Case presentation of spinal cord case

1. Columbia Asia Referral Hospital Yeshwantpur Bangalore
- Case presentation / Dr. Ronak Raheja
Department of Internal Medicine

2. Presenting complaints / Subjective
Age : 43/F
Presenting complaints
unable to feel lower limbs after alleged history of rta @ 6 am
No breathing difficulty and she was able to breathe adequately

3. Presenting complaints
43 year old female local of chikballapur was travelling in the backseat of a maruti omni when
the car tyre burst and caused the car to slide, with an apparent whiplash type of trauma she
was unable to feel her legs after the incident. She was taken to a nearby local hospital from
where she was referred to nimhans where she was referred to emergency room of our
hospital directly.
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Patient also complains of tingling in all limbs s/o cervical cord without any particular pattern
of which could be described.There was no pain associated
She reports weakness of both lower limbs (Progression_ external compression v/s sudden
direct neuronal injury poor prognosis ), with no strength to stand , sit or walk with our
without support . She mentions difficulty in turning around in bed, with decreased sensation
over trunk and body.

4. Patient presented to the emergency room where cervical spine was stabilized and
she was shifted for Mri whole spine screening and CT with focus on cervical spine.
She also complained of chest pain which was constant , non radicular and
persistent and dull
Catherized
CT reports were suggestive of c7 anterior subluxation
Ortho reference was taken and they advised 3 kg neck traction and asked to
increase traction by 3 kgs every hour , she was planned for spinal surgery and
decompression

5. Past history
No significant past history
No past surgeries
No habits
Normal appetite
No known drug allergies

6. Personal history
Habits none
Sleep adequate
Appetite decreased
Bowel and bladder : dependant but continent
Could mobilize before but not now

7. Summary of history
43 / f presented to the hospital post road traffic accident and she presented with
complete bilateral lower limb weakness and sensory loss of lower limbs with
occasional paresthesias on lower limbs.

8. General physical / Objective
She is bed bound and lying flat on the bed with cervical traction
Pr: 88
bp: 120/80 lying down
Temp : febrile
Spo2: 93 on room air
Piccle neg

9. HMF
HMF +---> Normal conscious cooperative to time place and person
Memory +
Orientation → good
Recall → normal
Attention → good
Language ---> normal comprehension normal repetition but dysarthria present

10. Central nervous system /Cranial nerves
CN 1 Normal Normal
CN 2 + optic field/ color /Pupil reflex direct /
indirect
Normal normal
CN 3 Normal Normal
CN 4 Normal Normal
CN 5 Sensory + motar Normal Normal
CN 6 Normal Normal
CN 7 sensory + motar Normal Normal
CN 8 Normal Normal
CN 9 Normal Normal
CN 10 Normal Normal
CN 11 Normal Normal
CN 12 Normal Normal

11. Motor system ( Bulk )
Bulk Right Left
Proximal upper limbs normal normal
Distal upper limbs normal Normal
Proximal lower limbs normal Normal
Distal lower limbs normal Normal

12. Motor system (Tone)
Tone Right Left
Shoulder elbow wrist Normal Normal
Fingers upper limbs Normal Normal
lower limbs Flaccid Flaccid
toes Flaccid Flaccid

13. Motor system (Strength)
Power Right Left
Shoulder , elbow , wrist 4/5 4/5
Fingers 4/5 4/5
Hip , knee , ankle 0/5 0/5
Toes 0/5 0/5

14. Motor system (Superfascial Reflexes)
Superfascial Right Left
Corneal normal No reflex
Abdominal Normal No reflex
Cremastric Normal No reflex
Plantar Unable to assertain Unable to assertain

15. Motor system (Deep reflexes )
Deep reflexes Right Left
Biceps Normal Normal
Triceps Normal Normal
Knee Decreased decreased
Ankle Decreased Decreased
Flaccid paraplegia of gbs v/s tml is power of pin ( sensory )

16. Motor system ( Abnormal Movements )
Abnormal movements Right Left
Face Normal Normal
Distal upper limbs Normal Normal
Proximal lower limbs Normal Normal
Distal lower limbs Normal Normal

17. Motor system ( Co-ordiation )
Coordination Right Left
Proximal upper limbs Normal Normal
Distal upper limbs Intact Intact
Proximal lower limbs Unable to determine Unable to determine
Distal lower limbs Unable to determine Unable to determine

18. Sensory system (Before surgery )
Superfascial Right Left
Fine cotton touch Normal upper limb (medial
part of arm t1 upper limb )
Decreased over ( mention
dermatomes trunk and
lower limbs
Normal upper limbs
decreased over trunk and
lower limb
Temperature (Not done ) Normal upper limb
decreased trunk and lower
limb
Normal upper limb
decreased trunk and lower
limbs lower limbs
Pain Normal face and upper
limbs
decreased trunk and lower
limbs
Normal upper limbs
decreased trunk and lower
limbs
Pressure and vibration Nomal face and upper limbs

19. Sensory system (1 day after surgery )
Superfascial Right Left
Fine touch Absent Over trunk and
lower limbs
Absent over trunk and lower
limbs
Temperature Unable to ascertain Unable to ascertain
Pain Normal face and upper
limbs
Decreased over trunk and
lower limbs
Normal upper limbs
decreased over trunk and
lower limbs
Pressure and vibration Absent Absent

20. Sensory system (2 days after surgery )
Superfascial Right Left
Fine touch Normal upper limb
Present all over
Normal upper limbs
Present all over
Temperature Normal Normal
Pain ( T2 -- L5)
Sensory recovery but motar
weakness persists takes
more time
Improved can now feel pain
in lower limbs anterior
lateral and posterior and
trunk
Improved can now feel pain(
anterior lateral in lower
limbs and trunk
Pressure and vibration Improved can now feel
pressure
Improved can now feel
pressure

21. Sensory system (Deep)
Deep Right Left
Vibration sense Cannot determine Cannot determine
Joint sense Cannot determine Cannot determine
Muscle sense Cannot determine Cannot determine
Distal lower limbs Cannot determine Cannot determine

22. Neurological deficit
1)Bilateral lower limb weakness (flaccid paraplegia) with
UMN involvement ( shock ) initial
2)loss of sensation over trunk T2 and bilateral lower limbs
3)Bladder involvemnet

23. Anatomical localization -
Spinal cord at level of C7 ( lower cervical cord – tingling )
T1 sensory level
motar level
Intrinsic vs extrinsic
sudden ( intrinsic v/s progressive extrinsic)

24. Pathological diagnosis
Compression by what ? Hematoma / bone/ mets
diffuse axonal injury only if radiology is normal and traumatic
spinal shock improving after decompression
Intrinsic v/s extrinsic