The dangers of chopping trees down.

 Have had an interesting run of trauma recently saw this on nights flying solo.

This patient was for me quite clinically challenging tho im sure some of those wise #FOAMites out there will get it in a flash.

Patient had been thinning trees  and one “twisted” and fell across him across his shoulder/neck. So thinning is cutting the smaller trees to allow good growth. No LOC at scene, witnessed by friend who called ambulance.

Running through the usual things,  A + C-spine immobilize, B seemed fine, C P 80 BP 120/75. Primary survey really nothing much to find. some haemotoma over his Left scapula but no other outward signs of injury.

Then his full assessment neuroexam, This guy works cutting trees for a living and he had weak grip on the right , like maybe 5- but if I was shaking his hand at the pub I would likely be grimacing. further exam I felt there was some weakness on his Left foot dorsiflexion. reflexes all present. He reported some parastesia in his Right forearm and possibly both arms at the scene but  thought it might have just been the cold.

So obviously he got squished, could be a few things. I really wasnt sure and my notes reflected this “?Brachial plexus injury on right, ??Spinal injury ”

So patient went through to CT which showed

Alignment is normal. No fracture is seen. No prevertebral haematoma seen. Spondylosis most severe at C5/6 and C6/7 and widespread facet joint arthropathy noted. If clinical findings suggest a cord injury, as discussed, MRI would be appropriate.

We don’t have MRI at our site and clearly it was needed so had the discussion with our spinal referral centre who were great. “It’s a probable spinal problem but if its brachial plexus we can sort it with the orthopods”

Patient was transferred for further investigations. I felt little bit happier that my confusion with the exam findings was not just me as pt had MRI of both brachial plexus and his C-spine.

 

Findings of: Normal alignment of vertebral bodies.  Posterior disc protrusion C3/4 with associated focal stenosis of the vertebral canal. Mild cord compression with mild focal T2 hyperintensity within the cord. Mild posterior disc bulge at C4/5 with mild focal narrowing of the canal. No evidence of cord impingement at this level. Mild vertebral canal and neural foraminal narrowing at C5/6. Mild bilateral formainal narrowing at C6/7. No abnormality of brachial plexus nerves bilaterally; no focal lesion or signal abnormality.

Summary of : Disc protrusion with mild cord compression and myelomalacia at C3/4.

Patient was taken to theatre for an Anterior decompression stabilisation C3/4

  

Post- op films.

Final diagnosis of  C5 ASIA D incomplete tetraparesis. Consistent with a  traumatic C3/C4 disc protrusion and resulting Central cord syndrome.

Patient had significant improvement with regards to strength. Gait returned to completely normal. Very mild residual reduced grip on his right hand. Only complaint of occasional Parastesia/Hyperastesia over Right forearm.

Had never seen a central cord syndrome before and only couple of brachial plexus injuries before. Thoughts anyone?

Good reference brief and clear http://www.wheelessonline.com/ortho/central_cord_syndrome_1

Comments

  1. Kath (@lanafeld) says:

    Great case! Have seen a few central cord syndromes but all had clear history of fall and much more classic neurology (such as complete upper limb paralysis and lesser lower limb weakness).
    Emphasises the need for a complete and proper neurological assessment in all trauma patients and getting the needed tests even when things don’t add up.

  2. Thanks Kath
    Yeah was a bit of a headscratcher. Patient was really good about it. As I examined him a the second time he said “Examine twice, Diagnose once?” (Builders always say “Measure twice, Cut once”)
    Cheers =)

  3. I have 3 videos on spinal cord injury and one of them is on central cord syndrome. Pretty funky disease! Andy

    http://vimeo.com/emedireland/videos

  4. Central cord syndrome is a favourite of the FACEM examiners I think.
    Remember it’s classic features as “old MUD”
    – usually older people, with degenerative disease of the spinal column
    – affects motor > sensory
    – affects upper limb > lower limb
    – affects distal > proximal
    Finally, remember what Amal Mattu says, “classic comes from the Latin for 15%” – atypicality rules!

    Chris

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  1. […] The dangers of chopping trees down.- Brilliant case – highlights that clinical exam still plays a huge role in clinical medicine over diagnostic imaging. […]

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