Daryll Klein R.

Joaquin June 15-30, 2017

Medical Intern Dr. Calderon

CASE REPORT

ABSTRACT
This is a case of JG, a 43-year-old male, nonhypertensive, nondiabetic, who presented with an 8-year-
history of progressive asymmetrical motor and sensory deficits involving both lower extremities, with associated
decrease in bladder and bowel control. Patient denied of any history of back pain, trauma, headache, blurring of
vision, or fever. Patient eventually sought consult at a local hospital, where MRI of the spine was done, revealing a
mass in the spinal cord. Patient then underwent surgery which revealed AV malformation situated at the spinal cord
at T6-T9 level, hence repair and laminectomy was done. During the interim, no progression of symptoms was noted,
however there was only minimal improvement; patient then decided to seek consult at our service for more definitive
management. Upon seeing the patient, patient was seen awake, alert, ambulatory, and not in cardiorespiratory
distress. Vital signs were stable and patient was afebrile. On inspection of the lower extremities, there was note of
atrophy of both leg and thigh muscles. On palpation, the lower extremities were noted to be spastic and weak. There
was limitation of range of motion of the lower extremities due to weakness. On neurologic examination, patient was
seen oriented to 3 spheres. Motor weakness was noted on both lower extremities as well with sensory deficit at the
level of T6. There was also note of decreased reflexes on both lower extremities. Based on the history and physical
examination, initial impression on the patient was Compressive myelopathy secondary to AV malformation, T6-T9,
s/p laminectomy s/p repair (2009). Compression myelopathy is a condition that may be secondary to several
pathologies; spinal cord compression by degenerative spine disease is one of the more common causes of
myelopathy, however tumors or other masses can also cause myleopathies. In the case of the patient, the
underlying pathology was an AV malformation situated at the spinal cord at the level of T6-T9 which probably lead to
intramedullary involvement at this level, causing compression, ischemia, or a combination. Although the case history
of the patient may provide a clue regarding a spinal cord involvement, the clinical findings in compressive myelopathy
of vascular origin are usually nonspecific and sometimes overlies other patologies; hence, early detection and
treatment is very crucial for the prognosis and chance for neurological recovery of the patient.
Arteriovenous malformations of the spine are commonly seen at the low thoracic or lumbar regions, and in a
lesser proportion, in the sacral and cervical regions. They are four times more frequent in men, with a mean age at
onset of 58 years. Initial symptoms include gait disorders, paresthesias or numbness, lumbar or radicular pain,
asymmetric weakness of the legs, and bleeding in up to 25% of cases. Arteriovenous fistulas may be differentiated
from other causes of myelopathy because symptoms are triggered by walking or standing for long periods of time.
Eighty per cent present with bladder dysfunction, when the malformation involves the cone. The disease may
progress over a period of months and even years, and may become exacerbated with exercise.
Spinal cord AVM are usually detected through imaging, particularly MRI, followed by MR angiography, and
selective arteriography. Findings on the imaging usually demonstrate serpent-like images with absence of flow
signals in most patients; these structures appear enhanced in T1 images with gadolinium.
The management goals in the case of the patient includes independent mobilization of the patient through
ambulation and gait exercises with assistance, core strengthening, pelvic bridging, and balance/coordination
exercises. Occupational therapy is also an important management for this patient to address house modifications
and adjustments in activities of daily living. Both physical and occupational therapy are very important in the
recovery and restoration of this patients functional capacity.
 Case of JG

Identifying Data Patient JG is a 43-year-old male, married, Roman Catholic, residing at Batangas.
Referral Patient was referred by Neurology service
Source and Reliability Information was provided by the patient himself. Patient was fairly reliable and was able to
answer questions appropriately and sufficiently regarding his health condition.
Chief Complaint both lower extremity weakness

History of Present Illness

Patient is a 43-year-old male, nonhypertensive, nondiabetic, who presented with an 8-year-history of
progressive asymmetrical weakness and numbness involving both lower extremities, with associated decrease in
bladder and bowel control. Patient denied of any history of back pain, trauma, headache, blurring of vision, or fever.
Patient eventually sought consult at a local hospital, where MRI of the spine was done, revealing a mass in the spinal
cord. Patient then underwent surgery which revealed AV malformation situated at the spinal cord at T6-T9 level,
hence repair and laminectomy was done. During the interim, no progression of symptoms was noted, and there was
only minimal improvement; no other interventions and rehabilitations done as well. Patient then decided to seek
consult at our service for more definitive management.

Past Medical History

No known allergies.
No previous history of accidents or trauma.
No history of hypertension, diabetes, or stroke.
(+) Compressive myelopathy secondary to AVM, s/p laminectomy and repair (2009).

Family History
Patient denies of any family background of stroke, spinal disorders, AVM, or any other related conditions.

