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What Could Be The Best Possible Line Of Treatment For Paralyzed Hands And Legs And Breathing Problem Post Surgery For Intradural Tumor?

Posted on Sat, 18 Jan 2014

Question: My Sister was operated at Artemis Health Institute, Gurgaon for Intradural Tumor below C3 and C4 Cervical Vertebrae on 03/12/2013 and surgery went on smoothly from 0830 to 1130 hrs and she was alright upto 1530 hrs and her limbs were working properly but at 1730 hrs suddenly her legs got paralysed and after MRI doctors told that there is unexplained swelling in medulla and at 0030 hrs after that she started having breathing problem and was immediately put on ventilator. Now her hands and legs are paralysed and she is still (54 hrs after the surgery) on ventilator. We were told that she would be given IVIG if improvement in breathing does not start by tomorrow. What could be the best possible line of treatment and what's the best and worst that we can expect?

Answered by Dr. Sudhir Kumar (19 minutes later)

Brief Answer: Thank you for posting your query. Detailed Answer: Hi Mr XXXXXXX Thank you for posting your query and informing about your sister's condition. C3 and C4 cervical levels are considered as high cervical cord, and the nerves there also supply the breathing muscles such as diaphragm. Therefore, it is not uncommon to see respiratory muscle paralysis requiring mechanical ventilation after surgeries done in high cervical cord region. However, swelling in medulla is difficult to explain on the basis of surgery done in cervical region, as these two regions are separated by a few centimetres. The swelling in the medulla oblongata can be caused due to bleeding, infection or demyelination (damage to the nerve covering called as myelin sheath). In any case, the first treatment for all of them would be injections of steroid called as methylprednisolone. If you can upload the MRI report of the medulla swelling, it would be useful in determining the nature of swelling. If the swelling is due to demyelination, then, IVIG injections would be helpful. I hope my answer helps. Please get back if you require any additional information. Wishing you good health, Dr Sudhir Kumar MD (Internal Medicine), DM (Neurology) XXXXXXX Consultant Neurologist Apollo Hospitals, Hyderabad, India Click on this link to ask me a DIRECT QUERY: http://bit.ly/Dr-Sudhir-kumar My BLOG: http://bestneurodoctor.blogspot.in

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Sudhir Kumar (13 minutes later)

The Zip File of MRI and CT Scan is 205 MB and I am unable to load it. It seems to be in some software which I am unable to understand (edgeviewer_lite). Kindly guide how I could I do it. XXXX The CT and MRI Images sent by Excel File on your Email id YYYY@YYYY Kindly review and revert.

Answered by Dr. Sudhir Kumar (32 minutes later)

Brief Answer: Thank you for getting back. Detailed Answer: Yes, I was able to see the images on the excel file. However, it would be better to send the scanned copy of the radiologist report of the MRI, to know what the actual pathology is. As of now, we have to continue the mechanical ventilator. Please discuss with your doctor regarding the steroid injections also. Best wishes, Dr Sudhir Kumar MD DM (Neurology)

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Sudhir Kumar (13 hours later)

As per the MRI done today morning, the swelling of medulla has subsided but it is still there in the operated region. She is still on ventilator but we are told that IVIG is not being started due to swelling of medulla improving and steroids are being contd. for further 24 hrs to watch the condition. In the mean time, I am trying to get scans of MRI/CT Scan reports and send for your review. regards A K XXXXXXX

Answered by Dr. Sudhir Kumar (1 hour later)

Brief Answer: Thank you for getting back. Detailed Answer: It is good to note that the swelling in medulla has subsided. Swelling in the surgery site is expected and is common. I agree with the current line of management- steroids and mechanical ventilator. Best wishes, Dr Sudhir Kumar MD DM (Neurology)

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Sudhir Kumar (9 hours later)

Dear Sir, Thanks very much for yr continued support. I have Emailed radiologists MRI reports for pre and post operative stage. While patient is stable on ventilator, there is no improvement in breathing which is still th ventilator even after 72 hrs of steroid therapy (around 6grms total. Dose given) . Dr is suggesting starting IVIG. after review of MRI report of tomorrow morning if breathing does not improve. Kindly review and comment. regards XXXX

Answered by Dr. Sudhir Kumar (6 hours later)

