IS YOUR PRACTICE PICTURE PERFECT ? A special deal for GLMS Members
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obtained and demonstrated ( drum roll , please ) ischemia vs . infarct from approximately C2-T5 with predominance in the anterior horns .
The literature review of non-traumatic spinal cord infarction is as rare as the pathology itself in the pediatric population and predominately consists of case studies . Causes typically include but are not limited to hypotension , vascular injury , thrombus , embolus or compression . Considering that many of these etiologies are already scarce in the pediatric population , finding cause proves to be a difficult task . Pain in neck , back or legs , weakness , tingling and numbness are commonly described symptoms in pediatric case studies and were present in the patient that presented to us . Prognosis studies have been performed on primarily adult patients ; one such study demonstrated > 40 percent recovery in ambulation amongst the 37 patients that left the hospital wheelchair-bound through aggressive physical therapy and rehabilitation programs . [ 1 ] Poor prognostic factors include female sex , advanced age , severity of symptoms and lack of improvement within 24 hours after infarction .[ 2 ]
It appears as though outcomes are primarily dependent on access to physical therapy and supportive care including psychological treatment . Workup and treatment recommendations if suspicious of atraumatic spinal cord infarct include obtaining an MRI for definitive diagnosis , followed by autoimmune , hypercoagulable and infectious evaluations . Treatment in the emergency department is mostly supportive and includes addressing any contributory conditions and the management of respiratory concerns .[ 3 ]
On follow up , I found that the patient required intubation after exhibiting respiratory decompensation after the MRI was obtained . Initial treatment with highdose steroids and IVIG were discontinued when infectious and immunologic workups were unrevealing . The hospital course was complicated by neurogenic bowel and bladder , neuropathic pain , anxiety , intermittent autonomic instability with hypotension , pneumonia and a urinary tract infection . The patient required tracheostomy and percutaneous gastric tube placement during his hospital stay . The patient continued to exhibit flaccid paralysis of all four extremities and ventilator dependence on discharge to acute rehabilitation .
Per my own investigation , I was relieved to find that Frazier has had success managing these cases and has many unique resources that may positively impact this patient ’ s course . See some video evidence https :// www . youtube . com / watch ? v = 8o _ w174rI3s ).
Needless to say , my differential for motor weakness , particularly in pediatrics , will forever be haunted by this case .
Dr . Hayes is an Emergency Medicine resident at the University of Louisville
[ 1 ] Robertson CE , Brown RD Jr , Wijdicks EF , et al . Recovery after spinal cord infarcts : long-term outcome in 115 patients . Neurology . 2012 ; 78 : 114 – 121 .
[ 2 ] Cheshire WP , Santos CC , Massey EW , Howard JF Jr . Spinal cord infarction : etiology and outcome . Neurology . 1996 ; 47 ( 2 ): 321 .
[ 3 ] Spencer , Sandra P . MD ; Brock , Timothy D . MD ; Matthews , Rebecca R . MD ; Stevens , Wendy K . MD . Three Unique Presentations of Atraumatic Spinal Cord Infarction in the Pediatric Emergency Department Pediatric Emergency Care . 30 ( 5 ): 354-357 , May 2014 .
This blog entry was featured on Room 9 Blogs , a blog for ER Residents . You can view other entries at www . room9er . com
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