open vertebroplasty, L2