ILA Spinal Cord Injury Dec 2010

8/3/2019 ILA Spinal Cord Injury Dec 2010

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INTEGRATED LEARNING

ACTIVITY

ROAD TRAFFIC

ACCIDENTBy

Ihab Zidan : Neurosurgery

Gihan Younis : Physical MedicineMaysa Amer : Medical Education

With contributions of : Anatomy , Histology, Physiology , PathologyDepartments Staff


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Adel, a young 20-year old fellow

was driving his brand new car on

the desert road with a speed that

exceeded 120 Km/hr, chatting withhis friend Sherif, who was sitting

in the front seat beside him.

All of a sudden, a truck came in

the way which forced Adel to turn

the car steeply to the right trying

to avoid it. However, he couldnt

control the steering wheel and his

car turned upside down 2 times

before it stopped by the edge of

the road.


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Both friends- not fastening their seatbelts- hit

the front glass forcefully and were ejected from the

car.

When the rescuers arrived they found Sherif

screaming from agonizing neck pain and was

unable to move his right upper and lower limbs.

Meanwhile, Adel was very anxious for being

unable to move his four limbs. He also had severe

neck pain. The examining doctor suspected injury ofthe vertebral spine for both.


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Q1: What might be the injured part of vertebralspine for both of them?

Q2: Can you describe the operating forces in

this type of injury?

Q3: What could be the value of fastening the

seat belt?


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How did the rescuers transported

each of them?


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Q4: Why did the rescuers used

this method and fixed them in

this position


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On arrival to the hospital :

Sherifs blood pressure was 60/40mmHg, pulse was

130 beat per minute

Adels blood pressure was 75/50 mmHg, pulse 124beat per min.

They were started on pain killers, Intra venous

fluids ,corticosteroids.


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Q5:What is your explanation for

hypotension ( low BP) ?

Q6: Explain how different groups

of pain killers act


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Both of them were breathing spontaneously

with normal breathing pattern.

Q7: What is the importance of

checking the breathing andensuring that the pattern is normal?

Q8: Explain why both patients werebreathing normally?


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The doctor who examined Sheriffound the following:

He was not feeling well the pricks of pin over his lower

limb, trunk, and medial aspect of upper limb and hand(including the middle finger) at the left side.

He was not feeling the touch of the cotton piece moved by

the doctor on the skin of the right side.

He was also unable to report on the movement or position of

his toes with diminished vibration sense on the right side.

He was unable to move his right lower limb at all.

The doctor found that the tone was decreased and he could

not elicit deep tendon jerks in this limb.

In the right upper limb, he was only able to flex the elbow

move the shoulder, and the hand grip was weak.

The triceps reflex was diminished with intact biceps and

brachioradialis reflexes.

Muscle power at left side of the body was normal.

Fi di N l i E i i


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Diminished

pin prick

sensation

Absence of sensation for

cotton piece all over this

side

Cannot move all lower limb

Normal musclepower

Decreased tone ,

absent tendon jerks

Moves shoulder

flex elbow

Findings on Neurologic Examination

Sherif

Cannot report movement &

position of Toes.

Lost triceps reflex

intact biceps and brachioradialisreflexes.


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This clinical picture is called the Brown Squard

syndrome and is due to hemisection of the spinalcord.

Q9: Where do you suspect the

probable spinal level of injury

would be?


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Q10- What are the structures present

at the probable site of injury?


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Q11- Label the tracts in the figure?

2

3

5

4

6

9

10

8

7

1


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Q12: Mention the anatomical pathwaysof each tract.

Q13: Deduce the functions affected

Q14: Describe the pathological

changes that happen after neural

injury.


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Q15: State the imaging studies youthink will be of help to diagnose

the site and degree of injury.

The doctor ordered some imaging studies:


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Q16 : What is this

imaging study

Q17: What do you see

in it ?

The first imaging study done is this one


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Q18: What is the type of radiological imaging in figures 1 &2 & what would be the added value of their use ?

Q19: What is the lesion seen ?

This was followed by 2 other imaging studies

Fig 1 Fig 2


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Neurologic findings for Adel

No movement in all four limbs

slight movement of the shoulder.

loss of superficial sensation ofall dermatomes of the four limbsup to shoulders

absence of the deep reflexes anddeep sensation of the 4 limbs.

M hil Th d h i d Ad l f d h


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No Movementexcept slight atthe shoulder

Meanwhile, The doctor who examined Adel found that :

loss of superficialsensation

absence of thedeep reflexes

and deepsensation


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The doctor ordered some imaging studies for Adel:

Q20: What is this type of radiological

investigation?

Q21 :What do you see in the figures?


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Q22: What is this type of radiologicalinvestigation?

Q23: What are the arrows pointing to?


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Q24: What is this type of investigation?Q25: Interpret the findings


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Diagnosis Stabilization Surgeryfor Both

Adel had Decompression and fixation usingplate and screws for C4,5


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Sherif had anterior cervical discectomy

(removal of the intervertebral disc betweenC6/ 7), with insertion of iliac bone graft, andanterior cervical fixation for C6/7 using plateand screws.


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They remained for one week in the hospital.

Progress :Sherif started to move his right lower limb;the tone in the limb began to increase

exaggeration of tendon jerkspositive Babinski sign.The power of the hand was partially resumed.

Adel showed the same picture in the four limbsbut more in the lower limbs.


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Progress

Sherif started to move his right lowerlimb;

the tone in the limb began to increaseexaggeration of tendon jerks

positive Babinski sign.

The power of the hand was partiallyresumed.


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ProgressAdel showed the same

picture in the fourlimbs but more in thelower limbs.


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Q26: What is the interpretationof the above mentioned

findings? Explain in viewof the anatomical andphysiological alterations.


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Q24: What do you think is thevalue of these exercises?


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After 6 months of intensive physical therapy, both

showed marked improvement in their

neurological functions.

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ILA Spinal Cord Injury Dec 2010