Below are notes transcribed from Nick's medical records in St. Louis
7/22/04 – New patient Visit
6-year old male who presents with post laminectomy kyphosis and is here for a consult for surgical correction and stabilization of a kyphosis. In his history, he had a spinal tumor T1 to T4 considered epidural from a primary renal cell tumor and is status post laminectomy in July 2002 with radiation and chemotherapy as well. 2 years after the surgery, mom noted “sinking in between the shoulder blades”. He as subsequently developed pain with the past 10 days. No weakness, numbness or tingling. He has remained fairly active according to his parents and seeds to have no deficits whatsoever. He now presents for surgical opinion regarding this post laminectomy kyphosis.
Past Medical History
Significant for clear cell carcinoma of the kidneys status post resection in February 1999. Recurrent sarcoma in the epidural space of T1 to T4, status post resection in July 2000.
On physical examination, Nick is a young boy in no acute distress. He is fairly active and seems to have normal strength. He walks with a normal gait and is able to walk on his toes and heels without any difficulty. On upright standing, he as some marked kyphosis about the upper thoracic region. This kyphosis is exacerbated or increased when he bends over to touch his toes which he does easily. Upon lifting him off the ground from is axilla, it seems the this kyphosis is somewhat correctable at this time. It is also correctable when he extends backwards as well. On neurologic examination he as a 5/5 motor strength of his quadriceps, hamstrings, gastroc soleus, tibialis anterior, extensor hallucis longus. His sensation is intact throughout bilateral lower extremities. He as intact pulses, dorsalis pedis and posterior tibial pulses. He as brisk capillary refill as well.
Review of X-Rays/Studies
AP and lateral x-rays of his spine show post laminectomy kyphotic changes about T1 to T4. There are visible laminectomies in that region as well.
Referred by Dr. Michael Schmitz, from the Scottish Rite Hospital in Atlanta. Nicholson had a clear cell carcinoma of his kidney removed in February 1999. He had recurrence of the cancer in the epidural spaces of the upper thoracic spine at T1 to T4, diagnosed in July 2000. He underwent a semi-emergent laminectomy with tumor debridement. He also had postoperative radiation. He has subsequently developed a significant post-laminectomy semi-cervical thoracic kyphosis and is here for a consultation regarding that. He as been disease free since 2000. he recently had lung biopsy thoracotomy in April 2004 which was negative. He is otherwise growing and developing quite well, although his parents think that his upper thoracic deformity is progressing slowly over time. He does complain of some pain up there. No neurologic complaints, very active.
Shows a well-developed, well-nourished male who is appropriate height & weight. His posterior thoracic scar is well-healed. He as a significant upper thoracic gibbus deformity that is fairly stiff. When we try to suspend him by his skull, those correct mildly. He has a good range of motion to his neck uninhibited. He as normal dynamic and static neurologic exam to upper and lower extremities inclusive. He is very active here in the office today.
Review of X-Rays/Studies
X-rays upright AP and lateral of the spine show an 84 degree kyphosis from C7 to approximately T6. The apex is approximately T4-5. he had a 3D CT scan as well as a MRI, which shows fairly wide laminectomy with cord length preserved from approximately C7 to T4. Magnetic resonance scan does show obvious tenting of his spinal cord against his posterior hyperkyphosis, although obviously he is currently neurologically intact.
Post laminectomy upper thoracic kyphosis following debridement of a renal cell tumor mestastasis four years ago
12/20/05 Established Patient Visit Notes
Patient returns today with his parents, he has a progressive upper thoracic kyphosis secondary to post laminectomy treatment for a clear-cell renal metastases in the epidural space in early 2000. Being prepared for halo traction followed by staged posterior and anterior spinal reconstruction.
42” tall at 46 pounds. Well-healed posterior upper thoracic and lower cervical scar.
AP and lateral x-rays of the entire spine show approximately a 90 degree kyphosis from C7 to C6 CT scan very nicely shows the laminectomy defect. MRI scan shows his stenosis at the apex as expected. Hyperextension shows some mild flexibility to the deformity currently.
Post laminectomy progressive upper thoracic kyphosis in a skeletally immature male with a previous history of metastatic clear cell epidural tumor.
3 weeks of halo-gravity traction followed by posterior instrumentation from the midcervical region to the midthoracic region using a combination of 3.5 mm/4.5 mm titanium system. Anterior spinal fusion which will be done under separate hospitalization as long as the posterior procedure goes well. He has gotten a lot of radiation to the area so we definitely need to perform a circumferential fusion to be able to get a strong arthrodesis on him.
The following was taking from the operative notes for Nicks 1/27/05 surgery. Most of this is the instrumentation that was placed in Nick's back:
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