This is a long one. But such an important topic.
The skinny on a case that I had. 80 yo M fell in front lawn while bending over to pick up sprinkler, fell forward striking head on ground (sounded like maybe from a foot or so) and then could not get up. Found by neighbor several hours later, and EMS called with transfer to ED. Patient ambulatory on scene. Denies any pain or symptoms other than stating he felt weak. My work-up in ED, negative CT head, EKG, troponin, CK, CXR, UA, and routine labs. I did note that patient had a very difficult time rolling over in bed due to weakness. Ambulated (known in the medical world as "leg stuff") without assistance or fall risk. Recommended admission but the thought of nursing home placement kept this stoic Iowan out of the hospital...until he was brought back into the ED 12 hours later noting difficulty buttoning shirt and eating (known in the medical world as "arm stuff"). CT C-spine attained which was negative, admitted to hospital with MRI several days later revealing central cord syndrome. Kind of sounds like a classic boards question in hindsight. So, this was my 2nd SCIWORA case in 4 years. Both patients injured their C-spines after falling from standing height. So, what have I learned (apparently not enough yet)...see below.
Spinal cord injuries can be very subtle. Why? I think for 2 main reasons; crappy neuro exams and crappy knowledge of presenting symptoms.
Pearl #1: Patients with spinal cord compression often do NOT have pain
. My guy had zero neck pain or tenderness on exam. We all tend to decide on the need to image the C-spine based on pain. No pain or tenderness, squeeze my hands and wiggle your toes..C-collar off...usually you are okay with this approach. However, you have to be really sure you are not missing subtle neurologic findings.
- Neurologic complaints without pain in the extremities are concerning for spinal cord compression. Neurologic complaints with neck pain and/or arm pain are concerning for cervical radiculopathy (i.e., compression on exiting dorsal root nerve)
- Obviously, neck pain is also concerning for potential fracture with osseous injuries leading to the most devastating injuries. So the take home message is not that neck pain is benign, but the absence of neck pain does not exclude serious injury.
Pearl #2 - Neuro exam findings are often symmetrical
. The cursory ED neuro exam misses these because we are so trained on detecting asymmetries, i.e., "brain stuff" or strokes.
- Motor complaints: Bilateral symmetrical weakness (or spasticity) concerning for spinal cord compression. Unilateral weakness suggests radiculopathy. To detect these deficits, you must test all joints that flex or extend, which will effectively test both proximal and distal motor function.
Pearl #3 - Sensory deficits are vague and NOT dermatomal
- Sensory complaints: vague bilateral non-dermatomal or multiple dermatomes involved is concerning for spinal cord compression. Sharp demarcation or dermatomal loss is concerning for radiculopathy.
Pearl #4 - Test reflexes
- Bilateral reflex abnormalities, positive Hoffman's sign, and positive Babinski's sign are concerning for spinal cord compression
- Slight retraction of lower extremities when testing Babinski does not equal volitional movement. I made this mistake in the intoxicated patient. Very well documented false positive so to speak.
Pearl #5 - Autonomic complaints are always concerning for cord compression
:
- Impotence or priaprism. Remember the saying, if they are raising theirs you should raise your eyebrows...maybe that was for Bells palsy
- Bladder or bowel dysfunction
- Horners syndrome
Pearl #6 - The "Eastvold Washcloth Test" = Pain and temperature run together via the spinothalamic tract (anterior cord)
- Testing only pinprick can be [a] difficult to pick up on subtle deficits given as we all know this test is so subjective, "feels a little duller", [b] people malinger
- Easier and probably much more sensitive (based on my own anecdotal evidence) method is to test temperature with a cold wet washcloth. Everyone wins, you will pick up on subtle deficits and the patient gets a sponge bath, which is hopefully their last as opposed to a sponge bath from the nurse at neuro rehab.
- If abnormality detected, then I test pinprick
Pearl #7 - Be Weary of Anyone with a Hyperextension Mechanism of Injury
- Both patients fell from standing height. 1st guy hit forehead on table with large laceration over forehead. 2nd guy had very small abrasion on chin, that's it. Both are hyperextension injuries, and the most common subtype of SCIWORA.
- "Commonly observed in the spondylotic spine in association with low-energy mechanisms, such as fall from standing height, although it can be observed in younger patients in association with higher-energy mechanisms and acute disc herniations. Clinically these patients often present with minor abrasions or lacerations on the scalp/forehead and a variable degree of neuologic impairment..." http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2989526/
Pearl #8 - Fractured (aka broken, Gromis) Osteophytes on CT scan May Not Be Insignificant = Cervical spondylosis is a potential red flag
- Does not equal unstable C-spine injury, true
- Insignificant, false.
- You will read that isolated osteophyte fractures are insignificant. They are not unstable, but they may represent soft radiographic evidence of serious underlying ligamentous disruption
- How? Due to spinal cord compression between a hypertrophied spondylotic disc-osteophyte complex and bulging ligamentum flavum
- Occurs with hyperextension (as well as hyperflexion) injuries. There was likely considerable translational movement within the 3 spinal columns and ligamentous disruption at the time of injury, but with muscle spasm and return to normal alignment of the neck this disruption can be very subtle. See Fig 7 below illustrating this important point. I have seen this exact case. Notice how well-aligned the spinal column is.
- > 80% of adult SCIWORA patients have underlying cervical spondylosis. I feel pretty good about a negative MDCT scan with recons and no underlying spondylosis...and no neuro complaints. If spondylosis is present, all patients with subjective or objective neuro findings need an MRI before clearing C-spine (and read pearl #7). Further, I do a really thorough neuro exam (after my 2nd missed case) on patients with spondylosis without neuro complaints before clearing these patients.
- Lastly, EMRAP has officially failed on this topic (dammit Mel) spouting comments that if the CT C-spine is negative the chance of surgical intervention is zero. Almost true, as the majority of these SCIWORA cases are managed conservatively. I do agree that the overwhelming majority of patients with negative MDCT with recons and no subjective or objective neurologic findings do not need an MRI. Patients with persistent severe neck pain is a judgment call, and if unsure you should involve your consultants. Just be really careful about diagnosing someone with hysterical paralysis.
Pearl #9 - Patients with acute cervical spine injuries need interrogation of entire spine
- I need to do a better job of this
- If there is any C-spine injury, the patient needs at least CT of TLS spine and likely MRI
Pearl #10 - If you are doing plain films or flex-ex films, please just stop it
Feedback always welcome.
Next topic is how to manage compression fractures, this one has always bugged me with the lack of recommendations.
Josh