somakumarMemberJune 27, 2013 at 6:50 pmPost count: 1
I am herewith giving below the Doctor’s Discharge Summary. You are requested give me more clear idea of the status of this report. It will be okay after some time and how long it will take to be normal. Right now I can walk with the help of walker. When am walking I feel I dont have balance. And I feel less sensation in my left leg. the movement is not normal while walking feels falling down. Please help me and let me know is there any medicine or further treatment i have to undergo ?.
Doctor’s report below:
Diagnosis : Post traumatic C 4-5 5-6 PIVD
Procedure : C 4-5, 5-6 Microdiscectomy and Cage Plate and screw fusion at both levels.
Mr. Somakumar Nair, (My self) a 47-year old male presented to Max Super Speciality Hospital, Saket, New Delhi, India with history of RTA on 30 december, 2011 early morning in car near Muzaffarnagar by truck hitting from Back just after accident patient was conscious and there was no history of Bleeding from ear or nose, patient present with incomplete quadriplegia, patient then taken to AIIMS where he recevied primary supportive treatment and underwent NCCT head which was normal, fast was negative, NCCT spine which shows Degenerative changes at c5, c6, c7 patient also have injury in face, showing Laceration over upper and lower lip, injure over frontal bone (supraorbital) Region on bilateral side which is sutured in AIIMS, patient also lost upper incisor teeth in accident, nasogatic tube placed which shows secretion blood Stained. Patient now admitted for further management.
Vitals were stable. Pulse rate was 72 min and the blood pressure was 114/76 mmHg. General and Systemic examination were normal. GCS was 15/15. He was oriented to time, place and person. Visual actuity and Visual fields were normal. The pupils were equal and reacting to light. Extra ocular movements were full. Rest of the cranial nerves were normal. Tone was normal. There was grade 5/5 power in all the four limbs.
All reports handed over to the patient.
The patient was admitted with above mentioned complaints. He was clinically evaluated and investigated in detail. His MRI brain revealed Post traumatic C 4-5, 5-6 PIVD. The condition and prognosis was discussed with the patient in detail. After a written and informed consent the patient was taken up for surgery on 2/1/2012 and a C 4-5, 5-6 Microdiscectomy and Cage, Plate and screw fusion at both levels was done under GA. The patient tolerated the surgery well and was shifted to Neurosurgical ICU after the procedure for postop care. The patient remained clinically stable and later shifted to the ward. He became symptomatically better after the surgery. Rest of the course in the hospital was uneventful and he is being discharged in the condition mentioned below.
Condition at Discharge:
At the time discharge patient is conscious, oriented, accepting orally, afebrile, continent with no new deficit.
Diagnosis : Post traumatic c 4-5, 5-6 PIVD
Surgery done : C 4-5 5-6 Microdiscectomy and Cage, Plate and screw fusion at both levels
Anesthesia : GA
Findings : C 4-5, 5-6 PIVD with osteophytes
Position : Supine
Folowing induction the patient was placed in the supine position with the neck in extension, by placing a sand bag between the shoulders. Traction of 7 kg was applied. The C 4-5, 6-7 levels were marked by using the C-arm and the parts were painted and draped. A transverse incision was made at the level and the platysma was incised. The medical border of the stemocleidomastoid was then delineated and dissection done in the fascial planes medial to this. The carotid sheath was identified and gently retracted laterally and the esophagus and the trachea retracted medially. The level was confirmed again under the fluoroscope, the preverterbral fascia dissected away. The longus colli on either side were seperated to expose the C 4-5, and 6 bodies and Trimline self retaining reactor placed. Dissection done to clear all soft tissue. Exposure was upto PLL. The disc removal at C 4-5, 5-6 was done with forceps and curette Vertebral spreader was applied and discectomy completed. Dissection done to expose the dura completely in the disc space Posterior osteophytes were nibbled. The PLL was firmly adhered to the dura. PLL was excised. The disc space C 4-5, 5-6 was measured and a cage was inserted at both levels. Two level plate was applied and was tightened with screws. The position was confirmed by C-arm. Complete haemostasis achieved and the wound was closed in layers. Patient tolerated the surgery well and was shifted to Neurosurgical ICU for further management.
Sir, this is the doctor’s report and notes. Kindly help me further and let me know how long it will take to cure and i will be able to walk independtly and what else I have to do for better improvement.
Hope to hear your advise in this regard.
Thanks & regards
IndiaDonald Corenman, MD, DCModeratorJune 30, 2013 at 12:18 amPost count: 8465
I have questions. What was your neurological status after the auto accident? Did you have normal strength and motion after the accident? The emergency room report notes full motor strength while you were in this department but I know that many ER departments do not do a complete and accurate neurological examination.
What is PIVD? I am sure in India that this is a common term but I cannot determine what this means. I assume you had some fractures of the cervical spine. What damage did it do to the spinal cord? A complete and accurate neurological examination before and after surgery would be very helpful to determine prognosis.
The OR report notes what appears to be a two level ACDF (see website) with cages and plate. There is no mention of what was found intraoperatively. Did the surgeon find fractures, dislocation or ???
What is your status now? I understand you use a walker. There is an examination form from the American Academy of Neurological Surgeons that will document each muscle group for strength, each dermatome for sensation and look for long tract signs (clonus, hyperreflexia, imbalance). Completion of that form would be helpful to understand what your deficiencies are.
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