Decorticate type posturing with normal GCS

[Smellypaddler]

Wondering if anyone can explain the patho related to a pt I transported today who had decorticate type posturing with a high GCS.

Pt was a 70yoM transfer out of a regional hospital who initially presented with sudden onset neck pain and bilateral arm pain. On arrival of the pt was agitated due to pain, had recently had 2.5mg IV Morphine and pinpoint pupils (initially considered to be opioid related). He had a GCS of 14 (E3, V5, M6) and was able to move all 4 limbs, nil grip strength and was holding his arms in a slightly flexed manner similar to the onset of decorticate posturing. Handover at the hospital was that the pt had an unknown mass at C4 ?haematoma, tumor or abcess.

Pt given 25mcg IV Fentanyl, pt became drowsy yet easily rouseable with well controlled pain. During the 2.5hr transport the pt progressively deteriorated becoming hypotensive, bradycardic with increased decorticate type posturing. By arrival at hospital they had nil sensation or movement from below the sternum, nil sensation and uncontrolled movement of upper limbs and decorticate posturing, pinpoint pupils remained despite nil further opiates and paradoxical breathing. Pt dropped HR to 35bpm, Systolic BP to 75 and required atropine.

Despite all of their symptoms the pt remained GCS 14 throughout.

Everything I could think of involved brain stem herniation with possible pontine involvement but I am at a loss to explain the posturing with such a high GCS.

Any ideas?

 

[Gurby]

Wondering if anyone can explain the patho related to a pt I transported today who had decorticate type posturing with a high GCS.

Pt was a 70yoM transfer out of a regional hospital who initially presented with sudden onset neck pain and bilateral arm pain. On arrival of the pt was agitated due to pain, had recently had 2.5mg IV Morphine and pinpoint pupils (initially considered to be opioid related). He had a GCS of 14 (E3, V5, M6) and was able to move all 4 limbs, nil grip strength and was holding his arms in a slightly flexed manner similar to the onset of decorticate posturing. Handover at the hospital was that the pt had an unknown mass at C4 ?haematoma, tumor or abcess.

Pt given 25mcg IV Fentanyl, pt became drowsy yet easily rouseable with well controlled pain. During the 2.5hr transport the pt progressively deteriorated becoming hypotensive, bradycardic with increased decorticate type posturing. By arrival at hospital they had nil sensation or movement from below the sternum, nil sensation and uncontrolled movement of upper limbs and decorticate posturing, pinpoint pupils remained despite nil further opiates and paradoxical breathing. Pt dropped HR to 35bpm, Systolic BP to 75 and required atropine.

Despite all of their symptoms the pt remained GCS 14 throughout.

Everything I could think of involved brain stem herniation with possible pontine involvement but I am at a loss to explain the posturing with such a high GCS.

Any ideas?

Did they do a CT? Was there any visible discoloration or deformity? Any more details about the C4 mass? Seems like that mass, whatever it was, must have been expanding and putting pressure on various important structures in the neck. If the pupils were pinpoint initially on only one side this could maybe be pretty well explained by a ruptured or dissecting aneurysm at the carotid bifurcation.

The carotid bifurcation is usually around C4, and is the most common place to get atherosclerosis in the carotids I think - did patient have any surgical history (especially carotid endarterectomy, peripheral vascular disease, etc)?

Horner's Syndrome is caused by interruption of sympathetic tone to the head and is an appealing explanation for the pinpoint pupils here. As the hematoma continued to expand it put pressure on other spinal cord structures, inhibiting ability of the more upstream brain structures to regulate things like BP and HR. https://en.wikipedia.org/wiki/Horner's_syndrome

The "posturing" would maybe be due to losing the upper motor neuron tone - similar to with a stroke, but here the lesion was further downstream so there weren't signs of cerebral infarct - https://en.wikipedia.org/wiki/Upper_motor_neuron_lesion

It would be interesting to know more details about the loss of sensation -- pain+temperature are carried through the spinal cord in a different location than vibration+proprioception+fine touch... If he had lost pain+temperature but maintained the ability to sense vibration that could help localize the problem better. If this were the case, maybe be a rupture of the anterior spinal artery around C4 or something would be a reasonable explanation? https://en.wikipedia.org/wiki/Anterior_spinal_artery_syndrome

 

[Brandon O]

Sounds a bit like the high spinal injury was causing sympathetic denervation (neurogenic shock) and respiratory compromise. Innervation of the diaphragm as well as sympathetic tone to the cardiovascular system run through the cervical spine.

