case files neurology
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case files neurology


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little benefit in terms of long-term neurological out-
come and an increased rate of complications such as wound infections. Recent
evidence indicates that intravenous methylprednisolone is beneficial for adult
patients with incomplete acute spinal cord injury if administered within 8 hours
of injury. Use of steroids in the setting of traumatic spinal cord injury should
therefore be considered controversial, particularly in patients with complete
spinal cord lesions and in children.
Long-Term Care and Rehabilitation
Maximizing long-term neurologic outcome for survivors of acute spinal cord
injury requires an intensive team-based approach to rehabilitation. Important
issues to be addressed include development of an appropriate bowel and bladder
care program, maintenance of skin integrity, and management of persistent auto-
nomic dysreflexia. As spinal shock subsides and spasticity begins to develop
over the course of 1 to 6 weeks, prevention of contractures with preservation of
functional position of the joints becomes crucial. Psychological and cognitive
rehabilitation is also vital, both in terms of adjusting to life after the injury and
also in terms of dealing with concurrent head trauma. In general, patients will
spend a significant period of time in an inpatient rehabilitation setting, followed
CLINICAL CASES 67
by a transitional outpatient program. Even after this period, however, the patient
should continue to be evaluated by a physical medicine and rehabilitation spe-
cialist at least yearly to maximize adaptation and function.
Comprehension Questions
[7.1] Currently, the best strategy for preventing further damage in patients
with acute spinal cord injury is:
A. High dose corticosteroids
B. Immediate exploratory surgery
C. Maintenance of oxygenation and spinal cord perfusion
D. Intravenous diuretic therapy
[7.2] A patient is brought to the ER following an MVA. On examination he
has weakness of his left arm and leg and loss of fine touch on the left
with loss of pain and temperature sensation on the right. This clinical
picture is most consistent with:
A. A complete cord syndrome
B. A central cord syndrome
C. An anterior spinal cord syndrome
D. A left spinal cord hemisection syndrome
E. A right spinal cord hemisection syndrome
[7.3] A 5-year-old child is brought to the ER following a fall from approxi-
mately 4 feet. He is now alert, moving all his extremities, and respond-
ing to touch on all four extremities, but he is somewhat irritable and
has a large laceration on his chin. Which of the following is true
regarding evaluating the child\u2019s spine:
A. Since he is moving all extremities and appears to have intact sen-
sation, no further spinal evaluation needs to be performed.
B. Given the child\u2019s age, spinal imaging should be performed.
C. Imaging should only be performed if cervical spine tenderness can
be demonstrated.
D. Spinal imaging should be arranged as an outpatient.
Answers
[7.1] C. The most important aspect of initial management is to avoid spinal
cord ischemia.
[7.2] D. This patient has the classic findings of a left cord hemisection
(Brown-Sequard) syndrome with ipsilateral weakness, ipsilateral loss
of fine touch, and contralateral loss of pain and temperature sensation.
[7.3] B. Children younger than 9 years of age who experience blunt trauma
or falls should have their spine imaged because clinical criteria can still
miss injuries. Even if this child were older, the presence of a distract-
ing injury (the large chin laceration) can mask cervical tenderness.
68 CASE FILES: NEUROLOGY
REFERENCES
Congress of Neurological Surgeons. Management of pediatric cervical spine and
spinal cord injuries. Neurosurgery 2002 March;50(3 suppl):S85\u2013S99.
Eleraky M, Theodore N, Adams M, et al. Pediatric cervical spine injuries: report of
102 cases and review of the literature. J Neurosurg Spine 2000;92(1 suppl):12\u201317.
McDonald J, Sadowsky C. Spinal cord injury. Lancet 2002;359:417\u2013425.
Saveika J, Thorogood C. Airbag-mediated pediatric atlanto-occipital dislocation.
Am J Phys Med Rehabil 2006;85:1007\u20131010.
Thuret S, Moon L, Gage F. Therapeutic interventions after spinal cord injury. Nat
Rev Neurosci 2006;7:628\u2013643.
Tsutsumi S, Ueta T, Shiba K, et al. Effects of the Second National Acute Spinal
Cord Injury Study of high-dose methylprednisolone therapy on acute cervical
spinal cord injury-results in spinal injuries center. Spine 2006;31(26):2992\u20132996.
CLINICAL CASES 69
CLINICAL PEARLS
\u2756 The most important step in the emergency care of children with
spinal cord injury is stabilization of the spine. The next step is to
maintain spinal cord perfusion pressure.
\u2756 The most common cause of spinal cord injury in the pediatric pop-
ulation is motor vehicle accidents (MVA).
\u2756 Traumatic brain injury commonly accompanies traumatic spinal
cord injury, including hemorrhage, ischemia, or diffuse axonal
injury.
\u2756 Superficial abdominal reflexes are elicited by scratching the skin in
all four quadrants around the umbilicus and watching for con-
traction of the underlying abdominal musculature. Stimulating
above the umbilicus tests spinal levels T8 to T10, whereas stim-
ulating below the umbilicus tests approximately T10 to T12.
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\u2756 CASE 8
An 18-year-old football player was covering a kickoff when he crashed into an
opposing player after losing his helmet, hitting the right side of his head
against the opponent\u2019s knee. He fell to the ground and was unconscious for 20
to 30 seconds. He was then immediately transported to the nearest hospital.
Twenty minutes after the accident, he was alert and conscious without neuro-
logic deficit, but he had amnesia for the event. He had a superficial bruise to
the scalp on the right. Approximately 1 hour after the trauma the patient devel-
oped a generalized motor seizure. Lorazepam 4 mg IV stopped the seizure.
A CT scan, performed 100 minutes after the trauma, was unremarkable. He
was then transferred to a larger hospital. On admission, neurologic examina-
tion showed a slight psychomotor slowing and slurred speech, which was
thought to have been caused by lorazepam administration, in the absence of
other neurologic deficits. The Glasgow Coma Scale score was 15 of 15.
Routine laboratory investigations and electrocardiography were normal. Eight
hours after the trauma, he had nausea, vomiting, and a headache.
\u25c6 What is the most likely diagnosis?
\u25c6 What is the next diagnostic step?
\u25c6 What is the next step in therapy?
ANSWERS TO CASE 8: Epidural/Subdural Hematoma
Summary: This is a case of an 18-year-old athlete with an acute brain injury
related to a sports-related trauma. The injury is associated with transient loss
of consciousness and a subsequent seizure. Although his examination is rela-
tively nonfocal and imaging of his brain is normal, his condition continues to
worsen with nausea, headache, and vomiting.
\u25c6 Most likely diagnosis: Intracerebral bleed\u2014epidural hematoma most
likely.
\u25c6 Next diagnostic step: Repeat noncontrast CT scan of the cranium.
\u25c6 Next step in therapy: Careful observation and neurosurgical
consultation. Careful evaluation for other signs of trauma.
Analysis
Objectives
1. Understand the mechanism of induction and progression of epidural
hematomas.
2. Know the hallmarks that require urgent intervention.
3. Understand the symptoms and signs associated with expanding epidural
hematomas.
Considerations
The key feature of this case is that this was a healthy individual who had a
closed injury. It was loss of consciousness, but then a normal lucent period. He
then had a seizure and later a downward course with cognitive deficit and more
fundamental neurologic problems. But, history suggests a delay consequence
of head injury. In this case one has to decide whether