April 2017

GSW to the neck

History 
••23yr male presents to ER s/p GSW to the neck
•Mandibular fracture, hyoid body injury
•No PMH
•No PSH
 
Examination
••BP 90/60 HR 65 RR 13 T 37
•Alert
•GCS 15
•C5 ASIA A
•Entry wound to posterior neck
•Exit wound left mandible
•Admission CT cervical spine obtained
•Flex/Ext films – gross instability (C5-6)
 
Further information
•Hospital Day #8
•Fevers and leukocytosis
•Neck CT – retropharyngeal abscess requiring neck exploration and esophageal repair.

•Hospital Day #15
•Unable to feel his arms
•MRI (w/ gado) obtained

 

Admission CT

Hospital Day 15

 
1. How would you initially manage the fracture?
2. What is your goal MAP?
3. What is your diagnosis based on the MRI obtained after neurologic worsening on hospital day #15?
4. How would you manage the patient after the MRI is obtained?
5. Which of the following describes you?
6. I practice in one of the following locations.
7. Comments
  • would also stabilize posteriorly
  • This type of cervical trauma with fracture and compression of the spinal cord should be treated with early decompression to avoid complications like an enfection
  • Excellent case
  • Posterior fixation and decompression once stablilized
  • Tough case. Drainage may be needed but high morbidity

Case Explanation: Explanation of Answers

•This patient requires ICU stabilization and management of neurogenic shock. Current clinical practice guidelines recommend the maintenance of mean arterial blood pressure (MAP) between 85 and 90 mm Hg for the first 5–7 days  following acute cervical SCI, and the general avoidance of systemic hypotension, defined as a systolic blood pressure (SBP) of <90 mm Hg.  Intramedullary abscess of the spinal cord (IASC) is a rare pathology associated with a high morbidity and mortality.  Fewer than 200 cases have been reported in the literature.  The most common organisms causing IASC are Staphylococcus and Streptococcus species.  Most commonly the etiology of IASC is seeding from other sources of infection such as osteomyelitis, endocarditis, tuberculosis, periodontitis, or meningitis; presentation in immunocompromised hosts or intravenous drug users; direct inoculation from interventions; or in patients with anatomic anomalies such as dermal sinus tracts, dural AV fistulas, spinal dysraphism, and patients with a patent foramen ovale. IASC can also be associated with dermoid and epidermoid tumors and are thought to occur as a result of the local ischemia from peritumoral compression of vasculature.  Additionally, syrinx formation could be especially linked to the development of abscesses as the septations provide an environment suited to bacterial overgrowth.
•In the few cases in which IASC occurs after penetrating trauma, it is key to differentiate between traumatic changes of the cord and abscess formation as early diagnosis leading to timely treatment with antibiotics is necessary to prevent irreversible damage to the spinal cord and reduce mortality. 
•Because IASC is so rare, a high level of clinical suspicion is required in order to obtain appropriate imaging and differentiate between other pathologies.  Intramedullary abscesses of the spinal cord (IASC) initially present as poorly defined intramedullary ring-enhancing lesions with associated expansion of the spinal cord. Spinal intramedullary ring-enhancing lesions are nonspecific and observed in other inflammatory and neoplastic pathologies including primary or secondary spinal cord tumors, traumatic injuries such as hematoma or contusions, infarction, or demyelinating lesion. MR characteristics of IASC include hyperintensity of the spinal cord on T2-weighted images, circular enhancement on post contrasted T1-weighted images, and a hypointense abscess capsule on T2-weighted spin-echo MR images. The purulent fluid contained in the abscess appears hyperintense on DWI and in contrast has low ADC values, representing restricted diffusion.
•The recommended treatment for IASC is prompt decompressive laminectomy, myelotomy and drainage of the abscess in combination with timely initiation of the appropriate intravenous antibiotic therapy.  By contrast, other studies have suggested that patients treated with antibiotics alone have similar outcomes.  The duration of antibiotics is generally thought to be 4-6 weeks, although no clear consensus has been established. 

References:

•Dorflinger-Hejlek, E., et al., Diffusion-Weighted MR Imaging of Intramedullary Spinal Cord Abscess. Am J Neuroradiol, 2010. 31: p. 1651-1652.
•Kurita, N., et al., Intramedullary Spinal Cord Abscess Treated with Antibiotic Therapy. Neurol Med Chir, 2009. 49: p. 262-268.
•Sinha, P., et al., Intramedullary abscess of the upper cervical cord. Unusual presentation and dilemmas of management: Case report. Clinical Neurology and Neurosurgery, 2013. 115: 1845-1850.
•Do-Dai, D., et al., Magnetic Resonance Imaging of Intramedullary Spinal Cord Lesions: A Pictorial Review. Curr Probl Diagn Radiol, 2010.  Jul/Aug: p. 160-185.
•Nadkarni, T., et al., An intradural-extramedullary gas-forming spinal abscess in a patient with diabetes mellitus. Journal of Clinical Neuroscience, 2010. 17: 263-265.
•Mohindra, S., et al., Intramedullary abscess in association with tumor at the conus medullaris. J Neurosurg Spine, 2007. 6: 350-353.
•Wright, R. Lewis, Intramedullary Spinal Cord Abscess. Report of a case secondary to stab wound with good recovery after operation. J Neurosurg, 1965. 23: 208-210. 
•Dutton JEM, Alexander GI. Intramedullary spinal abscess. J Neurol Neurosurg Psychiat, 1954. 17: 303–317.
•HawrylukG., WhetstoneW., SaigalR., FergusonA., TalbottJ., BresnahanJ., DhallS., PanJ., BeattieM., and ManleyG. (2015). Mean arterial blood pressure correlates with neurological recovery after human spinal cord injury: analysis of high frequency physiologic data. J. Neurotrauma 32, 1958–1967  
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