• History and Examination
    • A 59-year-old female presents immediately following a gunshot wound to the cervical spine. The weapon is identified as a medium-caliber handgun.
    • On presentation she has no movement or sensation below C5

    Figure 1

    Figure 2

    Figure 3

    Figure 4

    1. Which of the following is considered contraindicated in this patient's treatment?

    2. Which of the following is considered an indication for surgery in penetrating spinal trauma?
     
     

    3 . The patient returns 6 months later complaining of worsening spasticity in her upper extremities. She is on baclofen. What is the most appropriate next step?

    4. Despite appropriate medical management, the patient continues to experience worsening spasticity. A CT myelogram is ordered (see figures 3 and 4). What is the most appropriate next step

    5. Which of the following describes you?

    6. I practice in one of the following locations.

    7. Comments
     
    • Since there is a cyst or syringomyelia, like secuel. It is indicate the surgery to make decompretion of the spinal cord.
    • Question # 2: the last multiple choice is likely a typo - error "A and B" should be "A and B"
    • comments for each question:
    • 1. methyl prednisolone has no proven evidence, but still mentioned in books ( don't know if they give it as 'stress busters'!
    • 2.traverses is my pick: in the neck the major artery is vertebral artery, but it gives dural branches, so H (EDH/SDH) needs to be ruled out
    • 3. Baclofen: The typical starting dose is 5-10 mg two or three times per day, and the dosage can be increased by 5-10 mg per week. Although 80 mg per day is a commonly accepted maximum, dosing up to 200 mg per day has been used safely and effectively.
    • 4. i suspect an extradural 'SOMETHING'. antispasticity medication, spasticity blocks, botulinum toxin injections. is it intractable ? ( baclofen, diazepam, tizanidine or clonazepam ),
    • I am assuming that for question 2, the final answer choice should be A&B and that is why I chose it
    • None of STERIODS STUDIES LIKE NASCIS JNCLUDED gunshots
    • stabilization for better healing

     

    Case Explanation:

    • Answer to Question 1- Which of the following is considered contraindicated in this patient's treatment
      • C. High dose methylpredinisolone
        • The high dose methyprednisolone protocol for spinal cord injury remains controversial, however this protocol is contraindicated in penetrating spinal trauma. Steroids in this patent population can lead to worse outcomes
    •  Answer to Question 2 - Which of the following is considered an indication for surgery in penetrating spinal trauma?
      • E. A and B 
        • Destruction of bony elements resulting in instability and migration of foreign body causing neurologic decline are two possible indications for surgery.
        • In the absence of instability, an injury from a relatively low velocity weapon that traverses the neural elements is not, in and of itself, an indication for surgery.  Neurologic worsening can be an indication for exploration in these cases, and it is worth noting that some military literature regards high velocity injuries (e.g. high powered rifle) as an indication for decompression even in the absence of instability
        • The patient is taken to the operating room for operative fixation and debridement. Her initial postoperative course is relatively uncomplicated.
        • The patient is lost to follow up, but returns many months later complaining of worsening spasticity in the upper extremities. She had gained the ability to use a joystick controlled wheelchair, but recently this bacame more difficult. Her primary care physician placed her on baclofen 5 mg TID approximately 3 weeks prior to arrival at your office.
    • Answer to Question 3 - What is the most appropriate next step?
      • A. Increase baclofen dosage
        • 5 mg TID is a low dose of baclofen in an adult with spastic quadriplegia. This can be gradually increased to a maximum of 20 mg QID. 
        • Additional imaging is an option at this point, although simply increasing the baclofen may ease the spasticity.
        • Despite further attempts as medical management, the patient's spasticity continues to worsen.
        • Due to the presence of matallic fragments the patient cannot have an MR. A CT myelogram is ordered and is shown on the the images in figures 3 and 4.
    • Answer to Question 4 - What is the most appropriate next step?
      • B. Intradural Exploration
        • Post-traumatic syrinx is a recognized cause of delayed decline in patients who have suffered spinal cord injury. The patient appears to have either an intradural cyst or post-traumatic syrinx, and prior to other treatments operative exploration is advised.

     

    References:

    Prendergast MR1, Saxe JM, Ledgerwood AM, Lucas CE, Lucas WF.J Trauma. 1994 Oct;37(4):576-9; discussion 579-80. Massive steroids do not reduce the zone of injury after penetrating spinal cord injury

    Martin, MD and Wolfla, CE. Penetrating Spine Trauma in Loftus, CM, ed. Neurosurgical Emergencies, Second Edition. Thieme (2008). 

    Lyons BM, Brown DJ, Calvert JM, Woodward JM, Wriedt CH. The diagnosis and management of post traumatic syringomyelia.Paraplegia. 1987 Aug;25(4):340-50.

       

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