Personal Social History

Patient currently lives with his family at Batangas. Patient was used to be a tricycle driver. Patient was a previous
alcoholic beverage drinker and denied of any history of cigarette use.

Pre-morbid Status
Patient was used to be a tricycle driver. He was able to walk without assistance, and was able to do ADLs alone.

Post-morbid Status
Patient no longer works. Patient is unable to move both legs but can ambulate with walker. He can still do ADLs
alone, despite being paraplegic.

Review of Systems
General: The patient denied fever, recent changes in weight, weakness, fatigue, chills, or trouble in sleeping.
Skin: Patient denied the presence of lumps, rash, itching, discolorations, nevi, or any form of hair and nail changes.
HEENT: Head. The patient denied of headache or trauma. Eyes. The patient denied loss or change in vision, eye
pain, redness, blurring or doubling of vision, flashing lights, glaucoma, and cataracts. Ears. The patient denied a
decrease in hearing acuity, ringing or pain in the ears and drainage through the ear canal. Nose. The patient denied
nasal stuffiness, discharge, itching, bleeding, or sinus pain. Throat. The patient denied bleeding, dry mouth,
hoarseness of voice, oral thrush, non-healing buccal sores.
Neck: The patient denied of lumps, stiffness, or pain.
Respiratory: The patient denied cough, colds, hemoptysis, shortness of breath, dyspnea, wheezing, or painful
breathing.
Gastrointestinal: The patient admitted difficulty in defecating, with loss of bowel control. The patient denied
dysphagia, heartburn, change in appetite, nausea and vomiting, rectal bleeding, diarrhea, or jaundice.
Peripheral Vascular: The patient denied varicose veins, leg cramping, cyanosis, edema, and claudication.
Urinary: The patient admitted loss in bladder control, with incontinence and decrease in urinary caliber. Patient
denied polyuria, nocturia, hematuria.
Genital: The patient admitted erectile dysfunction. The patient denied genital pain, inflammation, lumps, or blood
and any other discharge.
Musculoskeletal: See HPI. The patient denied redness or swelling of joints, and any form of recent trauma.
Neurologic: See HPI. The patient denied dizziness, fainting, seizures, or tremors.
Hematologic: The patient denied easy bruising or bleeding tendencies.
Endocrine: The patient denied heat or cold intolerance, excessive sweating, or change in appetite.
Psychiatric: The patient denied lapses in memory, nervousness, or depression.

Focused Physical Examination

General: Patient was awake, alert, comfortable, wheelchair-borne, not in cardiorespiratory distress.
Inspection: With noted atrophy of the lower extremities, and associated dryness of the overlying skin.
Palpation: Spastic and weak muscles on both lower extremities.
Range of Motion (ROM): Limited range of motion on both lower extremities due to weakness.
Manual Muscle Testing:
Right Left
Proximal Distal Proximal Distal
Upper 5/5 5/5 5/5 5/5
Lower 3/5 2+/5 3/5 2+/5
Sensory:
Level Right Left Level Right Left
C2 100% 100% T8 40% 40%
C3 100% 100% T9 40% 40%
C4 100% 100% T10 40% 40%
C5 100% 100% T11 40% 40%
C6 100% 100% T12 35% 40%
C7 100% 100% L1 35% 40%
C8 100% 100% L2 35% 40%
T1 100% 100% L3 35% 40%
T2 100% 100% L4 35% 40%
T3 100% 100% L5 35% 40%
T4 100% 100% S1 35% 40%
T5 100% 100% S2 35% 40%
T6 40% 40% S3 35% 40%
T7 40% 40% S4-S5 35% 40%
Reflex:
Right Left
Upper 2+ 2+
Lower 1+ 1+

