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Re: Case Presentation #3
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Re: Case Presentation #3 - June 15, 2003 10:52:00 PM
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axon
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I am not sure on the recommended traima protocols regarding a head CT given her current findings, but her history suggests she could have hit her head on the way out of the car, and no time for swelling/ inflammation yet to show any neuro signs, due to maybe a slow intracranial bleed.
You said C1-2 CT scan is fine.
If performing a spine CT, you would probably want a myelo/CT or SKIP it altogether and do a MRI with gadolinium of cervical spine/ cord and brain to look for change in T1 signal from her cord. The skull base CT could show any bony anomalies around the foramen magnum/fossa,occipital condyles, but I don't know whether to weight the CT scan or MRI more highly in terms of safety priority and justified expense. Seems like the MRI with gadolinium may give you more clues as to where to then aim the CT scan. Then, you could maybe do a 3-D CT scan instead if you do find a blockage somewhere on enhanced MRI?
I think syrinx's/ subarachnoid bleeds can give lower extremity symptoms without upper extremity involvement. The hyper-reflexive unilaterall at L4 could be from mild swelling around the cord, but not enough to trigger an upper motor neuron response yet like a Babiski's sign.
Does she have pain sensation to her upper extremities?
I don't think you can take her collar off. She is not complaining of pain, but has neuro symptoms which make the lack of pain complaints an unreliable subjective symptom to rule out cervical trauma yet ( we try to make sure we don't kill her right?)
Any PRIOR history of headaches? ( Arnold Chiari malformation)
Interesting case Dr. Wagner!
Sam B
[This message has been edited by axon (edited June 16, 2003).]
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Re: Case Presentation #3 - June 16, 2003 3:01:00 AM
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Dr.Wagner
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You do a Head, C-spine, T-spine, LS-spine, abdomen/pelvis CT (only takes 20 minutes or so) THis is the typical ruling out of small fractures NOT seen on xray (they are always imperfect in the trauma bay). We do this because of the significant mechanism and to rule out other pathology in the abdomen despite benign physical exam. You can't skip to MRI because of the imperfect ability of it to detect fractures, and because of availablity and speed...CT is first.
Ok, all CT's are completely normal, no bleeds, no fractures, no dislocations...
As per protocol, when placing her on the CT table you do the "log roll" to examine the back/spine.
She complained of point tenderness at the level of the thoracolumbar junction.
But as previously mentioned her CT's were negative.
OK, what next? Still can't move or feel at the level of the iliac crest.
Review: good sphincter tone, possible hyper-reflexia at L4, right great toe "wiggles"
I forgot to ask, how would you elicit pain in this patients Lower extremities...or would you?
Also, does anyone know how to "clear" the c-spine? (important for sports injuries too)
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Re: Case Presentation #3 - June 16, 2003 4:30:00 AM
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Andrew M. Ball PT PhD
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Dr. Wagner,
I thought that the open-mouth x-ray followed by a clinical testing of the alar ligament would clear the upper-c-spine.
I've heard of some radiologists doing open-mouths with some cervical side-bending to observe the way that the Dens moves (or doesn't) if they are unsure.
Is there more to it?
Drew
P.S. I wasn't suggesting Narcan, only that the EMT's at Ithaca and Cornell used to administer it as standard practice whenever they came to rescue some drunk idiot from a frat party.
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Re: Case Presentation #3 - June 16, 2003 5:28:00 AM
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Dr.Wagner
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I didn't think you were...don't listen to those EMT's then, cause they sound like they aren't following protocol (or common sense)...it is strictly for opiate toxicity or the unconscious unknown (coma cocktail).
As for Clearing the C-spine in this case, there are ALWAYS 5 rules to remain in the C collar 1. neck pain and midline cervical tenderness following trauma
2. altered mental status 3. intoxication 4. focal neuro deficits 5. distracting injury
So, this lass has focal neuro deficits and must stay in her collar until cleared...
which again brings us to what tests NOW since CT of the head, c spine, t spine, LS spine, abdomen and pelvis were all NORMAL?
