The Case of the Mysterious Motorist

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The Case of theMysterious Motorist

• Jim Pointer, MD, FACEP
• Medical Director
• Alameda County EMS

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The Call

• You respond to the site of a solo MVA. The
  unrestrained 25 year-old male drivers car struck
  an embankment at 30 mph. He is ambulatory at
  the scene.

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Assessment

• ABCs no abnormalities
• Vital signs 120/100, 102, 16, 15,
• Pulse Ox - 98
• Pertinent physical findings
• Neuro no deficits noted
• Back midscapular pain that increases with
  respirations

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Field Treatment

• Full spinal immobilization
• Transport

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Hospital Findings

• Young white male c/o back pain
• Vital signs 110/85, 80, 20, 15,
• Pulse Ox 99

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Neuro Exam

• Upper extremities
• Strength - 1/5 hands
• 3/5 shoulders
• Sensation - slight decrease in temperature,
• pain, pinprick, and light touch
• from shoulders down
• Lower extremities
• Strength - 5/5 feet
• 5/5 upper legs
• Sensation - intact throughout

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Central Cord Syndrome
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Characteristics

• Most common incomplete cord lesion
• Bimodal distribution
• Spondylosis and trauma major causative agents
• Mechanism - hyperextension of the cervical cord

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Characteristics (cont.)

• Caused by pincer effect body/osteophytes and
  ligamentum flavum

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Characteristics (cont.)

• Damage
• Central spinothalamic tracts
• Central corticospinal tracts
• Upper extremities
• greater than lower

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Characteristics (cont.)

• Result
• Loss of motor function, much more profound
  in upper extremities, particularly distally
• Loss of pain and temperature sensation
  upper extremities, distally

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Spinal Cord Anatomy
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Spinal Cord Anatomy (cont.)

• Spinal tracts
• Long fibers originating
• in the brain and
• running together
• through spinal canal
• in pairs

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Spinal Cord Anatomy (cont.)

• Dermatomes
• Trigeminal
• Cervical
• Thoracic
• Lumbar
• Sacral

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Spinal Cord Anatomy (cont.)

• Central Cord
• Corticospinal tracts of the anterior cord
  arranged in concentric circles
• Hands most central
• Arms, shoulders intermediate
• Lower extremities outer zone

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Spinal Cord Anatomy (cont.)

• Anterior Cord
• Corticospinal tracts control of motor function
  on the same side of the body

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Spinal Cord Anatomy (cont.)

• Anterior Cord
• Spinothalamic tracts (lateral columns) carry
  pain (pinprick), temperature, and light touch
  from the opposite side of the body

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Spinal Cord Anatomy (cont.)

• Posterior columns
• Carry motion, position, light touch, and
  vibration from the same side of the body

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Other Spinal Cord Syndromes

• Anterior Cord Syndrome
• Posterior Cord Syndrome
• Brown-Sequard Syndrome
• Complete Transection
• 11,000 spinal cord injuries
• yearly in the US.

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Anterior Cord Syndrome

• Caused by pressure on paired anterior spinal
  arteries or damage by bony fragments
• Damage spinothalamic tracts
• corticospinal tracts

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Anterior Cord Syndrome (cont.)

• Result complete loss of distal motor function,
  pain, temperature sensation, light touch, motion.
  Position and vibration are preserved.

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Posterior Cord Syndrome

• Rare
• Existence doubted by some
• Damage to corticospinal tracts and posterior
  columns.

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Posterior Cord Syndrome (cont.)

• Retained spinothalamic function but lost movement
  and proprioception.
• Causes
• hyperextension injuries
• (falls to face/chin)

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Brown-Sequard Syndrome

• Cause usually penetrating trauma
• Damage all tracts on one side of the cord
• Results isolated loss of all functions
• Motor same side as damage
• Motion, position, vibration same side as the
  damage
• Pain and temperature opposite side as the
  damage

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Complete Transection

• Most common serious cord injury
• Cause trauma
• Damage all tracts on both sides
• Result total loss of function on both sides

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Treatment forSpinal Cord Injuries
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Treatment forSpinal Cord Injuries

• Spinal immobilization
• Steroids (benefit unproven)
• Early surgery
• Traction
• Experimental protocols
• Rehabilitation

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A Scheme for Assessmentof Spinal
Injuries(borrowed from the State of Maine
Guidelines)

• Mechanism
• Positive
• Negative
• Uncertain

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Assessment of Spinal Injuries

• Spine Pain/Tenderness
• Pain deep neck pain
• Tenderness stairstep
• exam over spinous
• processes from top to
• bottom

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Assessment of Spinal Injuries

• Motor exam Upper Extremity
• Finger Abduction/Adduction
• 4th and 2nd fingers together
• Tests T-1
• Finger/Hand Extension
• Push down on extensors
• Tests C-7

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Assessment of Spinal Injuries

• Motor exam Lower Extremity
• Foot Plantar Flexion
• Press against soles of feet
• Tests S-1, S-2
• Foot/Great Toe
• Dorsiflexion
• Press against top of foot
• Test L-5

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Assessment of Spinal Injuries

• Sensory Exam Upper Lower Extremities
• Pinprick spinothalamic tract
• Light touch many tracts
• Use a broken wooden q-tip on 1 or 2 sites, upper
  lower extremities.
• Ask the patient to distinguish between sharp
  (the broken end of the q-tip) and dull (the
  cotton end of the q-tip)

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Assessment of Spinal Injuries

• Reliable Patient Exam
• No
• Acute stress reaction
• Brian injury
• Intoxication
• Abnormal mental status
• Distracting injury
• Communication
• Yes
• Calm Cooperative
• Sober
• Alert