# Incomplete spinal cord injury OR...



## jholmes (Mar 6, 2011)

Had a child who fell from a tree, bystanders stated he fell flat on his back. 12y/o male, No significant vital signs worth reporting, obvious deformity to the left shoulder. 

*
BUT*

On the right arm, there was a loss of light touch sensation to the phalanges. But pain and motor functions remained the same. Checked PMS on both pedals, and it all checked out fine, and the left phalanges had loss of pain, but kept light touch and motor functions. Cap refill on this patients right phalange was 3 seconds. 

I suspected an incomplete spinal cord injury known as brown-sequared syndrome. Come to find out later, his increased refill was due to hyper extension of the right phalanges..  

But how do you explain the unbalanced PMS in the hands? (they returned in the ER)   :wacko:


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## Veneficus (Mar 6, 2011)

jholmes said:


> Had a child who fell from a tree, bystanders stated he fell flat on his back. 12y/o male, No significant vital signs worth reporting, obvious deformity to the left shoulder.
> 
> *
> BUT*
> ...



Sounds like a local nerve lesion to me. Probably from compression of fibres in the radial nerve. If the tension is relived, the return of blood flow may restore feeling if the nerve cells are hibernating and not severely damaged.

Doesn't sound like a cord injury.


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## jholmes (Mar 6, 2011)

Thats what i found so unique though is that his fingers were in a normal position. And what about the changing in PMS? I guess some things you just have to let go.


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## JPINFV (Mar 6, 2011)

Brown-Sequard would have had neurological deficits below the injury and the mechanism doesn't really match. If anything, it would be closer to thoracic outlet syndrome, but even that should present with more than a local deficit in the fingers (C5-C8 depending on which fingers). I agree that the limited deficit looks more like a local injury than any sort of central injury.


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## Veneficus (Mar 6, 2011)

Did he land on outstretched hands? You can have multiple injuries. 

You have to consider what the nerves inervate and the collaterals and variable fiber distributions. 

(way too much to type out here and pictures really help)


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## jholmes (Mar 6, 2011)

10 4 Thank you for clearing this up for me guys.


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## jholmes (Mar 6, 2011)

Going by what the bystanders told us "He fell flat on his back" I had a hard time believing that.


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## Veneficus (Mar 6, 2011)

That does make it hard to deform the shoulder.


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## JPINFV (Mar 6, 2011)

Veneficus said:


> That does make it hard to deform the shoulder.



This assumes that the ground underneath the tree was flat. If there was, say, a rock or something else on the ground, he could still land flat on his back, but his shoulder landing first.


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## Veneficus (Mar 6, 2011)

JPINFV said:


> but his shoulder landing first.



On my mind, whether by position of the body, or obstacle stuck, it cannot be "flat." 

The idea behind breakfalling is to fall flat to present no single impact points by speading the force out over a larger area.

These techniques work from considerable height. (I have plenty of first hand experience)

If you look at the animations, you can work out the medical implications.

http://www.judoinfo.com/ukemi.htm


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## M3dicDO (Mar 7, 2011)

jholmes said:


> On the right arm, there was a loss of light touch sensation to the phalanges. But pain and motor functions remained the same. Checked PMS on both pedals, and it all checked out fine, and the left phalanges had loss of pain, but kept light touch and motor functions. Cap refill on this patients right phalange was 3 seconds.



Just wanted to start off by saying......AWESOME assessment! Do you work on a 9-1-1 ALS rig? The reason I ask is because I don't know of many medics that would be so thorough in their neuro assessment......:beerchug:

I had flashbacks from my Neuroscience class when I read your scenario, I bet *JPINFV* and *Veneficus* will agree 

I apologize if this turns out to be a long explanation but I'll try to keep it concise. You were very close to forming a differential diagnosis with Brown-Sequard Syndrome, but there’s a bit more to it than that. Not that I'm a neurosurgeon, but this is my best shot at explaining why your patient presented with the symptoms he did. If you can follow my explanation, I promise you'll have a much better understanding on this "unbalanced PMS" finding.

Please use this figure to better get a visual on my narrative:

```
http://en.wikipedia.org/wiki/File:Spinal_cord_tracts_-_English.svg
```

Fine touch and proprioceptive information travel to your brain from the extremities through a pathway in the spinal cord called the "Dorsal Column, Medial Lemniscus System (DC-MLS)" It is located in the posterior-medial part of the spinal cord. Within this system, information at the thoracic level is carried in the "Cuneate fasciculus." This pathway crosses over to the other side of the CNS (i.e. decussate) in the medulla, eventually ending up on the contralateral side of the brain (post-central gyrus).

Using this information, you can localize the lesion on the right side of the spinal cord. I can almost guarantee that if you tested proprioception on your patient’s right hand, it would be as obviously pathologic as your test for fine touch.

