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Q. Please go through the patient's history, and tell me if she will ever recover fully?

Answered by
Dr. Rajyaguru
and medically reviewed by iCliniq medical review team.
This is a premium question & answer published on Sep 07, 2017

Hello doctor,

My relative's daughter, who is 16 years old, met with a car accident. She is admitted to the hospital. Please give your suggestions on her case. She is currently undergoing surgery. The below extract was of her case study. The doctors say that the body below her neck is not moving. Can she be shifted to another hospital? We want to get her to some specialist hospital, which is almost 1000 km far. What is her prognosis?

Her case study it says the patient sustained cervical injury followed by instability to move all four limbs. On investigation, the patient was found to have fracture dislocation at C4-5 and right humerus. Bilateral pupils are equal and reacting. She has got grade 0 quadriplegia, and her breathing was paradoxical and mainly abdominal. Hence, the patient was intubated and connected to the ventilatory support. She has persistent hypotension, so Inotropes were started. The patient was planned for open reduction with fixation of fracture dislocation at C4-5. Given the patient's persistent low BP and feeble pulse, the surgical procedure was canceled. Now, the patient is on ventilatory support and Inotropes. Motor power grade is 0 in all four limbs. Solu-Medrol was started on arrival at the hospital. She is on the following medications, injection Oframax, injection Pan, injection Emeset, injection Dynapar AQ, and Solu-Medrol infusion. She is receiving chest and limbs physiotherapy.

#

Hi,

Welcome to icliniq.com.

I understand the case scenario.

  • The reason behind her low blood pressure and inability to move all four limbs is actually the cervical spinal cord injury.
  • Surgery is risky because of low blood pressure, but it is possible to operate if the anesthetic team is able to manage the blood pressure properly during the surgery.
  • I will not recommend travel at this point because she can become critical on the way, then the situation will be difficult to handle. If open reduction and fixation can be done at the same center, there is no need to take her anywhere. Because even in the higher center, the form of treatment will be same.

For more information consult a neuro surgeon online --> https://www.icliniq.com/ask-a-doctor-online/neuro-surgeon

Thank you doctor,

Are there any possible risks in the future? In fact, I just came to know that the surgery is on and the doctor is expecting the surgery to be over in another hour. How long will it take for her to recover completely? Are there any other complications that you might be anticipating, looking at the case report?

#

Hi,

Welcome back to icliniq.com.

  • The timeline and possible extent of recovery can be discussed properly only based on her MRI cervical spine reports. If the cord is grossly visible transected on the MRI, then the chances of recovery are almost nil.
  • If it is not that bad, and the cord is without hemorrhage, then we may expect some recovery down the line, say around six months. Other complications possible are mostly long-term, like persistent low BP, chest infection, urinary infection, pressure sores on the skin, etc.

For more information consult a neuro surgeon online --> https://www.icliniq.com/ask-a-doctor-online/neuro-surgeon

Hello doctor,

Thank you for replying. I just came back from the hospital where she is admitted. I am going to provide you the summary of events which took place after the above sequence. I am also attaching the images of her MRI, CT, and x-ray. After the surgery, the doctor said that she has C5 fracture dislocation with spinal cord injury resulting in weakness of all four limbs and respiratory paralysis. The C5 fracture had been fixed. Postsurgery sensation has increased. Spinal cord injury will recover with time, but only time will tell how much. 

She was kept on a ventilator support for the first four days, then this support was removed. Her vision, hearing, memory, and speech were quite good. The only issue is frequent congestion in left lung resulting in frequent left lung collapse with saturation level dipping to 75 to 80. The doctors used to perform suction to remove congestion every time and the saturation level used to improve. The day before yesterday, there was a lot of congestion, resulting the saturation to drop to 60. So, the doctors again put her under ventilator support to observe for next three days. They performed bronchoscopy and CT. The results revealed some infection in the left lung. They started some medicine to rectify that infection. Yesterday her chest x-ray throughout the day was absolutely fine and the doctors are saying that ventilator support can be removed if the same situation continues for the next two days.

One significant event occurred yesterday, she had a severe seizure attack and for 15 to 20 minutes, and her situation became critical. At that point, her saturation level dipped to 30 and the heart rate reached to 205. With all the efforts, the doctors were able to restore her to normal. At present, her arm has sensation. However, the part below the waist does not have any feeling. Will she survive this? How critical is she?

#

Hello,

Welcome back to icliniq.com.

I have read the details and seen all the images (attachment removed to protect patient identity).

