Pott’s Spine

Pott's Spine

Dr. Rank, the protagonist of Henrik Ibsen’splay “A Doll’s House” (If I am not mistaken) suffered from the same disease as this lady who got admitted when I was in the Orthopedic posting.

A 32 year old female presented with bilateral weakness of legs (paraparesis) which progressed to bilateral paralysis of the legs (paraplegia). She had a complain of long standing back pain for the past 4-5 months, as also a history of incompletely treated tuberculosis 2.5 years ago. Of late, she started showing similar symptoms as that previous episode. She had stated to have been suffering from weight loss, anorexia, evening rise of temperature, night sweats.On physical examination, the patient seemed anemic, was cachectic, had mild fever. There was a spinal mass at the level of D2-D4, which was tender to pressure. There was  patchy loss of sensation from the chest downwards. There was paraparesis and plantar was extensor, other deep reflexes were exaggerated, and superficial reflex (abdomen) absent. The bladder and bowel control was present!

A chest X-ray was ordered and a compression fracture was evidenced at the level of D3 in addition to bilateral apical infiltration suggestive of tuberculosis.

The patient was admitted and this MRI was obtained. Compression collapse of the D3 vertebra is seen here. Destroyed vertebral components along with anterior epidural collection is causing a canal narrowing and outting pressure on the thecal sac. Loss of dorsal curgvature is seen with intervertebral disc adjaent to the D3 vertebrae showing loss of morphology. Rest of the visualized vertebrae are normal in height and morphology, except for the occurrence of Schmorl’s node in D11.

All of this is routine, and what I didn’t know was about Schmorl’s nodes. According to the authors of a recent study (1),

Schmorl’s nodes are areas of “vertical disc herniation” through areas of weakness in the endplate. In younger patients, it seems to be more common because the annulus is strong and intact, and thus nuclear material herniates through the weaker endplate. As the annulus degenerates with time and age, transverse or posterolateral herniations are more common.

The deal with the Schmorl’s node is that it is more common in the younger age groups and may also explain the incidence of low back pain in this population, especially in thise involved with sports or activities that may be responsible for causing this (2).

Pott’s spine is a fairly common complication of Tuberculosis in India. In plainspeak, this is a form of TB in which there is extrapulmonary dissemination. Usually, the lower dorsal and upper lumbar vertebrae are most affected, but this case shows us a rarer site of affliction. Usually, the spread is by hematogenous route and is known as tubercular spondylitis.

This is, however, not to be confused with Pott’s Fracture, which is bimalleolar fracture of the ankle. Sometime later, I will put up the X-ray of the pott’s fracture that I have (yes, I have seen that too during the short course of my internship!). I must say internship has thrown up a lot of cool clinical stuff!

Patient Consent: Obtained

Reference:

1.Hamanashi C, Kawabati T, Yosii T. Schmorl’s nodes on MRI. Their incidence and clinical relevance. Spine 19(4) p.450-453 1994.

2.Takahashi T, Miyazaki T, Ohnari H, Takino T. Schmorl’s nodes and low back pain. Eur Spine J 1995, 4:56-59.

Shit People Do!

Depression

Depressed anterior fontanelle is one of the signs which sends our hearts racing while evaluating a newborn, mainly because it signifies ample dehydration to have caused the soft fontanelle, which is usually flush with the skull bones or slightly raised to have sunk.Usually, this is one of the clinical signs which are better felt than seen (yo, what are the other such stuffs? State one each in the comments section!), but in some cases, well, let us just say Shit Happens!!!

This 3 week old boy was brought in by the parents with complains of severe lethargy, floppiness, lack of weight gain, and very very poor feeding. One look at the head and we were scandalized. THE PARENTS HAD SHAVED OFF THE HEAD OF THE NEONATE COMPLETELY!!!! And that too, using standard issue stuff that barbers use on people’s faces day in and day out.

A physical examination was done and one didn’t need the results to declare the child to be very very sick.  Blood work was sent for and fluid resuscitation started, child put under radiant warmer and antibiotics started. Over the next few days a needless struggle for life ensued… one which was entirely avoidable had the child’s parents not decided to crop his hair.

