Case Files 5 - Orthopedics: My Neck Ain't Breaking (Answers)
Q1. What orthosis are commonly used to stabilize the cervical spine for patients as such in the ED? What would you recommend instead if you have access to most orthotics in the Orthopedics?
Hard cervical collar (One-piece cervical collar). If the cervical spine can't be cleared within 6 hours (max 12 hours), a 2-piece cervical collar should be used, such as the Philadelphia collar or the Aspen collar.
*Philadelphia collar immobilized the cervical spine and upper thoracic spine, so the limitation of motion is greater, also it reduces strain on the muscles of the neck.

Q2. What is the possible mechanism of injury for this patient?
Hyperextension injury

Q3. What is the significance of bulbocavernosus reflex (BCR)?
BCR is absent in spinal shock.It is one of the first signs to return after patient recovers from spinal shock.
Homework: How do you do a BCR on a male, or a female patient? 

Q4. Given that MRI is not available in your institution/ hospital at this hour of the night, what are the other modalities of investigations would you like to do on this patient initially?
1)AP and Lateral view of Cervical Spine X Ray. ( +/- Swimmer's view to view C6/C7 better)
*depending on clinical suspicion, you may want to order a lateral cervical X-ray on flexion or extension.
2)CT cervical

Q5. In view that this patient may have spinal cord edema, how would you treat this patient?
IV Corticosteroids to reduce the spinal cord edema.

The patient was admitted to the wards for observation and further management. On admission clerking, it was found that the patient had underlying long term gastritis.

Q6. How would this affect your management?
Firstly, you would need to give PPI cover. Omeprazole or other PPI would do the job. Depending on the condition(severity and extent of edema), you may need to taper down the corticosteroids as it may worsen the gastritis. It is urgent to rule out spinal cord edema as prolonged corticosteroids can be detrimental.

Q7. What is your differential diagnosis of this patient at this point of time?
 i) Central cord syndrome
*Go google and come out with other differentials if you can. :)

Q8. Is MRI indicated in this patient, and what is your point of argument?
When your plain radiographs and CT scan could not pinpoint the problem, MRI is especially indicated when it will affect your management, particularly when the decision lies in to go for conservative or surgery. It is advisable to observe the patient over a few days (preferably ICU). Should there be any deterioration, such as worsening of neurological deficits or loss of urinary or bowel incontinence, MRI may be required.

In this patient, no, it is not necessary, as his neurological condition was improving, although it was being done anyway.

Q9. How would your management be from this point of time? Give your notion for conservative or surgical intervention, depending on your reasoning

Since the patient's neurological symptoms improved and there was no incontinence in the first place, MRI is not indicated as the patient would be planned for conservative management, which is for the continuation of Philadelphia collar and physiotherapy until his next clinical review.

Should the patient's neurological condition deteriorates, an urgent MRI is indicated to determine if there is any intrathecal bleed or soft tissue swelling compressing the cervical cord. In such cases, a cervical spinal decompressive surgery would have to be done in an attempt to reverse the neurological deficit.

However, should you have a different perspective, you can share it with us. :)

Upon discharge, the patient's upper limbs' power was 4.5/5. He was discharged with a Philadelphia collar and planned for physiotherapy as part of the conservative management. He was planned to be reviewed in the clinic as an outpatient in 6 weeks time.

*This case is part of a discussion open to all, and may  not be entirely accurate or correct in the description or management of the case. Should you have any opinion, do leave it in the comments area.


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