INTEGRATED LEARNING ACTIVITY

ROAD TRAFFIC ACCIDENT

By Ihab Zidan : Neurosurgery Gihan Younis : Physical Medicine Maysa Amer : Medical Education
With contributions of : Anatomy , Histology, Physiology , Pathology Departments Staff

Adel, a young 20-year old fellow was driving his brand new car on the desert road with a speed that exceeded 120 Km/hr, chatting with his friend Sherif, who was sitting in the front seat beside him. All of a sudden, a truck came in the way which forced Adel to turn the car steeply to the right trying to avoid it. However, he couldnt control the steering wheel and his car turned upside down 2 times before it stopped by the edge of the road.

Both friends- not fastening their seatbelts- hit the front glass forcefully and were ejected from the car.

When the rescuers arrived they found Sherif screaming from agonizing neck pain and was unable to move his right upper and lower limbs.
Meanwhile, Adel was very anxious for being unable to move his four limbs. He also had severe neck pain. The examining doctor suspected injury of the vertebral spine for both.

Q1: What might be the injured part of vertebral spine for both of them? Q2: Can you describe the operating forces in this type of injury? Q3: What could be the value of fastening the seat belt?

How did the rescuers transported each of them?

Q4: Why did the rescuers used this method and fixed them in this position

On arrival to the hospital :

Sherifs blood pressure was 60/40mmHg, pulse was 130 beat per minute Adels blood pressure was 75/50 mmHg, pulse 124 beat per min. They were started on pain killers, Intra venous fluids ,corticosteroids.

Q5:What is your explanation for hypotension ( low BP) ?

Q6: Explain how different groups of pain killers act

Both of them were breathing spontaneously with normal breathing pattern.

Q7: What is the importance of checking the breathing and ensuring that the pattern is normal?

Q8: Explain why both patients were breathing normally?

The doctor who examined Sherif found the following: He was not feeling well the pricks of pin over his lower limb, trunk, and medial aspect of upper limb and hand (including the middle finger) at the left side. He was not feeling the touch of the cotton piece moved by the doctor on the skin of the right side. He was also unable to report on the movement or position of his toes with diminished vibration sense on the right side. He was unable to move his right lower limb at all. The doctor found that the tone was decreased and he could not elicit deep tendon jerks in this limb. In the right upper limb, he was only able to flex the elbow move the shoulder, and the hand grip was weak. The triceps reflex was diminished with intact biceps and brachioradialis reflexes. Muscle power at left side of the body was normal.

Absence of cotton piece all over this side Moves shoulder

flex elbow
Lost triceps reflex

Findings on Neurologic Examination Sherif sensation for

intact biceps and brachioradialis reflexes. Cannot move all lower limb Decreased tone , absent tendon jerks

Diminished pin prick sensation

Normal muscle power

&

Cannot report movement position of Toes.

This clinical picture is called the Brown Squard syndrome and is due to hemisection of the spinal cord.

Q9: Where do you suspect the probable spinal level of injury would be?

Q10- What are the structures present at the probable site of injury?

1 2

7
8 3

6
10

Q11- Label the tracts in the figure?

Q12: Mention the anatomical pathways of each tract.

Q13: Deduce the functions affected

Q14: Describe the pathological changes that happen after neural injury.

The doctor ordered some imaging studies:

Q15: State the imaging studies you think will be of help to diagnose the site and degree of injury.

The first imaging study done is this one

Q16 : What is this imaging study Q17: What do you see in it ?

This was followed by 2 other imaging studies

Fig 1

Fig 2

Q18: What is the type of radiological imaging in figures 1 & 2 & what would be the added value of their use ? Q19: What is the lesion seen ?

Neurologic findings for Adel

No movement in all four limbs

slight movement of the shoulder.

loss of superficial sensation of

all dermatomes of the four limbs up to shoulders absence of the deep reflexes and deep sensation of the 4 limbs.

Meanwhile, The doctor who examined Adel found that :

No Movement except slight at the shoulder

loss of superficial sensation

absence of the deep reflexes and deep sensation

The doctor ordered some imaging studies for Adel:

Q20: What is this type of radiological investigation? Q21 :What do you see in the figures?

What is this type of radiological investigation? Q23: What are the arrows pointing to? Q22:

Q24: What is this type of investigation? Q25: Interpret the findings

Diagnosis for Both

Stabilization

Surgery

Adel had Decompression and fixation using plate and screws for C4,5

Sherif had anterior cervical discectomy (removal of the intervertebral disc between C6/ 7), with insertion of iliac bone graft, and anterior cervical fixation for C6/7 using plate and screws.

They remained for one week in the hospital. Progress : Sherif started to move his right lower limb; the tone in the limb began to increase exaggeration of tendon jerks positive Babinski sign. The power of the hand was partially resumed. Adel showed the same picture in the four limbs but more in the lower limbs.

Progress
Sherif started to move his right lower

limb; the tone in the limb began to increase exaggeration of tendon jerks positive Babinski sign. The power of the hand was partially resumed.

Progress Adel showed the same picture in the four limbs but more in the lower limbs.

Q26: What is the interpretation of the above mentioned findings? Explain in view of the anatomical and physiological alterations.

Patients were discharged from the hospital and referred to the physical medicine department. They received rehabilitation therapy in the form of range of motion exercises, and other measures

Q24: What do you think is the value of these exercises?

After 6 months of intensive physical therapy, both showed marked improvement in their neurological functions.