Spinal Cord Cases

1997 Exam I Case 04

CHIEF COMPLAINT

A 19-year-old male is brought into the emergency room with paralysis and neck pain following a motorcycle accident.

HISTORY OF CHIEF COMPLAINT:

This 19 year old male was brought in by ambulance to the emergency room from the scene of a motorcycle accident. The patient was the helmeted driver of a motorcycle traveling at approximately 35 mph when it skidded on wet leaves. The patient was thrown from the motorcycle across the street and into a telephone pole. Witnesses found the man unconscious, but breathing. Head and neck stabalization was preformed by a physician who arrived at the scene shortly after the accident. The passenger regained consciousness in the ambulance enroute to the hospital.

PHYSICAL EXAM:

He is awake and oriented with respect to person and place. He does not recall the events immediately preceeding the accident or the ambulance ride. Temperature is 98.5. heart rate is 120, blood pressure is 140/100, respiratiry rate is 22. External auditory canals are clear there is no hemotympanum. Nares are clear without drainage. Significant paravertebral hypertonicity is present in the cervical musculature. There is tenderness over the neck and shoulders with evidence of abrasion. Heart has a rapid rate and regular rythm. Lung sounds are full bilaterally without wheezes. Abdomen is without guarding or rebound. There are abrasions over the right shin and thigh. Foley catheter was placed and clear urine drained which showed no evidence of red blood cells.

NEUROLOGIC EXAM

CRANIAL NERVES: Pupils are equal and reactive to light and accomodation. Extraocular muscles are intact. There is no evidence of papilledema or retinopathy. Sensation to light touch and pin prick is present over the face. Tongue protrudes in the midline and gag reflex is intact. He can shrug his shoulders.

MOTOR EXAM: Cross table cervical spine x-rays show no evidence of instability in the cervical spine. He has limited ability to abduct his upper extremities; power is 4/5 in the deltoids, but he has no ability to move his elbow, wrist, or hand on either side. He has no control over either lower extremity. Deep tendon reflexes were absent at the triceps and bicepts as well as at the wrist.

SENSORY EXAM: Sensation was normal over the head, neck, and shoulders, but was entirely absent below the C8 dermatome.

FOLLOW UP:

After two weeks a neurological exam was performed on this patient and the following noted: He still lacked response to any sensory stimuli below the C8 dermatome. He also lacked control of muscles in the upper and lower extremities with the exception of the deltoids. His deep tendon reflexes were hypotonic in the arm and hypertonic around the wrists, hands and through both lower extremities. Fasciculations were prominent in biceps and triceps muscles with the first signs of muscle wasting. Remaining muscles in the upper and lower limbs exhibited elevated deep tendon reflexes and resistance to passive range of motion. The patient remains incontinent of urine and feces. His bladder fills, then partially empties by reflex contraction.

INSTRUCTIONS: Provide the BEST or MOST LIKELY answer to the following multiple choice questions.

1. Muscle fasciculations can arise from all of the following except:

a. damage to ventral horn motoneurons.

b. damage to ventral roots of spinal nerve

c. damage spinal nerve

d. damage to dorsal roots of spinal nerve

e. damage to the lateral corticospinal tract

ANSWER

2. The hyper-reflexia in the lower extremities of this patient suggests that you can rule out significant damage to the:

a. ventral horn of the cervical spinal cord

b. ventral horn of the lumboscaral spinal cord

c. corticospinal tracts in the cervical spinal cord

d. corticospinal tracts in the lumbar spinal cord

e. corticospinal tracts in the medulla

ANSWER

3. The incontinence expressed in this patient suggests that there is little or no damage to the patient's:

a. pons

b. medulla

c. lower cervical spinal cord

d. upper lumbar spinal cord

e. sacral spinal cord.

ANSWER

4. The incontinence expressed in this patient is best described as:

a. atonic (flaccid) bladder

b. neurogenic (spastic) bladder

c. ataxic bladder

d. structural (stress) incontinence

ANSWER

5. The loss of power in the arm suggests damage to the:

a. corticospinal tract in the medulla

b. ventral horn in the cervical spinal cord

c. corticospinal tract in the cervical region

d. ventral horn in the lower throacic region

ANSWER

6. The lack of conscious proprioception (position sense) seen in this patient is most likely due to damage of the:

a. dorsal columns and anterolateral tract

b. anterolateral tract and spinocerebellar tract

c. dorsal columns and spinocerebellar tracts

d. inferior cerebellar peduncle and medial lemniscus

e. spinocerebellar tracts and medial lemniscus

ANSWER

7. In this patient degenerating axons would most likely be found in the ________________________ above C8.

a. dorsal columns

b. lateral corticospinal tract

c. rubrospinal tract

d. vestibulospinal tract

e. peripheral nerves

ANSWER

8. In this patient, you would expect to find chromatolytic neurons in all of the following areas EXCEPT:

a. dorsal root ganglia below T1

b. dorsal horns below T1

c. dorsal nucleus of Clarke below T1

d. nucleus intermediolateralis below T1

e. lateral motor cortex

ANSWER

9. This lesion is best described as:

a. focal and on the right

b. focal and on the left

c. focal and bilaterally symmetrical

d. diffuse

ANSWER

10. The most likely location for this lesion is the:

a. pons

b. medulla

c. lower cervical spinal cord

d. lower lumbar spinal cord

e. sacral spinal cord

ANSWER

Case 03

(2000 Exam I)

CHIEF COMPLAINT: This is a 45-year-old male with weakness and sensory loss following a traumatic injury

HISTORY OF CHIEF COMPLAINT: During an argument in a tavern, the bartender, who was attempting to resolve the fight, was stabbed with a thin knife in the back of the neck by one of the combatants.  It was noted that the injured individual fell to the floor immediately and was unable to regain a standing position.  He was rushed to the emergency room. 