And...can she come off the board?
What is the working diagnosis?
How should we elicit pain in the lower extremities?? Or should we?
Do we need more history?
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Re: Case Presentation #3 - June 16, 2003 3:43:00 PM
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axon
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The working diagnosis seems to be spinal cord injury, the location unknown yet.
We can't clear the neck for collar removal, and hence not the thoracic/ lumbar for the same reason...neuro deficits.
I think maybe time to MRI the cord with contrast.
Relevant history may be to question a pre-existing cord problem at a sub-clinical level, or disorder making trauma to the spine more likely to damage the cord, eg RA, Basilar invagination, syringiomyelia, facial pain ( cerebello-pontine angle tumor) headaches, dizziness, tinnitus, blackouts, visual disturbances, previous episodes of balance problems/ inco-ordination, speech problems, double vision or eye twitching ( optic neuritis from early MS)
Pain could be tested by heat, cold, pinprick to the upper extremities, face ( mandible)
Are we getting ANY warmer...? [IMG]http://www.rehabedge.com/forums/smile.gif[/IMG]
Sam B
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Re: Case Presentation #3 - June 16, 2003 5:13:00 PM
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prohealth
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It is both interesting and educative....especially as I try to remember what I can recollect from my classes. Seems need a lot more of the remote memory.
1. Okay, I am thinking if spinal tap is contraindicated, so is myelography. Is it time to get nuclear med going. NMR scan.
2. History- any previous vascular problems, hx. thrombosis? Apart from trauma, acute paraplegia may suggest a vascular cause- haematomyelia (as I try to recollect one of my neurology classes)? Any congenital cardio-vascular conditions, any angiomas? Probably, the sudden onset paraplegia led to the accident versus vice-versa? Never heard of it but who knows. Any previous neurological conditions per history?
3. Paraplegia may also be caused d/t the corticospinal tract damage for the leg areas- cannot rule out the head as yet.
4. Keep the back board on/ C-collar on until MRI results?
5.Working diagnoses- Motor Vehicle Accident/ Paraplegia
6. Check thermal/pain as Axon said on the facial area (trigeminal). I would think that trying to elicit pain in LEs would not be suggested as we are still expecting a SCI.
Makes me appreciate the ED a lot more!
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Re: Case Presentation #3 - June 16, 2003 5:40:00 PM
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DcK
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Hmmm... this is an unusual case. I'm surprised no CT findings. I'd assume the next step is mri, and where's the neurosurgeon? I'm also guessing a spinal cord injury, and I aksi believe w/should leave the c-collar and backboard on still.
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Re: Case Presentation #3 - June 16, 2003 5:47:00 PM
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Diane
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Cauda Equina Syndrome? (If no fracture and no burst discs, vascular supply damage?)Still don't know how you would test for that.
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Re: Case Presentation #3 - June 16, 2003 6:40:00 PM
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axon
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How about a possible arachnoid tear resulting in a subdural hygroma?
Should we check for history of syphilis (neurosyphilis/ tabes dorsalis?)Any recent flu/ viral symptoms?
Could get cord signs from this mimicking a subdural hematoma?
Probably too early to be thinking this.
I'll keep thinking....
Sam
[This message has been edited by axon (edited June 16, 2003).]
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Re: Case Presentation #3 - June 17, 2003 5:01:00 AM
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Dr.Wagner
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Working diagnosis thus far is "Spinal Cord Injury Without Radiographic Abnormality" (SCIWRA)...but this raises a concern, that is a PEDIATRIC diagnosis, a classic board question...RARELY an adult diagnosis.
WE are NOT done yet.
To elicit pain, I used my trauma shears pressed DEEPLY into the nail bed of the great toe bilaterally. Not satisfied, I took an 18 gauge needle (big) and pushed it into the ankle of the right foot.