  • The seizure could have been because of lowered oxygen levels due to the lung problem. The doctors have restored the parameters, but that event could have potentially, though minimally, damaged her brain also. I would like to know the GCS (Glasgow coma scale) score after the event.
  • If the brain damage was not much, I think it will not be much significant because the doctors restored parameters quickly, it will not affect the chances of survival much. But, as we discussed last time, the threats to survival are persistent low blood pressure, lung infection, and urinary infection.
  • If she comes out of this infection completely, she will survive well, provided limb and chest physiotherapy, mobilization, and regularly bed turning is followed.
  • I have seen the MRI images, the spinal cord is not fully transacted, but it is contused meaning there are specs of blood within the damaged and expanded cord. So there is a chance of recovery, the sensations improved that itself says that cord is recovering from trauma.
  • She will not be completely normal, but she may be able to walk with a walker or crutches. But here we should not forget that we have to analyze the status of her brain as well, after the event in the ICU.

For further queries consult a neuro surgeon online --> https://www.icliniq.com/ask-a-doctor-online/neuro-surgeon

Hello doctor,

Thank you for your detailed reply. So, she will not be able to come back to her normal life even after her recovery. I do not have the access to her GCS score after the seizure. However, after the seizure, she was communicating without a voice. There are no signs of brain malfunctioning. What are the chances of recurrence of this type of seizure? Can all these incidents be directly linked to her spinal injury? Are you able to see the percentage damage in the spinal cord in the MRI report? And apart from the limbs, what other damages can happen if she survives? What are the possible side effects of continued ventilator support? Are these kind of infections during a ventilator support common? If yes, are these life-threatening?

After the seizure event yesterday, she was quite restless due to pain in the mouth due to the intersection of ventilator pipe. The doctors have started giving medicines for sleep. They are saying that the more she rests the more she will be better. Is this continued dose for sleep advisable, keeping her current status in view? What are the chances of survival? Will her limbs get better?

#

Hi,

Welcome back to icliniq.com.

  • No signs of brain malfunction are good. From the description, I can understand that the brain is not significantly damaged. The recurrence of such event is very unlikely.
  • Yes, these symptoms are linked to the spinal cord injury. The injury makes the muscles weak, which leads to breathing difficulties and lung complication. And poor oxygenation leads to fits.
  • I have to sit front of an MRI console and look for the percentage damage of the spinal cord. Apart from the limbs, bowel and bladder control will be impaired. Long time ventilation may increase the chance of lung infection. And yes, if the infection is by a resistant bug, they can be life-threatening.
  • Continuing the sleep for 48 hours is good. It is hard to predict if she will survive this.

For more information consult a neuro surgeon online --> https://www.icliniq.com/ask-a-doctor-online/neuro-surgeon

Hello doctor,

Thank you for replying. The patient is still in the hospital. I am attaching the case summary with a brief summary of her current status. Besides the facts mentioned in the case summary, I am stating some more key facts. She is recovering. She is without any artificial support, and her vital are normal. One issue is consistently bothering us. She has congestion regularly in her left lung. This is resulting in poor air circulation by the left lung, and the same is also evident in the chest x-ray. However, with half an hour session of physiotherapy, the lung situation improves. This is continuously going on, and the doctor is of the opinion that gradually this situation will improve and her lung situation will also improve.

Now as per the hospital, they have almost completed the treatment, and they are quite satisfied with her improvement. Now, the only thing required is regular physiotherapy. I am also attaching some images of her current spine x-ray. Kindly have a look at them and suggest the best possible plan for her complete recovery.

#

Hello,

Welcome back to icliniq.com.

I saw the x-rays (attachment removed to protect patient identity), and they are fine.

  • The lung complication is the most common problem that we face. Chest physiotherapy is the key to avoid that. The best thing would be, the family members learn chest physiotherapy and do it at home by themselves, at least thrice a day.
  • Turn her every two hours. She should be sitting in a chair for few hours a day while she is in the hospital because this can reduce her BP, and the monitoring of the same is possible in the hospital only.
  • The family should learn about the type of bed to be used at home, air or water bed usually, but air bed is preferable. They should learn to take care of her catheter. Once when they learn all this, she can be taken home. No issues.
  • All the care, like chest and limb physiotherapy, mobilization out of bed, turning in the bed, regular catheter care, etc., have to be continued at home.

For more information consult a neuro surgeon online --> https://www.icliniq.com/ask-a-doctor-online/neuro-surgeon


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