Case 4 History

Presented by: Dr. K. Kumar, Neurosurgeon, Regina

History: Severe pain in the back and pelvis, left S.I. area and left upper thigh after a car accident in 1993.
Examination: a heavy set lady. Any movement of the lumbar spine produced severe back pain. S.I. joint -- tender. No other localizing signs. Confined to the bed most of the time due to the pain.

1. X-Ray of the Lumbar spine -- Normal
   
   
2. X-Ray of the pelvis -- Healed fracture in the pubic bone.
   
   
3. CT scan of the lumbar spine -- Normal.
   
   
4. CT scan of the pelvis -- Irregularity in the left sacroiliac joint.
   
   
5. Bone and gallium scan -- Increased uptake in the left sacroiliac joint.
   

   Pelvic X-Ray showing separation of pubic bone symphysis and irregularity of left S1 joint.	X-ray showing Normal Spine.
   CT of pelvis showing irregularity of left S1 joint.
   Bone scan showing sacroiliac joint uptake.

   
   Treatment:
   
   1. S.I. joint injections -- Not fruitful.
      
      
   2. July, 1996 -- A synchromed pump impalnted to deliver Morphine intrathecally at 1.7mg/day. Good pain control initially. Subsequently the dose of Morphine had to be gradually increased. Present dose -- 15.2mg/day with partial pain control, requires supplementary oral Morphine and nonsteroidal anti-inflammatory drugs.
      
      • Side effects of Morphine -- Edema of her feet and amenorrhea.
   
   QUESTION:
   1. Should we just continue to increase the dose of Morphine?
      OR
   2. Increase her supplementary oral narcotics?
      OR
   3. Add some other drug to her present infusion; if so which, or change it totally to some other agent?