Not sure about the posturing without seeing it, unless it was simply related to shock, but perhaps it's as simple as weakness of the upper extremity extensors with relative preservation of the flexor muscles (i.e. he could bend but not straighten).

 

[Gurby]

Sounds a bit like the high spinal injury was causing sympathetic denervation (neurogenic shock) and respiratory compromise. Innervation of the diaphragm as well as sympathetic tone to the cardiovascular system run through the cervical spine.

Not sure about the posturing without seeing it, unless it was simply related to shock, but perhaps it's as simple as weakness of the upper extremity extensors with relative preservation of the flexor muscles (i.e. he could bend but not straighten).

Something I have never understood about this... Look up any diagram of the SNS, and it will show you neurons with cell bodies in T1-L2. But lesion of the hypothalamospinal tract causes Horner's Syndrome. Is it that the hypothalamus regulates the autonomic nervous system, but it isn't technically a part of it?

 

[Brandon O]

Is it that the hypothalamus regulates the autonomic nervous system, but it isn't technically a part of it?

I guess what you consider "part of it" is semantics. Neuronal cell bodies in the hypothalamus connect to and regulate the sympathetic chain.

At least as far as I can remember. FFS you're really bringing me back here.

 

[VFlutter]

Sounds similar to Spastic Hemiplegia/Diplegia

The most common cause of posturing is increased ICP / brain injury however I am sure a spinal injury "downstream" could have similar appearance with normal GCS. I would assume it just appeared to be posturing and is actually technically something else, like listed above. Otherwise sounds like progressive neurogenic shock. As swelling and cord compression worsens so do symptoms.

 

[Peak]

I wonder if he has a spinal epidural abscess that is putting pressure on is spinal cord and is showing relatively late squeala (a spinal hematoma would have a similar presentation but without a recent procedure or precipitating event I would guess to be less likely). It would be great if we could see his CT or MRI, a reported abnormality at C4 could be so many things.

 

[phideux]

How can you score them a 6 on motor control with no sensation or movement in the lower extremities and no sensation and uncontrolled movement in the upper extremities???

 

[Smellypaddler]

How can you score them a 6 on motor control with no sensation or movement in the lower extremities and no sensation and uncontrolled movement in the upper extremities???

Good pick up, my bad. I should have written something along the lines of he remained cognitively unimpaired. I actually scored him a 13 as he was able to localize to central painful stumuli using his upper arm motor control although his wrists remained heavily flexed and he had no grip strength or hand motor ability. After stimulus was removed he appeared to have no control or proprioception of his upper arms as they kind of waved about before retracting into the previous posturing described.

To answer some of the other questions. I only know what was done at the transferring hospital so far. He had a CTB as well as the neck, head was clear and as the hospital is a small rural hospital they had not yet had the CT analyzed so they were unsure if hematoma, abcess or tumor. The pt was anticoagulated on Rivaroxaban post CABGs a considerable time ago.

On arrival the pt had no sensation, movement or pain response to lower extremities.

Pupils were not documented as being unequal by nursing staff prior to my arrival.

I don't have copies or access to the CT.

There is a specific follow up email address for all pts presenting to the recieving hospital that assists paramedics with what was wrong with their pts, treatment recieved and disposition. It said to allow two weeks for a reply so I emailed same day. Will post up the response.

 

[RocketMedic]

I reckon he has some sort of inflammatory/crush injury progressively worsening, as described above. He needs surgery and magic and Dr. Pepper.