# Neurological deficits



## Foxbat (May 4, 2009)

This happened to an acquaintance of mine.
She worked at a plant and her job involved a lot of physical activity like lifting heavy objects.
One morning, she woke up feeling burning in her lower back and weakness in her legs. Within a few hours, symptoms progressed so she was not feeling her body from the waist down and unable to move her legs.
She was hospitalised; as far as I know, doctors could not make a definitive diagnosis, but whatever treatment they administered worked; she's recovering slowly but surely.
So here's my question: suppose you were on a call where patient had symptoms described above but no history of trauma; pt. was involved in strenuous physical activity the day before but it's been hours between it and onset of symptoms.
What would you do? Specifically, would you immobilize this patient? Would you administer O2 if vitals were within normal limits and pt. did not exhibit respiratory distress?


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## Joel Yarberry (May 4, 2009)

Yes i would immobilize the pt. spinal injury could have occured a day or two before. o2 admin probably cannula never can hurt


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## Aidey (May 4, 2009)

Yes, I would immobilize due to the deficits. Even without trauma, a patient in this scenario could have slipped a disk or done something that is causing swelling around the spinal column. Preventing additional movement may prevent additional pressure from being put on nerves. 

O2 would depend. Are they showing signs of neurological shock? What color is the skin in the legs and feet? If they aren't showing signs of NS and the skin is warm, pink and dry then no I wouldn't give O2.


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## JPINFV (May 4, 2009)

/me wonders if people immbolize stroke patients because of decreased sensory and motor function...


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## emtech419 (May 4, 2009)

JPINFV said:


> /me wonders if people immbolize stroke patients because of decreased sensory and motor function...



If a potential stroke patient is unable to tell me reliably whether or not there was trauma that may have caused the sensory/motor problems, then hells yea I immobilize.


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## MSDeltaFlt (May 4, 2009)

Foxbat said:


> This happened to an acquaintance of mine.
> She worked at a plant and her job involved a lot of physical activity like lifting heavy objects.
> *One morning, she woke up feeling burning in her lower back and weakness in her legs. Within a few hours, symptoms progressed so she was not feeling her body from the waist down and unable to move her legs*.
> She was hospitalised; as far as I know, doctors could not make a definitive diagnosis, but whatever treatment they administered worked; she's recovering slowly but surely.
> ...


 
Why?  The pt awakened to this condition, and *then* symptoms progressed.  What does the average human being do in their sleep?  Exactly.  They move around in all kinds of weird ways, so why package?  The pt may require to be on LSB in order to be moved without causing any unnecessary pain/discomfort, but C-Spine Precautions?  It would be very dependent on my detailed pt assessment.

Also, how does O2 factor into this equation?  According to the information given, there is absolutely no reason why this hypothetical pt would require any O2.

Place this pt in a position of comfort, maybe a LSB, and transport nice and easy.


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## mycrofft (May 5, 2009)

*Know your wiring*

Only two non-pharmaceutical things can cause the sort of paraesthesia and paralysis you described: near-transection of the lumbar spine, or the brain, most likely psychological affect. Perhaps it hurt so bad (tingling) she couldn't operate, versus no sensation and no movement? That could be a bilateral impingement, from which you can recover, sometimes miraculously. The former means probably permanent total paraplegia.

That level of true spinal damage would also probably discontinue bowel and bladder control.

It is sometimes difficult to differentiate between complete paraesthesia (no sensation), or "numbness" which often on closer questioning is a sensation like electric shocks, burning, buzzing, or cold. Ditto paralysis, versus hurts-too-bad-to move, versus area has buzzing etc. and so movement is inhibited by the brain because there is no proprioception to tell the brain where those body parts are moving to or from.  ASK!


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## Aidey (May 5, 2009)

JPINFV said:


> /me wonders if people immobilize stroke patients because of decreased sensory and motor function...



For me, it's not about the decreased sensory and motor function, it's more about the lack of cause for the symptoms. Aside from the degenerative neurological diseases, I can only think of 2 reasons for paralysis and paraesthesia. Damage to the actual nerves in the spinal column disrupting transmission or pressure being put on the spinal column disrupting nerve transmission. 

In someone who has no MOI that I can detect, I'm going to take every precaution I have to prevent exacerbating a problem, including using a long spine board. 

If I was called for a patient that "fell down" and is now slurring their speech, can't move well, and has no grip strength. I have no way of determining if the fall caused the neurological symptoms, or the neurological symptoms caused the fall. Immobilizing the patient is appropriate in my opinion since you can not rule out trauma as a cause of the symptoms.


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## Veneficus (May 5, 2009)

I just can't help myself...

If the patient did have swelling around the cord, a LSB would likely make it worse. 

Mycrofft brought up an excellent point about hurts too much or actual nerve paralysis. Was any neural assessment performed? sharp sensation, dull sensation? was there any signs of cord impingement, loss of sphincter tone or bladder incontinence? (no need to do a digital exam, you'll smell it) 

"Whatever the docs did made it better." 
Perhaps they treated for Gullian-Barre? 