PHYSICAL EXAMINATION:  On evaluation, he is found to be overweight, well nourished and in good health except for the immediate trauma.  He is not intoxicated.  His heart rate, blood pressure and respirations were elevated, but he was in stable condition. He had a small, penetrating wound 1 cm to the left of the midline and 5 cm above a horizontal plane determined by the the spine of the scapula.  He complained of intense cervical pain. 

NEUROLOGIC EXAM: 
MENTAL STATUS:  He is awake and oriented for person, place and time.  His speech was clear and articulate and his fund of knowledge and memory were intact.  He was angry, but cooperative. 

CRANIAL NERVES:  Visual fields were full and eye movements complete.  The left pupil was 2 mm and the right pupil was 3.5 mm. The left pupil was only minimally responsive to light. Corneal, gag and jaw-jerk reflexes were intact. Tongue and uvula were positioned on the midline. Facial expressions were complete except that the left eye opened to 3.5 mm and the right eye opened to 5 mm. 

MOTOR EXAM:  Strength was absent in the left leg and grip strength was 2/5 in the left hand and 3/5 at the wrist. Otherwise strength was normal in both right extremities and in the left upper extremity at the shoulder and elbow. Deep tendon reflexes were absent at the left knee and ankle joints and about the wrist on the left, but were 2/4 at the right knee and ankle and 2/4 in the right elbow and wrist. The lower extremity had no resistance to passive motion. 

SENSORY EXAM:  He had diminished two point discrimination, vibratory and position sense about the left hand and digits, otherwise discrimination, position sense and vibratory sense were intact in the right leg and both upper extremities. He had a loss of sensation to pin-prick from C8 down through the right leg but normal response to pin-prick in the left leg and left upper extremity. 

FOLLOW-UP: Examination at three months post injury finds the sensory exam remained unchanged, however, he now had elevated deep tendon reflexes about the left knee and ankle.  A Babinski response is present in the left foot.  There were only trace increases in his strength in this extremity. The left extremity demonstrasted a velocity-dependent resistance to passive range of motion. The left hand continues to display minimal grip strength and there is marked atropy of the thenar eminance and in the lumbrical spaces. Fasciculations are present in the thenar muscles and the deep tendon reflexes about the digits are still absent.

Case 04

Chief Complaint:
This is a 12-year-old male presenting with progressive weakness.

History of Chief Complaint:
The patient recently emigrated from India with his parents about 2 weeks ago. Until this point, he had been an athletic and very active child.  One week prior to his arrival in the United States he had a short viral-like illness including sore throat, nausea, vomiting, and diarrhea lasting about 4 days. One week ago, he began complaining of difficulty in walking and his parents state that he began having difficulty holding various objects in his right hand. The weakness has progressed rapidly over the past week. By the end of the week he could not walk unassisted and was unable to feed himself with his right arm.  He has not received any childhood immunizations.

Physical Exam:
This is an alert and oriented boy carried into the office by his parents. His righ arm hangs limply by his side when seated.  He appears well-hydrated with moist mucosa and good skin turgor. Throat is non-reddened with no tonsillar edema. Lung sounds are clear to auscultation in all fields. No murmurs, rubs, or gallops are heard. Abdomen is soft and non-tender. Obvious muscle atrophy is noted in the right upper extremity, especially the thenar eminence, and in the left lower extremity around the calf muscle.  Parents deny any urinary or fecal incontinence.

Neurological Exam:
Mental Status:
He is awake, alert, and oriented. Knowledge is appropriate for age. Speech is clear and meaningful. Although weak, he can follow 2 step commands without confusion.

Cranial Nerves:
Visual fields are intact to confrontation. Extra-ocular movements are intact bilaterally. Sensation is intact throughout the face. Facial motion is symmetrical. Corneal reflex is present. Uvula is midline with symmetrical elevation of palate. Shoulder shrug is strong and symmetrical. The tongue protrudes in the midline with no fasciculations.

Motor Exam:
Strength in the upper extremity on the right was 2/5 at the shoulder, 1/5 at the elbow and wrist with 2/5 grip strength.  Deep tendon reflexes were trace about the right elbow and wrist.  Strength was normal in the left upper extremity and deep tendon reflexes were 2/4 about the elbow and wrist on the left.  In the left lower extremity, strength was 5/5 at the hip and knee and 1/5 at the ankle.  Deep tendon reflexes were 2/4 about the knee and 1/4 about the ankle.  Strength was normal in the right lower extremity and deep tendon reflexes were 2/4 about the knee and ankle on the left.  Past-pointing was not present in the upper extremity on the left or the lower extremity on the right; it could not be tested in the upper extremity of the right nor in the lower extremity on the left.  Bladder and bowel functions were intact.

Sensory Exam:
Proprioception, vibratory sense, 2–point discrimination, and pin–prick are intact throughout his body.

Follow-Up: Re-examination at 6 months post initial presentation finds him in good health except for a dense weakness and severe atrophy of muscles throughout the right upper extremity and in the calf muscles of the lower extremity on the left.  All reflexes are absent in the effected extremities and a few fasciculations are left, especially in the gastrocs muscle.  He walks assisted with a crutch and is awaiting an appointment for the fitting of a leg brace.