No response with either.
We have nothing for neurosurgery to do at this point so we continue the IV dexamethasone as per protocol.
MRI is the next modality. We do the T-spine, and LS-Spine...THEY ARE BOTH NEGATIVE!!
So let us review, we have a 28 year old female involved in MVC flown via helicoptor, stable with apparent paraplegia.
SCIWRA is the working diagnosis, but she has sphincter tone (why hasn't anyone addressed this?) Her physical exam is pristine.
To get more history (hey we had alot of time at this point), I ask about social history...she begins to cry. Her only family contact are her parents. Recently her boyfriend of 5 years broke up with her. She also lost her home and now lives with her parents.
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Re: Case Presentation #3 - June 17, 2003 5:06:00 AM
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axon
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Somataform disorder?
Sam B
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Re: Case Presentation #3 - June 17, 2003 5:09:00 AM
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axon
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From: Illinois, USA
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[QUOTE]Originally posted by axon:
Somataform disorder?
Sam B[/QUOTE]
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Re: Case Presentation #3 - June 17, 2003 6:51:00 AM
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DcK
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CT, MRI, Xrays are all normal, very unique case.
A loss of sphincter tone would indicate spinal injury... not a news flash in this case, but you said it was normal ("good"), so, what's there to address w/it?
Right now, I'm leaning toward Lower Motor Neuron Paralysis. It's definately not upper, no babinski (per above), but lower would have no deep tendon reflexes, you didn't mention this as a finding above w/neuro exam? Any twitching? The L4 hyperreflexia made me first think upper motor neuron, but hyperreflexia can be found in spinal trauma cases.... Hmmm...
Okay, my guess is Lower Motor Neuron Paralysis for now. [IMG]http://www.rehabedge.com/forums/smile.gif[/IMG]
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Re: Case Presentation #3 - June 17, 2003 11:44:00 AM
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Bournephysio
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I think we should get a psych consult. She may at least be suicidal.
I was a little confused with the rectal tone as well as the apparent L4 hyperreflexia. Shouldn't she be in spinal shock and have no reflexes?
I think the two leading candidates are: 1. Hysteria or whatever it is called now. 2.a transient occlusion of the spinal canal leading to an incomplete lesion (although I would have thought that this would show up as soft tissue damage on mri.)
[This message has been edited by Bournephysio (edited June 17, 2003).]
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Re: Case Presentation #3 - June 17, 2003 12:00:00 PM
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Diane
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From: Vancouver, B.C., Canada
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This site says that 60-80% of the time sphincter tone is reduced in CES...which means that CES still needs ruled out somehow. Or did the MRI already do that.
[URL=http://www.acponline.org/journals/news/may95/backpain.htm]http://www.acponline.org/journals/news/may95/backpain.htm[/URL]
[This message has been edited by Diane (edited June 17, 2003).]
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Re: Case Presentation #3 - June 17, 2003 1:47:00 PM
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flexion
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Wondering if some psych case now. I would have thought for sure the MRI would have pick ed something out.
Depression questionnaire? suicide attempt or Hx of any?
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Re: Case Presentation #3 - June 17, 2003 1:57:00 PM
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DcK
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Psych?? I don't think it's psych, look at this again:
[QUOTE]"To elicit pain, I used my trauma shears pressed DEEPLY into the nail bed of the great toe bilaterally. Not satisfied, I took an 18 gauge needle (big) and pushed it into the ankle of the right foot. No response with either." [/QUOTE]
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Re: Case Presentation #3 - June 17, 2003 2:42:00 PM
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Bournephysio
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Conversion disorder. I new it had a different name now.
DcK: not my scope but I was under the impression that conversion disorders are very real to the patient. They are not faking it. Whether or not the above stimuli would still be painful, I don't know. She probably needs a psych consult anyway for a potential suicide attempt.
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