I know some will argue with "I always follow protocol like it is the word of god." That is a sign of a very poor provider. Protocols were never meant to replace "sound clinical judgement."

If your physical exam and history taking is lacking, there are several aides to help. 

If you do not know enough about medicine to make sound clinical decisions, there are several very thick books that will help as well. 

No matter what position you have in healthcare, there is nothing that stops anyone from increasing their knowledge.


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## Aidey (May 5, 2009)

Why do you feel a LSB would make it worse? 

Honestly, there is no protocol where I work for the treatment of non-traumatic spinal injuries/impairments. Since this is a pretty general scenario, I gave a pretty general response. I wouldn't automatically LSB any patient with a neurological deficit, it does depend on the situation, but it is an option I would consider as part of protecting the spine. If they already have evidence of a deficit, I don't want to moving any more than absolutely necessary since I can't determine the cause of the deficit in the field.


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## Foxbat (May 5, 2009)

I was not on that call so I can't add much more info, unfortunately.
I know pt. did indeed have bladder incontinence, I should've mentioned it in the first post. I was also told CT (or MRI, I don't remember which) performed in the hospital did not show abnormalities.


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## Veneficus (May 6, 2009)

Aidey said:


> Why do you feel a LSB would make it worse?
> 
> Honestly, there is no protocol where I work for the treatment of non-traumatic spinal injuries/impairments. Since this is a pretty general scenario, I gave a pretty general response. I wouldn't automatically LSB any patient with a neurological deficit, it does depend on the situation, but it is an option I would consider as part of protecting the spine. If they already have evidence of a deficit, I don't want to moving any more than absolutely necessary since I can't determine the cause of the deficit in the field.



The spine does not exist in its own little world, there is several muscle groups as welll as other soft tissue surrounding it.

Because of the spinal curvature and the location of the lumbar sacral nerve plexus, placing somebody on a board would transfer the force from the sacrum to the movable lumbar vertebrae, further compressing them. 
Additionally, a considerable amount of spinal cord injuries are not actual transections from subluxations of the vertebrae, but depletion of vascular oxygenation. The local soft tissue will already be swelling from an illness or injury, when you add further compression you will lower vascular supply and cause your very own local compartment syndrome. Granted it would not be enough to cause a systemic acidosis, but it would very likely kill a lot of nerve tissue.

(this point was actually argued ad nauseum on another board about disk injuries.)

The body also has a defense mechanism where the position of comfort is the position where the least amount of damage is occurring. Forcing a different position is a very sure way to cause damage. For example, if you went to an MVA and the patient’s head was turned sideways and they could not move it under their own power or complained of pain, you certainly wouldn’t force it back midline. Why would you force the lower part back into position?

I suspect somebody will start talking about padding the board but with the amount of padding needed, you would either likely create more of a curvature or make the board superfluous.

Furthermore most lower back pain is muscular in nature, and actual herniated disk (from improper lifting) most often prolapses towards the cord compartment; with the nucleus pulposus moving laterally and compressing the nerve root, posterior compressing the cord, or both. A soft supine position will increase the area between the disks allowing for some relief. (which the patient probably already placed themselves in the best position) If you compress by adding force in the direction of the spinous process towards the anterior you will decrease the compartmental area. This also runs the risk of compressing the posterior spinal arteries depriving the cord of oxygen. Nervous tissue is totally dependant on oxygen from TCA cycle and electron transport and doesn’t allow for a lot of debt. With the impeded circulation the temporary back up of ketone bodies also cannot reach the site. 

Gullian-Barre is auto immune, the board certainly will not help that. I have even seen a few patients with GB that came with the primary complaint of “fell.” Talk about tunnel vision, everyone was fooled that these were non traumatic and discovered in neuro. In this case, you get all the side effects of a board with no possible benefit. ( benefits which have never been demonstrated anyway and I doubt they exists)

In either scenario, the board either directly causes harm or does nothing and causes pain and skin breakdown. (shown in as little as 10 minutes) 

VOMIT (Victim Of Medical Imaging Technology) if nothing shows on CT or xray, it doesn’t mean nothing is wrong, it means what is wrong doesn’t show up on those studies.


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## redcrossemt (May 6, 2009)

Gullian-Barre or another syndrome of nerve or spinal cord inflammation seems most likely with symptoms progressing over a short amount of time. However, with the urinary incontinence, you would also want to consider disc herniation with spinal cord or nerve impingement. Veneficus explained it very well and gave some great reasons to NOT use a LSB. 

The patient will likely stay fairly still once they find a position of (most) comfort on the cot. If you put them on a LSB, they will be wiggling all over. I don't see any positives to a LSB for this patient - and there are lots of negatives to placing a patient on a long board, including making their problem worse.


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## redcrossemt (May 6, 2009)

Veneficus said:


> VOMIT (Victim Of Medical Imaging Technology) if nothing shows on CT or xray, it doesn’t mean nothing is wrong, it means what is wrong doesn’t show up on those studies.



I hadn't heard this mnemonic before. Very true. Correlate your imaging findings with your clinical findings. A lack of findings on imaging studies doesn't mean that the patient is faking!


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