But what about the loss of pain in the contralateral arm? Read on…

Pain and crude touch information are transported to the brain through a different pathway called “Spinothalamic Tract (STT)” which is part of the “Anterolateral System.” This system is located in the lateral aspect of the spinal cord. Unlike the DC-MLS, the STT actually decussates in the spinal cord instead of waiting to cross over in the brain stem. The pathway travels up on the contralateral side two vertebral segments above the root and ultimately ends up in the brain very close to the DC-MLS. So, the STT of C5 would be on the contralateral side at C3.

Using this information, it explains why your patient had loss of pain on the left hand but intact fine touch and motor. You stated that the motor was intact in both arms, so the lesion is not close to the corticiospinal tract.

Using all this information, you can localize the lesion around the center of the spinal cord, a bit lateral to the right but medial to the corticospinal tract. This area is supplied the *right lateral branch of the “Anterior Median Spinal Artery” around C4* **C4 because the STT of the left phalanges (C6) will be on the contralateral side at that level** My best guess is a temporary compression or spasm due to traumatic insult of that blood supply, causing a transient ischemic or inflammatory event. The other parts of both the DC-MLS and STT were spared due to blood supply from the posterior spinal artery.

This is a very localized lesion indeed, but the best one, given the information you provided.

I will encourage critique on this potential diagnosis. It’ll be a learning opportunity for me as well considering this is a REAL case. I left out quite a bit more detail in an attempt to keep my narrative short for this forum.


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## JPINFV (Mar 7, 2011)

Ack... I missed the contralateral loss of pain (and most likely temperature). 

Here's that picture:


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## M3dicDO (Mar 7, 2011)

JPINFV said:


> Ack... I missed the contralateral loss of pain (and most likely temperature)



Yes, and temperature (thanks!) I've gotta learn how to post pics on forums 

So now that you considered the contra lateral loss of pain, you think this preliminary diagnosis is plausible? What about somatic dysfunction (TARt), or an extended lesion at C4 (C4ERSL) LOL!


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## JPINFV (Mar 7, 2011)

Yea... spasm sounds much more likely than thoracic outlet. It's probably a cord issue, but definitely not a break or Brown Sequard. While a somatic dysfunction may be present and could contribute, I'd expect it to be more unilateral towards the sidebent side than anything. However my personal opinion on OMT is that some modalities hold promise as an adjunct or second line treatment, but rarely as a first line treatment. I almost came unglued in lab a few weeks ago when one instructor suggested using Chapman's points to help differentiate between cardiac and non-cardiac chest pain in urgent care or emergency departments. Don't get me started on the A.T. Still quotes or (/me shutters, especially since we spent a week on cranial), Sutherland and his "gills."


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## M3dicDO (Mar 7, 2011)

JPINFV said:


> definitely not a break or Brown Sequard


Yea, these would show paralysis/anesthesia at all levels below the lesion, rather than the localized one seen in the scenario


JPINFV said:


> \ I'd expect it to be more unilateral towards the sidebent side than anything.


Hmmm, I see your point. I guess a right rotation and sidebending could have more of an influence on the anterior blood supply than a left sidebending.


JPINFV said:


> However my personal opinion on OMT is that some modalities hold promise as an adjunct or second line treatment, but rarely as a first line treatment.


Yea, I know……I was just kidding. You thought I wouldn’t include OMT as part of a “comprehensive and holistic” approach to patient care 


JPINFV said:


> \ Chapman's points to help differentiate between cardiac and non-cardiac chest pain in urgent care or emergency departments. Don't get me started on the A.T. Still quotes or (/me shutters, especially since we spent a week on cranial), Sutherland and his "gills."


LMAO! Don’t get me started on some of the opinions I’ve heard about the use of Chapman’s points in an acute-care setting. That’s just crazy dude! Hehe. Cranial? You’ve gotta be the master on that stuff considering you’re studying at the Mecca of OMM. As for me, it’s only for the sake of boards and then it’s out the window! (just Cranial, the rest is cool)


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## JPINFV (Mar 7, 2011)

COMP? It's the California school. I think you're thinking of KCOM (Kirksville).


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## M3dicDO (Mar 7, 2011)

Oops, I saw an album of KCOM in your profile and thought you go there. Damn, I'd do anything to be going to school in Cali. The weather here in the midwest sucks.


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## JPINFV (Mar 7, 2011)

Yea... I interviewed at KCOM. I never got around to posting my pictures from my Nova interview or COMP. I did like KCOM's campus, and the truth is that even though it's in the middle of nowhere, there really isn't any free time in med school anyways.


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## Atlas (Mar 7, 2011)

I know this doesn't help at all with the case but damn, I have to say that reading through the posts on this thread has left me feeling stupid. I have six tabs open to different sites thanks a few of the posts on here haha...here comes some serious reading.


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## jholmes (Mar 7, 2011)

M3dicDO said:


> Just wanted to start off by saying......AWESOME assessment! Do you work on a 9-1-1 ALS rig? The reason I ask is because I don't know of many medics that would be so thorough in their neuro assessment......:beerchug:
> 
> I had flashbacks from my Neuroscience class when I read your scenario, I bet *JPINFV* and *Veneficus* will agree
> 
> ...





