Intro to Neuro Case Study 1

History of Presenting Condition

Steven is a 21 year old student and experienced climber, who fell 25ft to the ground while bouldering with friends. His friends were experienced first aiders and were first responders to the accident. One friend called 911 while the others checked on Steven. Steven was awake and alert and reported severe pain in his neck initially followed by an inablility to move his arms and legs. They kept Steven in the position they found him in, covered him with a blanket to maintin his bofy temperature and stayed with him unable assistance arrived.

Paramedics arrived at the scene within 15 mins. Steven was lying in the supine position, he was still unable to move any extremities and complaining of neck pain. He was awake, alert, and oriented to his current location, the date and day of the week, and the details of his fall. He complained that he could not feel his arms and legs. His pupils were equal and reactive to light. He showed no other signs of injury except for some minor scrathes on his arms. His vital signs revealed a blood pressure of 110 / 72, heart rate of 82 beats per minute, respirations of 18 per minute. The paramedics applied a cervical collar, placed him on Ferno Scoop Stretcher, immobilized his head, and transported him to the trauma center by helicopter. He arrived at the hospital and underwent initial assessment within 75 mins of the accident.

Past Medical History  

ORIF Right Wrist Fracture 3 years ago 

Social History  

Full time student studying Engineering in his second year at University. He is right hand dominant. 

Steven loves the outdoors. In his spare time he loves Rock Climbing and Bouldering, both Indoor and Outdoors, Mountain Biking and Running. He also has a part time job as a climbing instructor at the University Climbing Wall.

He currently lives in a two storey house with 4 other university students during the University year and spends his holidays at home where he lives with his parents and two younger sisters. 

Initial Medical Assessment

Vital Signs:

  • Blood Pressure 94 / 55
  • Heart Rate 64
  • Respiratory Rate 24 with shallow breathing
  • Oral Temperature 39 Degrees Celcius
  • Color Dusky
  • Skin Warm and Dry to the touch

Reflexes:

  • Minimal biceps brachii stretch reflexes, with no triceps or wrist extensor reflexes.
  • All other muscle stretch reflexes in the upper and lower extremities were absent.

Sensation:

  • Perception of sensory stimuli ended bilaterally at an imaginary line drawn across his chest 1/2 inch above the nipples.
  • Some sensation in his arms, but could not localize touch or describe texture with any consistency there.

Strength:

  • Able to raise his shoulders and tighten his biceps brachii slightly in each arm, but could not raise either arm against gravity.
  • Lower extremities were flaccid, despite attempts to move them

Investigations

X-Rays:

  • Cervical Unilateral Fracture Dislocation of the Rght Sided Facet Joint at C5-6 with minimal Subluxation Contralateral Facet Joint 
  • Thoracic No Abnormality Detected
  • Chest Decreased Lung Expansion upon Inhalation

MRI:

  • Spinal Cord Contusion with Oedema
  • Minimal Right Sided Cord Compression

Blood Tests:

  • Normal, with the exception of a respiratory acidosis (blood pH = 7.25)

Medical Management

Intensive Care:

  • Stabilise Condition
  • Monitor for Neurogenic Shock
  • Monitor Respiratory Function
  • Transferred to ward after 3 days

Immobilisation:

Drug History

Pre Inury:

  • Nil

Post Injury:

  • Steroids (Methylprednisolone) administered within 3 Hours following Injury over 24 Hours

Presenting Condition

Day 1 2 Hours Post Injury

  • Assessment - C4 ASIA A
  • No Motor or Sensory Function below Lesion

Day 3 72 Hours Post Injury

  • Assessment - C4 ASIA B 
  • Returned Sensation Right Upper Limb and Trunk but altered
  • No Motor Function below Level

Day 7

  • Assessment - C5 ASIA B
  • Increased Sensation Right Side below Lesion
  • Increased Motor Function Left Side > Right Side
  • Biceps Grade 3 Bilateral
  • Wrist Extensors Grade 2 Left, Grade 1 Right
  • Elbow Extensors Grade 1 Bilaterally

Day 10

  • Scheduled for Transfer to Spinal Unit for Ongoing Management

Week 5

  • 5 Weeks on Halo Traction with Oscillating Bed - Being transferred to Halo Brace to allow for Sitting out of Bed & Initiation of Rehab
  • 5 Weeks Splinting & Passive ROM Upper Limbs
  • ASIA Assessment 
    C5 ASIA C - Increased Motor Function Left Side below Level

ASIA Form.jpg

Functional Assessment

Spinal Cord Independence Measure (SCIM)
To find out more about completing the SCIM check out this video

SCIM 1.jpg SCIM 2.jpg