Emergency Medicine Forum

While you are preparing for a trauma code (pedestrian struck by a car), your resident joins you in the resuscitation suite and notes he just saw a 72 y/o syncope patient, no chest pain, no shortness of breath. He explains the patient hadn’t been eating or drinking for a few days, and passed out when he stood up to go to the refrigerator. He notes the vital signs were fine, and he assures you he started the syncope workup.

After the trauma code is stabilized, you return to the syncope patient. (about 25 minutes have passed). He has a working IV, is getting a 500 cc normal saline bolus, and labs have been sent.  An EKG is available which shows normal sinus rhythm, without injury or ischemia changes. 

Vital signs HR 95, RR=24, BP=152/87, Temp= 97F, Sat=96%

Patient has a history of newly diagnosed colon cancer.  He is planning on leaving for the Mayo Clinic tomorrow for a second opinion.  His internist recently ordered a CT scan of the abdomen because of the weight loss (20 lbs in 6 months) and chronic back pain.  This revealed metastatic cancer, presumed to be colon. He has not had much appetite, and has to force himself to drink or eat.  He has not had any new pains, but has had chronic back pain for the past 6 months that he has had treated by a chiropractor. Prior to the fall, he did not have any chest pain, or dyspnea.  No history of vomiting, diarrhea, bleeding.

When he got up from the chair to go to the refrigerator, he became dizzy, and passed out.  His wife came to his side (she heard the thump), and called 911.

PMH:  Recently diagnosed colon cancer, hypertension.  He had a myocardial infarction years ago, and has a stent.
Social History:  Neg
Meds:  Lopressor, aspirin
FH:  Noncontributory
PE:  Thin male, in no acute distress
HEENT:  normal pupils, he denies any neck pain, and no neck tenderness, normal oropharynx
HEART: RRR, no murmurs, rubs or gallops
Lungs:  Equal Breath sounds, no abnormalities
Abd:  Soft, schaphoid, no AAA
Ext:  No edema
Neuro, Alert and oriented, normal cranial nerves. Motor grip strength:  patient able to slightly wiggle fingers, unable to grasp (2/5).  Cannot move shoulders, elbows, or wrist (0/5).  Legs:  able to lift heels barely off cot, but then, they quickly fall back to the cot.  (3/5).  Sensation decreased below C-6.  Rectal tone present but weak, and sacral sensation is preserved.  Patient is areflexic.
Rectal:  Guiac negative.

1. What is the name for this neurologic entity and how is it related to syncope?

With the paresis of arms > legs after a fall, it is classic for central cord syndrome ( http://www.emedicine.com/pmr/topic22.htm for quick review).  It is related to the syncope only because with the syncope, came the fall, and with the fall, the patient likely suffered a hyperextension injury to the neck. Elderly are more likely to have spondylosis (“http://www.spineuniverse.com/displayarticle.php/article1440.html” for review) which narrows the spinal canal and makes the cord more likely to suffer compression during hyperextension. (1)

2. How do you grade muscle strength?

The usual grading system is 0-5, with 0/5=no contraction, 1/5 muscle flicker, but no movement, 2/5=some movement, but not against gravity, 3/5=movement possible against gravity, but not against resistance, 4/5 movement possible against some resistance, but not normal resistance, and 5/5=normal strength.  See : “http://www.neuroexam.com/content.php?p=29” for a great neuro exam review). 

3. What are the 5 criteria for NEXUS and how is the Canadian c-spine rule different?  Which is better?

This is an interesting question.  I raise this because the resident took the C-Spine collar off because the patient had no neck pain, and was not intoxicated, had a normal mental status, and had no distracting injuries.  What he failed to do was the neuro exam (I certainly understand he was getting quickly called to resuscitation for the trauma code that was coming in, however a quick neuro exam still should have been done before collar removal.)   NEXUS (stands for National Emergency X-Radiography Utilization Study) describes low risk criteria, that when all are present, a C-spine X-Ray is not necessary. 

NEXUS Low-Risk Criteria

a. Absence of posterior midline cervical-spine tenderness.
b. No evidence of intoxication.
c. A normal level of alertness and consciousness.
d. Absence of focal neurological deficit.
e. Absence of any distracting injuries. 

In this case the C-spine was not fractured, and there were no ligamentous injuries (which is likely why there was no pain or tenderness of the C-spine on palpation). But, as the rule describes, any focal neurologic deficit warrants an x-ray to rule out fracture, and the collar should stay on until a fracture is ruled out.  One review found up to 28% of patients suffering spinal cord injuries in the setting of spondylosis did not have any bony abnormalities (1), and another reference found this was up to 47% (2).

The Canadian Cervical Spine rule includes age, mechanism of injury, and paresthesias in extremities, then goes on to assess range of motion (assuming no contraindication).  A quick review of both can be found at: “http://www.aapsga.org/ajcm/2006/fall/pdf/ajcm-fall2006-article03.pdf“.

This review found that the Canadian C-spine rule (CCR) was more sensitive and specific than NEXUS, but that physicians were less comfortable and less accurate when applying the CCR approach compared to NEXUS.  (3)  Another study comparing both also concluded the CCR was more sensitive and specific.

Outcome:  The plain x-rays were negative, the patient had a stat MRI which did not reveal any hematoma, but did have changes in cord signal and spondylosis with canal narrowing. The cause of the syncope was ultimately determined not to be cardiac related.  The patient’s wife thought that her husband likely hit his head on the refrigerator during the fall. The patient was admitted, and ultimately succumbed to his advanced colon cancer within 2 weeks.  He did regain some of his strength, but was unable to use his arms for activities of daily living at the time of discharge to hospice.

Final diagnosis:  Central cord syndrome from a fall and spondylosis.

1. Regenbogen VS, RogersLF< Atlas SW, Kim KS. Cervical spinal cord injuries in pateitns with cervical spondylosis.  AJR Am J Roentgenol 1986 Feb;146(2):277-84.  Abstract accessed at:  “http://www.ncbi.nlm.nih.gov/pubmed/3484576?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=3&log$=relatedarticles&logdbfrom=pubmed“ 

2. Koyanagi I, Iwasaki Y, Hida K, Akino M, Imamura H, Abe H.  Acute cervical cord injury without fracture or dislocation of the spinal column. J Neurosurg 2000 Jul;93(1Supl):15-20.  Abstract accessed at:  “http://www.ncbi.nlm.nih.gov/pubmed/10879753?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=1&log$=relatedarticles&logdbfrom=pubmed“ 

3. Eyre A, Overview and Comparison of NEXUS and Canadian C-Spine Rules. Am J Clinical Medicine.  2002 Fall, 3(4):12-15.  Entire article accessed at:  “http://www.aapsga.org/ajcm/2006/fall/pdf/ajcm-fall2006-article03.pdf”

4. Stiell IG, Clement CM, McKinght RD, et al.  The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma.  N Engl J Med 2003 Dec 25;349(26):2510-8.  Abstract accessed at:  “http://www.ncbi.nlm.nih.gov/pubmed/14695411?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=3&log$=relatedarticles&logdbfrom=pubmed“