Salient Features
Patient is a 43-year-old male, nonhypertensive, nondiabetic, presenting with an 8-year history of progressive
motor and sensory deficits on both lower extremities with associated decreased bladder and bowel control. No
associated back pain, trauma, headache, or blurring of vision. MRI done revealing AVM in the spinal cord; patient
underwent laminectomy and repair. However only minimal improvement was noted and no rehabilitation procedures
were done after. On PE, patient was seen awake, comfortable, oriented to three spheres, wheelchair-borne, with
noted atrophy, spasticity, limited motion, decreased sensation at T6 level, decreased reflexes and weakness (2-3/5)
of both lower extremities.
DISCUSSION
The patient presented with chronic progressive lower extremity weakness and sensory deficits at the T6
dermatomal level, as well as associated decrease in reflexes, bladder and bowel control, which are consistent with a
spinal involvement particularly at the low-thoracic level. Myelopathy is the most considered condition in this case.
This term refers to spinal cord involvement relating to different etiologies. Spinal cord diseases however often have
devastating consequences ranging from quadriplegia to severe sensory deficits, and in this case, the patient
presented to have paraplegia. Many of these diseases however is potentially reversible hence early recognition of
the etiology is significant in the management and recovery of the patient. In this case, an MRI was done revealing a
mass in the spinal cord. However, a mass itself is still a broad term particularly in spinal cord pathologies, as this
may be due to a neoplasmic process, an abscess, vascular abnormalities, or even due to an inflammatory etiology.
In this case the patient was noted to have AVM which was only revealed during his operation.
Compressive vascular diseases however present with non-specific clinical findings which can be also be seen in
other space occupying lesions such as neoplasms and abscess. Ninety percent of AVM however are usually seen at
the low thoracic region which is consistent with the patients case at the T6-T9 level. Males are also noted to have
higher incidence with four times more than females, with a mean age of onset at 58 years. Expected symptoms are
also consistent to the patient with gait problem, paresthesia, asymmetric weakness of legs, and bladder or bowel
problems. Standard imaging in such cases is usually requested, particularly MRI of the spine. However, MR
Angiography is the definitive imaging for vascular compressive myelopathies, which usually reveal serpent-like
images with absence of flow signals in most patients.
Because of the involvement of the T6-T9 level, weakness and numbness below these regions are expected,
with note of lower extremity weakness, sensory deficit below T6, and a evident problem in controlling urination and
defecation, which are very much consistent with our patients clinical presentation. Keeping in mind the clinical
history and presentation of the patient, despite the successful surgical intervention, rehabilitation was however not
done to the patient, which would have played a vital role in the patients recovery in terms of functional capacity. Due
to the poor recovery of the patient, he eventually decided to seek consult in our institution and was eventually
referred to the Rehab Medicine service for assessment and definitive management. Upon reviewing his history and
physical examination physical and occupational therapy were done advised to the patient.

Assessment
Compressive Myelopathy secondary to AV malformation, involving T6-T9 levels

Management
Problem List Goals
Lower extremity weakness -strengthen upper extremity and trunk muscles to allow
ambulation even with assistance
-stimulate lower extremity muscles to prevent further
atrophy
Decrease in mobility and ambulation -improve balance, and encourage mobility
-encourage ambulation even with assistance
-to increase mobility to be able to do ADLs
Bladder and bowel dysfunction -achieve better bladder and bowel control

Standing balance Pelvic bridging

Weight shifting and balance Core strengthening
Gait training Bladder training
Standing push up Bowel program
RATIONALE of TREATMENT
The overall management of the patient involves intensive physical and occupational therapy including
multiple sessions considering the chronicity and severity of the patients condition. Physical therapy of the patient
would include exercises and activities that would help him increase his strength, edurance, balance, and
coordination. This will also allow him to walk, stand, and sit using assistive devices, preventing risk of falls and
injuries. Bladder and bowel control are also addressed as well by the PT. Occupational therapy, on the other hand
will be essential for the patient for him to learn how to do certain ADLs such as bathing, dressing, preparing a meal,
house cleaning, and eating, and accomplish them well.

Standing balance
The rationale for this exercise is to effectively improve patients balance, maintain his posture, and prevent the risk of
fall and accidents. This is very important as this allows the patient to improve his ability to tolerate standing, sitting,
and even perform daily activities to a certain complexity.

Weight shifting and balance

This is another activity that can improve balance of the patient. This allows him to shift his weight to different
positions, more importantly is the lateral shifting. Weight shifting and balance activities are used to give patients
practice with maintaining off-center COP postures, thereby increasing their thresholds of stability.

Gait training
Gait training strategies are again essential for this patient, as this exercise will allow him to strengthen his
lower extremity muscles and joints, improve his balance and posture, build endurance, enhance walking
and standing ability, as well as lower the risk of falls while increasing patients own mobility.
Standing push up
This exercise is very appropriate for the patient as this will allow him to strengthen his upper body including his chest,
arms and shoulders, especially since he will be relying on these muscles when walking on assistive devices, as well
as doing most of his ADLs.

Pelvic bridging
In addition to strengthening patients core, pelvic bridging exercise also stretches the abdominals. It massages the
organs in your abdominal region. It basically strengthens the quadriceps, hamstrings, abdominals and buttocks. It
also helps stabilize the hips and waist, which is essential in strengthening the trunk muscles, and improves balance
control and stability.

Core strengthening
Core exercises actually aim to strengthen the muscles in the pelvis, lower back, hips and abdomen to work in
harmony. Thus, this leads to better balance and stability, for the patient, particularly in mobilization and in daily
activities.

Bladder training
Since the patient has lost control of his urination. Bladder training is important to prevent urine from building up and
overflowing from his bladder. A bladder training program includes this and other methods to empty his bladder to
improve his quality of life and prevent UTIs.

Bowel program
This will help prevent and decrease the chance of having a BM for the patient. A bowel program will also help prevent
constipation, impaction, and obstruction, as this will also be part of the overall quality of patients life as well.
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