| SCI HOME | COLUMN | TECHNIQUE PEEK | STUDIES | QUIZ |
|
|
|
MTO Case Study #2
This one will give the bare bones only, it is up to you to ask the right questions and come to an appropriate management plan. In fact depending on how this goes, we may have two or three different diagnoses. I don't know myself where this is going to go.
A forty two year old man involved in a rear end collision with his car as the front vehicle. He attended at the request of his physician three days after the accident. The impact speed was estimated to be in excess of 35 mph or 70kph. The patient suffered no direct trauma to the head, neck or chest. He did not remember losing conciousness. The patient expereinced mild pain for the first hour or so then more severe pain on waking next morning. The pain was felt in the suboccipital and occipital regions with right temporal headaches. He complained of some dizziness the morning after the accident and this lasted for three or four days and then disappeared. The suboccipital and occipital pain had improved a little but the pain had spread into the neck and right upper trapezius. The temporal headache had changed and was now felt more diffusely. The patient had no previous history of headaches of any relevance and no cervical pain. Observation Medium build, healthy with no excess weight. No postural deformities or deficits, no bruising or muscle deficits, no atrophy in the trunk or legs. No congenital abnormalities. His occupation was a lawyer. Decide what questions you want to ask and what tests you want to do. Email me with them and I will send back the patient's responses. Given the vague nature of the opening of this case study, I will let it go on for as long as I am getting questions. Case Study #2 Update #1 The second part of the case study on the headache patient includes answers to questions asked by readers. The cranial nerves tested out negative, there were no long tract signs, nor evidence of fracture. Vertebrobasilar tests were not done at this time due to the limited ROM precluding them. There were no symptoms of spinal cord or spinal nerve compression. Cervical range of motion was restricted in the following pattern.
Each movement produced pain in the posterior neck. In addition, extension and both side flexions caused suboccipital and trapezius pain. None of the movements caused or altered the temporal headache. Compression reproduced the suboccipital and posterior neck pain. Neurological examination of the upper limbs was negative in that there was no weakness, reflex changes or sensory deficit. Tilting the patient anteriorly and posteriorly while stabilizing the neck caused nausea and giddiness. Case Study #2 Update 2 May 1st 1997 From the pattern of the restriction of motion, the patient is clearly suffering from a posttraumatic arthritis. Cranial nerve and long tract testing was negative except for the dizziness produced when the patient was tilted. As the neck was stabilized, the dizziness was unlikely to be cervical joint or vertebral artery induced. Other possibilities are labyrinthine concussion, cerebral concussion or 8th nucleus/nerve damage. Given that there were no other cranial nerve signs, the latter seems improbable. The patient denies being knocked unconscious but does not remember the impact or some minutes after the accident so concussion has occurred and is a serious contender for cause of the dizziness. My treatment at this stage would consist of rest using a hard collar (article on Collars and Whiplash in MTO column), anti-inflammatory modalities, gentle painfree exercises and advice on activity level and work. Preferably I would like the patient to come off work for three or four weeks until the inflammation has resolved. Two weeks later, the range of motion of the neck has increased and has become non-capsular:
All movements are still painful but less so with minimal pain on flexion and mild to moderate pain on right rotation and right side flexion. Extension, left side flexion and left rotation are still moderately to strongly painful with spasm being felt on left rotation and extension. The painful movements reproduced posterior neck pain except extension and right rotation which also reproduced sub-occipital and trapezius. The temporal headaches were a little less intense but had spread throughout the head. What tests would you do at this point and what are your thoughts? Is this patient progressing normally and optimally or not? Where do you go from here?
The cervical problem seems to be progressing reasonably except for the headache. While its intensity has lessened, it is more diffuse. The concern at his point is that the headaches are not cervicogenic. Mainly neck headaches are felt in the suboccipital, occipital, temporal, occiptiofrontal, retro-orbital and/or frontal regions. Isolated retro-orbital pains from musculoskeletal causes are rare, as are diffuse headaches. A more serious cause of diffuse headaches is slow intracranial bleeds. A more common cause however, is post-concussion (posttraumatic head injury syndrome). Post-concussion headaches obviously follow concussion but then so do (usually) intracranial bleeds. However, with post-concussion syndrome, the condition is usually fairly stable and the patient commonly exhibits other symptoms such as irritability, anxiety, sleep disturbances, mood swings etc. Of the two the intracranial bleed is obviously the more serious. This therefore has to be eliminated as a possible cause. Questions to ask the patient would include those concerning intellectual functions and level of alertness these would include increasing drowsiness, difficulty in concentrating during conversations or reading, poor comprehension of reading materials or conversations. If the clinical picture is one of progressive headaches, especially diffuse and deep, associated with increasing drowsiness and/or intellectual impairment it is a good idea to refer the patient to the physician indicating your concern that there may be intracranial bleeding present. Continuation of treatment would probably continue to improve the neck pain and increase its range of motion but if the patient is bleeding then this improvement may be accompanied by the patient's sudden demise. As the old joke goes, the surgery was a success but the patient died. Slow intracranial bleeds have been documented in patients involved in rear end collisions at speeds as low as thirty miles an hour (50kph) and can be mistaken for cervical or post-concussion headaches. Regardless of the cause of the headaches, manual and other therapy have failed to improve the headache and the patient merits further medical investigation rather than continuance of treatment. The question of posttraumatic headaches will be discussed in an upcoming MTO column.
|
|