Brief Answer: Thank you for getting back. Detailed Answer: We expect the patient to be on ventilator for some time, as there is swelling in high cervical cord and medulla. As mentioned earlier, IVIG is required for treating a demyelinating illness. What is the doctor's current diagnosis for which he wants to use IVIG? Best wishes, Dr Sudhir Kumar MD DM (Neurology)

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Sudhir Kumar (5 days later)

Dear Sir, Thanks for invaluable support. IVIG given for 5 days (completed yesterday). As per MRI done on 10th Dec morning, Swelling subsided from medulla region but still present on surgery site (in between C3 C4). Patient is breathing on CP-AP mode for last 3 days. Tracheotomy done yesterday (8 th Day of Surgery, 7th day of Ventilator) Patient is conscious, responding and recognizing and trying to speak, asked for food and water yesterday, 100 ml water and semi solid food given by ICU doctors. Bowel movement restored. (passed stool without enema), however, no limb movement, due to which we are extremely worried. Kindly guide how much and how fast recovery we can expect and any other suggestions for treatment. How long she may need ventilator support ? regards XXXX

Answered by Dr. Sudhir Kumar (7 hours later)

Brief Answer: Thank you for getting back. Detailed Answer: I am glad to note her improvement so far. The management seems to be going along correct lines. Weakness of arms and legs can be explained on the basis of swelling/damage to the cervical cord. Though it is difficult to predict the time frame for recovery, we expect gradual recovery in the strength of limbs over few weeks to months. She could come off the ventilator in a few days, if there is no further complication such as chest infection. Best wishes, Dr Sudhir Kumar MD DM (Neurology)

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Sudhir Kumar (30 hours later)

13/12/2013 Dear Sir, My sister was breathing on CP-AP mode till yesterday evening and doctors switched to IPPV mode in the night for safety but since today morning she is not breathing on CP-AP mode. Doctors conducted Chest X-Ray to look for any problems but concluded that there is no problem and told that she is not willingly breathing on her own. This is worrying us a lot and please tell us that could it be possible? If yes, then what could be done? Her other symptoms are OK as she is conscious, understands what we say, responds by moving her neck and twitching her tongue, taking semi solid food through tube, passing urine and stool normally, has no fever for last 3 days, but does not move her limbs at all. Please guide us that if the limbs remain motionless for long, even then can they return to normal when cervical swelling subsides might be after 3-4 weeks? If there is still swelling in the cervical region, what could be the reasons and a faster remedy? Thanks and regards, XXXX

Answered by Dr. Sudhir Kumar (9 hours later)

Brief Answer: Thank you for getting back. Detailed Answer: As I mentioned earlier, it may take about a week for her to be breathing on her own without mechanical ventilator. This is because the area of cervical cord affected with tumor, surgery and swelling also controls the breathing muscles. So, we need to give her time. Weakness of her limbs would take longer than few weeks, in my opinion, may be 3-4 months. However, it would depend on the extent of injury to the cervical cord nerves due to tumor and surgery. So, the exact timeframe for recovery can not be predicted. In the meanwhile, physiotherapy for the limbs should be continued to facilitate the recovery. Best wishes, Dr Sudhir Kumar MD DM (Neurology)

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Sudhir Kumar (15 days later)

Dear Sir, Thanks for your extremely valuable guidance and support. I am updating my sister's condition below : Breathing without ventilator for last 5 days, shifted from ICU to private room 3 days back, but Tracheotomy tube is still there, complains of excessive neck pain and oxygen still being given, infection in eyes and stool not passed for last 3 days. I am uploading latest MRI done on 25.12.2013. There is some sensation in hands which is improving day by day. There is very slight sensation in right leg also. We are still worried because no limb movement even now. Kindly guide when can we expect visible improvement in her condition. I have Emailed you the 25.12.2013 MRI File. regards XXXX XXXXXXX

Answered by Dr. Sudhir Kumar (5 hours later)

Brief Answer: Thank you for getting back. Detailed Answer: It is good to note that she is getting better. She is off ventilator and breathing on her own. The regaining of sensations is also a good news. Motor power (muscle strength) would take longer to improve, as there seems to be injury of the spinal cord due to tumor and surgery. Exact time period can not be predicted, but about 3-6 months would be reasonable time frame for recovery. Best wishes, Dr Sudhir Kumar MD DM (Neurology)

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Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar