The only reason we get away with giving such large doses of epinephrine to these patients is that they are already dead.

- Rogue Medic

Extreme Spinal Injury With Preservation of Neurologic Function

ResearchBlogging.org
 

How bad can spinal injuries be without causing paralysis?
 

A 44-year-old man presented to the emergency department with severe pain after an accident at the gym. He reported he had been doing squats while balancing a 200-kg bar across his trapezius. His knee gave way and he fell to the floor, with the weight landing on his lower back. The patient managed to crawl out from under the weight but did not attempt to walk.[1]

 

This is a very bad spinal injury, but the outcome is much better than the X-rays would suggest.
 

 

The spine is supposed to be continuous.

The spine should not zig, zig, or take any other detours.

The red line over the spine should be drawn as a roughly straight line, with slight curvature, which can be extreme with kyphosis, scoliosis, or other diseases affecting the spine.
 

 

I wonder about the method of transport and any possible attempts at immobilization for this patient.

He is in pain with movement, so anything that is painful should be avoided – including immobilization on a backboard, if that causes pain.

I would expect it to cause pain. Pain is an indication of possible injury.

Why is a backboard so rarely the patient’s choice for position of comfort?

Medic – Let’s get you comfortable.

Patient – I would love to be strapped to a rigid piece of plastic, or wood.

Maybe I just need to start hanging out with some people who really appreciate S&M/ – and I don’t mean the doctors who refuse to allow aggressive pain management.
 

On arrival at the emergency department he had full power in both lower limbs and normal sensation to light touch in all dermatomes of the lower limbs.[1]

 

Postoperatively, he had preservation of normal neurologic function, with the exception of mild paresthesia on both sides of his trunk in a T12 dermatomal distribution.[1]

 

The injury could easily have been prevented by using a squat tower to keep the weight from falling all of the way to the flood. Assuming that 440 pounds (200 kg) is significantly more than the weight of the patient, this would be prudent. Even using a spotter with this amount of weight is probably only for appearances.

Assume that you are trying to spot this guy. His knee gives out and now you are trying to control the combined weight of 600 to 700 pounds of him and the weight on his shoulders.

Will you be able to control that?

I wouldn’t be able to – and I am not small.

Will things really be better if you are part of the pathetic pile of pain on the floor?
 

This is the kind of instant paralysis injury that we keep hearing about.

There was no paralysis.

No instant paralysis.

No delayed paralysis.

Scare stories should not be the basis for medical treatment.

What if we were to actually learn what we are doing, rather than to childishly base treatments on avoiding the imaginary monster in the closet?

Go check out the rest of the images from this patient at the New England Journal of Medicine.

Footnotes:

[1] Thoracolumbar Fracture with Preservation of Neurologic Function
Laura Jane Evans, M.B., B.S.
N Engl J Med 2012; 367:1939
November 15, 2012
DOI: 10.1056/NEJMicm1101495

Free Full Text from N Engl J Med

Evans, L. (2012). Thoracolumbar Fracture with Preservation of Neurologic Function New England Journal of Medicine, 367 (20), 1939-1939 DOI: 10.1056/NEJMicm1101495

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Comments

  1. I would think the patient’s preservation of neuro function may have had to do with expeditious transport to ED and rapid eval. I believe that if time were wasted to secure to a backboard the patient would have faired worse AND the subsequent pain caused by the procedure would have exacerbated the swelling and increased any secondary injury. Thanks for posting this!

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