- 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.
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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