After a week’s struggle, we managed to save the baby, but after a lot of needless battle. All just because the parents think that’s what is supposed to be done with the heads of just born people.

Awareness? Yes, I think so…

Patient Consent: Obtained

Incisional Hernia 2

Incisional Hernia 2

Ok, This is in continuation of the post HERE, as promised!

On trying to reduce the herniated mass, thankfully, I managed to reduce it completely, and the patient did not complain or anything. The thing that surprised me greatly was the length of the defect on the anterior abdominal wall. It was so large, that I could almost completely insinuate all the four fingers through it! It is going to be a nightmare for the surgery team repairing it, because, the recurrence rates on Incisional hernia increase with an increase in the size of the defect to repair.

Anyways, the surgery resident on-call concurred with me on the mater that it was probably a mild touch of acute gastroenteritis that was causing her problem, and not the hernia, thankfully. So we prescribed some antispasmodics, antiemetics, ORS for drinking, antibiotics, PPI and asked her to come back to the surgery OPD the next morning for further evaluation of the incisional hernia.

Overall, not a case unheard of, not at all (P.S.: I got a couple of THOSE up my sleeves, but not right now. Let me see if I can get them in some journals! If not, then the blog ain’t goin’ nowhaay yo!!), but a rather interesting study for me.

I know that the picture is brighter than I intended it to be. Let us just say my photography sucks and I am too lazy to edit them before putting them up!

Patient Consent: Obtained

Make-over!

Red and White

Medical College Kolkata has long been regarded to be the red med school (the more politically punned “laal baari”, for those who get Bengali!). However, I was a little surprised to see this happening when I was walking by the Admin Block a few days ago.

Now, the 175th year of foundation celebrations are impending and hence the college is getting a thorough face lift, but I would not have imagined that they would go ahead and make such a drastic change. Lets see how this goes!

What say you?

Narcissism

Narcissisme

I know I was supposed to post the result of trying to reduce the Incisional Hernia that I had talked of HERE but I decided that instead of doing that I will just post a picture of what I look like at 2:33 in the morning after cleaning up the ER and stemming the patient influx for the night, albeit somewhat temporarily! And all day I had not been able to sleep on account of having to had attended the Ophthalmology OPD in the morning.

Sigh… If only for an ounce of the Killer Looks Shahid sports in the new movie Chance pe Dance…

Anyways, if anyone posts bad comments on this, they go straight to the spam bin! My blog, my way!

Incisional Hernia

Incisional Hernia

This patient came in at the time when the ER is at its height of business. Anyways, she was complaining of colicky pain in the abdomen and several episodes of vomiting since morning. She admitted to have had gone out for food the day before since her family was not at home. Oh, must be acute gastroenteritis, I thought. Usually, in a busy ER when people with AMIs, Strokes and convulsions are waiting to be treated in a queue and there are only a couple of Interns and residents handling the whole thing, the AGE tends to get a back seat. However, I thought that it might be well advised to have a physical examination before making any diagnostic or treatment oriented decision. And lo behold, when I asked her to expose the abdomen, this stared out at me!

Incisional Hernia is a condition in which there is protrusion of abdominal contents through an area of weakened abdominal musculature, especially in areas along the midline, extending from the xiphoid process to the symphysis pubis.

In this case, there was prior history of emergency hysterectomy about 19 years ago due to a ruptured ectopic pregnancy. The mass had started building up around 4-4.5 years ago and was progressively increasing in size.

Now, whenever a hernia patient presents with abdominal cramps and vomiting, the alarm bells start ringing: strangulation of herniated gut or mesentery followed by ischemic necrosis. A surgical emergency! So, despite the patient not being in any obvious discomfort, I tried to reduce the hernia, and guess what, you need to see this post to see what happens next!

I know petty technique but I am sure it will work!

Till later then folks. Leave lovely comments!

Photo Credits: Awesome Me

Patient Consent: Obtained

Narendrapur Reunion 2009

Reunion 2009

If you aren’t there in the frame, then where the hell were you?

