25th March, 2023
MEDICAL REPORT
E.A, 26YEARS, MALE
WCA/6096/2023
Diagnosis: Pathologic collapse of Mid Thoracic spine and
Cord compression 2 to ? Bacterial Sponndylitis, Potts Disease, Metastatic bone
tumor, wafer spine collapse? Caused
Operation: Thoracic spine decompression and fixation.
Date of Admission: 25/03/2023
Date of Operation: 27/03/2023
Background information; Above named is a 26yr old male who presented with progressive difficulty with walking associated with back pain and gibbus. There is associated parasthesia of both lower limbs and urinary incontinence. No history of bowel dysfunction. There is no significant past history of trauma, tumour, infection
Neurological Examination: Profound upper motor neuron features in both lower limbs; hypertyonia, hyperreflexia. Power 4/5 in both lower limbs
Imaging: ( T-Spine MRI) shows collapsed vertebrae at mid thoracic spine with retroprolapse segment causing cord compression. There is also signal changes in the cord suggesting cord edema. Myelogram shows complete interruption at level of compression.
05 May, 2023