Just a EMT-B volunteer. I enjoy reading the in depth explanations. Thanks a bunch! We never got in to nerves really in EMT, hence my diagnosis of the Brown Sequard. Just going off what I personally knew in my mind. Thanks a bunch for the insight!


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## Veneficus (Mar 7, 2011)

JPINFV said:


> Ack... I missed the contralateral loss of pain (and most likely temperature).



Me too, until the post by m3dic


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## M3dicDO (Mar 7, 2011)

jholmes said:


> Just a EMT-B volunteer. I enjoy reading the in depth explanations. Thanks a bunch! We never got in to nerves really in EMT, hence my diagnosis of the Brown Sequard. Just going off what I personally knew in my mind. Thanks a bunch for the insight!



No problem! You had the right idea when you thought about Brown-Sequard indeed. I left out a few details here and there, so let me know if you want me to elaborate any of it.


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## JPINFV (Mar 7, 2011)

jholmes said:


> Just a EMT-B volunteer. I enjoy reading the in depth explanations. Thanks a bunch! We never got in to nerves really in EMT, hence my diagnosis of the Brown Sequard. Just going off what I personally knew in my mind. Thanks a bunch for the insight!



Here's everything you're missing... 

[youtube]http://www.youtube.com/watch?v=8bygOaphU4o&feature=related[/youtube]


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## usafmedic45 (Mar 7, 2011)

> I suspected an incomplete spinal cord injury known as brown-sequared syndrome



To the OP, don't take this personally but I have a good point to make.

USAFMEDIC45's Rule #28 of EMS: If they can't spell the name of the condition, chances are their diagnosis of it is questionable at best.

This goes for every level of provider, be they an EMT-B, EMT-P, RN, RT or DO/MD. 

However, it does sound like there was something going on with this case.  That said, you should follow up with your medical director to see what the true answer to the question of diagnosis is.


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## lightsandsirens5 (Mar 7, 2011)

Atlas said:


> I know this doesn't help at all with the case but damn, I have to say that reading through the posts on this thread has left me feeling stupid. I have six tabs open to different sites thanks a few of the posts on here haha...here comes some serious reading.



I was just going to say something like that. 

Neuro is where I really get lost at the moment. I am studying it still, but sheesh....you would have to be a genius to figure this all out in the first place.


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## usalsfyre (Mar 7, 2011)

lightsandsirens5 said:


> ....you would have to be a genius to figure this all out in the first place.



Hence the neurologist reputation in medicine as "the smartest doctor that doesn't do anything" 

(I kid if course)


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## JPINFV (Mar 7, 2011)




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## usafmedic45 (Mar 7, 2011)

There were only four specialties I ever seriously considered for any length of time:
-Pathology (specifically forensic pathology)
-Radiology
-Neurosurgery
-Anesthesiology

I keep trying to tell the director of one of the public health programs that I am seriously considering that I don't want to do an MD/PhD program.  It would be funny to have the MD so that when someone pulls the "You're not an MD" card on me, I have a rebuttal that'll shut them up.  However, I think 4 years of hell is excessive to simply have a really good smartass comment.


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## M3dicDO (Mar 8, 2011)

usafmedic45 said:


> USAFMEDIC45's Rule #28 of EMS: If they can't spell the name of the condition, chances are their diagnosis of it is questionable at best.



Amen! 



usafmedic45 said:


> However, it does sound like there was something going on with this case.  That said, you should follow up with your medical director to see what the true answer to the question of diagnosis is.



Absolutely. There's never anything wrong with coming up with a good list of differentials and then coming up with the best possible diagnosis after further testing. What I offered was a possible diagnosis based on the limited information provided. If possible I too would highly recommend following up with the receiving hospital and see what the outcome of the patient was. It is a great way to learn, and more importantly makes you a better clinician.



lightsandsirens5 said:


> you would have to be a genius to figure this all out in the first place.



Nope, doesn't take a genius to come up with something like this. Only 4 years of med school.......




usafmedic45 said:


> I am seriously considering that I don't want to do an MD/PhD program.  It would be funny to have the MD so that when someone pulls the "You're not an MD" card on me, I have a rebuttal that'll shut them up.  However, I think 4 years of hell is excessive to simply have a really good smartass comment.



Go for it!!!!! I'm not sure how old you are but have you looked at recent stats? The median age of incoming classes seems to get older every year. I am a non-traditional student myself, and there are a dozen other students in my class that come from other full-time careers to become physicians. Some have families, even little children. I know of a fellow classmate with two small kids and a wife who's a stay-at-home mom. He takes out loans not only for tuition but for his entire family's expenses! And I thought I had it rough being in debt for $50,000 each year :glare:


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## usafmedic45 (Mar 8, 2011)

M3dicDO said:


> Amen!
> 
> 
> 
> ...


I'm 30, still have two to three years left on undergrad, then have to do my masters.  I'm lucky in that I'm a non-custodial parent and have had a vasectomy so no more kids for me.  However, I just generally don't have that much interest in dealing with patients again unless it's on my terms.  I think the clinical rotations (especially primary care and obstetrics) would likely push me completely over the edge.


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