SUMMARY Sparing of sensation in sacral dermatomes and of sphincter control was found in eight out of fourteen cases of severe cauda equina compression from massive central lumbar disc prolapse. Although the triangular shape of the lumbar spinal canal may be one factor for this it was found from a necropsy model that the increase in linear strain on the stretched roots of the cauda equina is least in the more centrally placed lower sacral roots. It is argued that the lower tension in these roots is determined by Young's Modulus.It is well known in cases of spinal cord compression from intrinsic or extrinsic tumours, cutaneous sensibility may be preserved in the sacral dermatomes when it has been lost or impaired in the lumbar and thoracic territory below the segmental level of the lesion. This phenomenon has been ascribed to lamination of the dermatomes within the spinal cord, so that the sacral spinal pathways may be the least compressed, particularly from extrinsic lesions. The fact that the same phenomenon combined with sphincter preservation may occur with a large central lumbar disc prolapse causing cauda equina compression has passed largely unobserved. No reference to this feature could be found in the English or American literature, though some authors noted that the sensory loss was asymmetrical, incomplete or even absent.' 2 Paillas and his colleagues did observe sparing of sensation in sacral dermatomes in two out of six cases of severe cauda equina syndrome due to central lumbar disc prolapse, and believed that the explanation was the triangular shape of the lumbar spinal canal; they believed that the more centrally situated sacral nerves would be less compromised than the more laterally placed lumbar roots.3 (fig 1). A personally studied case prompted the further investigation of the phenomenon. Case report A male, aged 42 years had six years previously suffered an episode of severe low back pain after heavy lifting which lasted several weeks; recovery was complete. Two weeks before his transfer from another hospital, he again lifted a very heavy object, and experienced excruciating back pain spreading to the front of both legs, and then he gradually lost the power in his lower limbs, so that after ten days he was unable to walk or stand; the front of his thighs, and of his legs below the knees felt numb. There was no difficulty in holding or passing urine although he was constipated. It was not possible to examine him standing because of pain and weakness. Straight leg raising was very limited and the femoral stretch test strongly positive. At the hips, the power was about MRC 4, both for flexion and extension; at the knees, for extension it was MRC 3 and flexion MRC 4; ankle and toe movements were between MRC 3 and 2.There was gross blunting to pin prick in the front of the thighs below the second lumbar dermatome which extended down over the shins and lateral borders of the calves to the dorsum and outer borders of the feet. However, in the soles of the feet and the back of the calves, back of the...
Ulcer prevention and its management has been a challenge in the practice of rehabilitation medicine and more so, with the tetraplegic subjects. We herein report a case of a 42-year-old tetraplegic male, who presented with multiple pressure ulcers and atypical grade-II ulcer in the right groin due to mismanagement of indwelling urethral catheter. Groin is extremely an unusual site for ulcer and no similar case has been previously reported with an ulcer in the groin in a spinal cord injury (SCI) patients. This case highlights the importance of proper positioning of indwelling urethral catheter, its care, and prevention of medical devices related (iatrogenic) complications in patients undergoing treatment.
Medical science is full of surprises. We faced one such surprise while treating a 47-year-old male patient with difficulty in walking for 6 months duration along with occasional seizures since childhood. After thorough clinical examination and investigations, patient was diagnosed as a case of Dyke Davidoff Masson syndrome (DDMS). It is a rare syndrome due to hemiatrophy of cerebral hemisphere and associated with hemiplegia or hemiparesis. But in this case, patient had only ankle clonus, causing difficulty in walking without any other motor deficit. Alcohol neurolysis of gastrosoleus muscles was done followed by gait training and improvement of gait was noticed over time.
Haemorrhage is responsible for around 11% of stroke syndrome. Haemorrhage usually occurs at a single site. However, it can be at multiple sites in some specific conditions i.e. coagulopathy, vascular malformation, malignancy etc. A 56-year-old male with left sided hemiplegia was admitted in the rehabilitation ward of RIMS, Imphal. He was hypertensive and was on irregular medication for that. He was also an alcoholic and chronic smoker for last 20 years. Patient was conscious and clinical examination revealed left 7th and 12th cranial nerve involvement with left hemiplegia. Non-contrast CT scan of brain revealed right thalamus and left basal ganglia haemorrhages. Thorough history and investigations did not reveal any aetiology for bilateral haemorrhage. Patient was treated with conservative management and improvement was noticed in serial follow-ups. There are very few case reports about bilateral spontaneous intracerebral haemorrhage associated with other diseases like migraine, Japanese encephalitis etc. Cause of bilateral haemorrhage in our case is doubtful.
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