Archive | March, 2017

Torticollis (quick review)

21 Mar

submitted by Christina Brown, M.D. 

 

Definition – “Twisted neck” (L. tortus, twisted + collum, neck).29727

Synonyms: Cervical dystonia, wry neck

Self-limited, symptoms resolve in 1 to 2 weeks

Possible Etiologies:

  • Fracture
  • Dislocation, subluxation
  • Cervical spine disease
  • Infections
  • Spondylosis
  • Tumor
  • Scar tissue–producing injuries
  • Ligamentous laxity in atlantoaxial region
  • Drug induced
  • Otolaryngologic:
    • Vestibular dysfunction, Otitis media
    • Cervical adenitis, Pharyngitis, Retropharyngeal abscess
    • Mastoiditis
  • Esophageal reflux
  • Syrinx with spinal cord tumor

 

Physical Exam

  • Intermittent painful spasms of sternocleidomastoid (SCM), trapezius, and other neck muscles
  • Head is rotated and twisted to one direction

 

Management:

Imaging

  • Plain film if cervical fracture is suspected.
  • CT or MRI of cervical spine if retropharyngeal abscess or tumor suspected

INITIAL STABILIZATION/THERAPY: Cervical spine immobilization if fracture is suspected

ED TREATMENT/PROCEDURES

  • Soft collar and rest,
  • Physical therapy,
  • Massage,
  • Local heat,
  • Analgesics

 

MEDICATION:

  • Diphenhydramine (for drug-related dystonia)
  • Valium: 2–5 mg IV, 2–10 mg PO t.i.d. (peds: 0.1–0.2 mg/kg per dose IV or PO q6h)
  • Botulinum toxin is an option for treating non-drug-induced torticollis, though this is not typically administered in the ED setting.

 

References:
1. Schaider, J. & Barkin, R. & Hayden, S. & Wolfe, R. & Barkin, A. & Shayne, P. & Rosen, P. (2011). Torticollis. Rosen’s and Barken’s 5-Minute Emergency Medicine Consult. http://www.r2library.com.proxy.its.virginia.edu/Resource/Title/1608316300/ch0020s16613
2. Harries PG. Retropharyngeal abscess and acute torticollis. J Laryngol Otol 1997; 111:1183.
3. Soundappan SV, Darwish B, Chaseling R. Traumatic spinal epidural hematoma-unusual cause of torticollis in a child. Pediatr Emerg Care 2005; 21:847.
4. Mutsaers P, Fick M, Plötz FB. Acquired torticollis as the only initially presenting symptom in a child with a brainstem glioma. Eur J Pediatr 2007; 166:1075.
5. Shanker V and Bressman S.: What’s new in dystonia? Curr Neurol Neurosci Rep. 2009; 9:278–284.

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Cauda Equina Syndrome

16 Mar

submitted by Christina Brown, M.D. 

 

Definition – Compression of lumbar and sacral nerve fibers in cauda equina region

back-pain-image-2
RISK FACTORS 

  • Neoplasm
  • IV drug use
  • Immunocompromised state.

ETIOLOGY

  • Herniated disc most common:
    • L4–L5 discs > L5–S1 > L3–L4
    • Most common in 4th and 5th decades of life
    • Mass effect from: Myeloma, lymphoma, sarcoma, meningioma, neurofibroma, hematoma
    • Spine metastases (breast, lung, prostate, thyroid, renal)
    • Epidural abscess (especially in IV drug users
  • Blunt trauma
  • Penetrating trauma

 

SIGNS and SYMPTOMS

  • Low back pain
  • Sciatica/radicular pain (unilateral or bilateral)
  • Lower extremity numbness or weakness
  • Difficulty ambulating owing to weakness or pain
  • Bladder or rectal dysfunction (Retention or incontinence)

 

Physical Exam

  • Lumbosacral tenderness
  • Lower extremity sensory or motor deficits (May be asymmetric)
  • Decreased foot dorsiflexion strength
  • Decreased quadriceps strength
  • Decreased deep tendon reflexes
  • Saddle hypalgesia or anesthesia
  • Decreased anal sphincter tone


Postvoid residual volume (PVR):

  • Estimate by bladder catheterization or using US.
  • >100 mL is considered abnormal.
  • Residual increases with age.

 

Labs – Depends on differential diagnosis. Options include CBC, urinalysis, ESR, and C reactive protein (CRP)

IMAGING – MRI of spine is definitive study. CT myelogram if MRI unavailable

ED Treatment/Procedures:

  • Immediate neurosurgical consultation in all cases
  • Initiate antibiotics for epidural abscess in consultation with neurosurgery.
  • Controversy exists regarding urgency of decompression:
    • Recommendations range from within 6 hr of onset to within 24 hr.

 

Disposition:

  • All patients with acute cauda equina syndrome must be admitted to neurosurgical service.
  • Patients have good prognosis with rapid surgical decompression.
  • Treatment should not be delayed.
  • Patients presenting late (>48 hr) also benefit from surgical decompression.

 

References:

1. Fraser S, Roberts L, and Murphy E.: Cauda equina syndrome: A literature review of its definition and clinical presentation. Arch Phys Med Rehabil. 2009; 90(11):1964–1968.
2. Hussain S A, Gullan R W, and Chitnavis B P.: Cauda equina syndrome: Outcome and implications for management. Br J Neurosurg. 2003; 17(2):164–167.
3. Shapiro S.: Medical realities of cauda equina syndrome secondary to lumbar disc herniation. Spine. 2000; 25(3):348–352.
4. Schaider, J. & Barkin, R. & Hayden, S. & Wolfe, R. & Barkin, A. & Shayne, P. & Rosen, P. (2011). Cauda Equina Syndrome. Rosen & Barkin’s 5 Minute Emergency Medicine Consult.

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