Jhuki Jhuki Si Nazar 2

Jhuki Jhuki Si Nazar 2

I held a jewel in my fingers
And went to sleep
The day was warm, and winds were prosy
I said, “Twill keep”

I woke – and chide my honest fingers,
The Gem was gone
And now, an Amethyst remembrance
Is all I own

Emily Dickinson

Cuts Like a Knife

Self Cutting

Seems like I have Psychiatry as the theme for the day! First I post that and now this!

Anyways I never gave this issue of deliberate self harm much thought and believed that it was one of the socio-cultural things that the media had hyped to be a disease. But then I saw a patient in the ER and my views changed. self cutting or self harm or deliberate self harm is a form of impulse neurosis, in which the affected person knowingly inflicts on the self injuries, cuts, poisonings or tissue damage (burns) without a suicidal intent. The definition has been expanded to include the eating disorders like anorexia nervosa and bulimia.DSM-IV (Diagnostic and Statistical Manual 4th edition) defines this to be a form of depressive disorder or borderline personal disorder.

As expected, this is a condition affecting the adolescent females more than any other groups of population. While I was workin in the ER, a guy, apparently my age came in and said he cut his arm while working and needed to get dressings and such. Usually, we just take a look and if the bleeding is not much and the laceration is clean we just pack it up and send the person home. If deeper injury is suspected, we try suturing it safely and then send the person home. If the wound is too deep or we are too busy with other patients (DON’T read too lethargic) Surgical consult is called for. I asked the guy to show me what it was like and found it was a small cut and nothing major. Just an anti-septic dressing was enough. Just as I was to send him off to the Minor OT for dressing, I noticed several other cuts.

When he came back out, I asked him what the deal was, really. After a lot of talking and cajoling, he admitted that he was a self-cutter. He spoke of the classic manner in which cutting would seem to take the weight off his mind, but then he would be engulfed with guilt and shame and come to the hospital for some attention.

I talked to him for a long while. And he seemed quite a fine person. I tried to help him and asked him to cometo the Psych OPD next morning, gave him my phone number and told him that I would personally talk to the Psych HOD to ensure that he gets complete anonymity and personal attention. At that time, I also thoguht of writing about him. He agreed to that heartily, and consented to taking the pic to accompany my post.

Guess what, he never called back the next morning. Or thereafter, ever…

Patient Consent: Verbal consent given to publish picture and case details on maintenance of complete anonymity. I hope I have been able to honor his wishes, as I tried to write the post out after thinking it through we.ll. If you find any loops here, let me know ASAP, I will modify this.

Some More Readings:

Farber, S. K. (1997), “Self-Medication, Traumatic Reenactment, and Somatic Expression in Bulimic and Self-Mutilating Behavior.”, Clinical Social Work Journal 25 (1): 87–106, doi:10.1023/A:1025785911606

Haw, C. et al. (2001), “Psychiatric and personality disorders in deliberate self-harm patients”, British Journal of Psychiatry 178 (1): 48–54, doi:10.1192/bjp.178.1.48, PMID 11136210

Iwata, B. A., et al. (1994), “Toward a functional analysis of self-injury.”, Journal of Applied Behavior Analysis 27 (2): 197–209,

Undinism: Fetishes

Just Pissed... err Missed

OK. Now the fun with the search tags will start. I have always had a lot of fun reading what people “googled” to land up on my blog. And as the topic suggests, there will be a lot of fun-fodder  for the search tags. Rest assured I will reveal them as and when (in)appropriate.

Coming back to more mundane affairs like explaining the picture displayed. Undinism is a fetish for fluids, specifically, urine. Go Google it to get the juicy details! I don’t want more creeps finding this page out.  Anyways, here is the 411 on the pic. I have seen that we Bengalis have this utterly abominable habit of peeing in every accessible nook, cranny and corner. And I think that is utterly unacceptable. I have tried to ask people to not pee in public, and that has not worked. Not at all. All I got were sneers and jeers. And then I had this brainwave. Since asking them has not stopped, I will take a camera out and start taking pics. Lets see what else he has got to do but stop! Like this guy, who had to pull out midstream! If I was a bit quicker with the clicking, I might have caught him in the act! And ahem…that last sentence was not at all creepy!

Oh India. What a nation! I cannot kiss my girl (or guy) in public, but I can unzip and let it fly all in public.