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20 year male was sitting over back seat of car, suddenly car ctossed a breaker with high speed, boy head impect to roof of car, LOss of conscious for 30 min, No post amnesia, after some time he told pain over nape of neck, andantetior chest wall. DTR Brisk in all 4 limb, tone slightely increased all over limb, power 4 /5 , Planter flexor. NCCT hea normal, ECG normal, what will be likellydiagnosis and treatent
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Case History Write-Up
Patient Details
- Age/Sex: 20-year-old male
- Date & Time of Admission: [to be filled]
- Mode of Admission: Emergency
Chief Complaints
- Loss of consciousness (LOC) — 30 minutes
- Pain over the nape of neck
- Pain over the anterior chest wall
History of Present Illness
A 20-year-old male was a rear-seat passenger in a car that crossed a speed breaker (road hump) at high speed. His head struck the roof of the car, causing a vertical compression + hyperflexion/hyperextension injury to the cervical spine. He lost consciousness immediately for approximately 30 minutes.
On regaining consciousness, there was no post-traumatic amnesia (PTA). He complained of pain over the nape of the neck (suggesting cervical spine involvement) and anterior chest wall (suggesting possible sternal/rib contusion or anterior cord stretching).
Past History
- No history of similar episodes
- No prior surgery, hypertension, diabetes, or neurological illness
Personal History / Social History
- [to be filled]
Examination
General Examination:
- Conscious, oriented
- No external head laceration documented
Systemic Examination:
| Parameter | Finding |
|---|---|
| Tone | Slightly increased in all 4 limbs |
| Power | 4/5 in all 4 limbs |
| Deep Tendon Reflexes (DTR) | Brisk in all 4 limbs |
| Plantar response | Flexor (normal) |
| Sensory | [not mentioned — examine and document] |
| Bladder/Bowel | [not mentioned — examine and document] |
Investigations
| Investigation | Finding |
|---|---|
| NCCT Head | Normal |
| ECG | Normal |
| X-ray Cervical Spine | [Not mentioned — must be done] |
| MRI Cervical Spine | [URGENT — must be done] |
Likely Diagnosis
Primary Diagnosis:
Cervical Spinal Cord Contusion/Injury — likely at C3–C5 level Possible SCIWORA (Spinal Cord Injury Without Radiological Abnormality)
Reasoning:
| Clue | Significance |
|---|---|
| Head struck car roof at high speed | Axial loading + hyperflexion/hyperextension of cervical spine |
| LOC for 30 min | Concussive injury to brainstem or upper cervical cord |
| No post-traumatic amnesia | Against primary diffuse axonal brain injury |
| NCCT Head normal | Rules out intracranial hemorrhage |
| Pain at nape of neck | Points to cervical spine involvement |
| Brisk DTR all 4 limbs | Upper Motor Neuron (UMN) sign → cord injury above C5 |
| Increased tone all 4 limbs | UMN lesion — spastic quadriparesis developing |
| Power 4/5 all 4 limbs | Mild motor deficit — incomplete cord injury |
| Plantar flexor | Early/mild injury — extensor response may appear later |
| Anterior chest pain | Sternal contusion from impact, or anterior cord stretching |
| Normal NCCT | Cord injury is soft-tissue, not bony — MRI is essential |
The clinical picture is classic for incomplete cervical cord injury — likely a central cord syndrome or cord contusion from axial loading. The mechanism (high-speed bump → head hits roof) causes vertical compression and rapid flexion–extension of the cervical spine, which can injure the cord even without fracture — this is SCIWORA, now better termed cord injury without CT/X-ray abnormality, requiring MRI confirmation.
(Grainger & Allison's Diagnostic Radiology: "Any patient with neurological abnormality following acute trauma warrants an MRI, which will demonstrate the soft-tissue injuries.")
Differential Diagnoses
| Diagnosis | For | Against |
|---|---|---|
| Central Cord Syndrome | UMN signs, incomplete deficit, mechanism | Arms usually weaker than legs |
| Cervical cord concussion | Transient, mechanism fits | UMN signs suggest structural injury |
| Diffuse Axonal Injury (DAI) | LOC, high-speed trauma | Normal NCCT, UMN signs point to cord |
| Anterior Cord Syndrome | Motor deficit preserved | Posterior columns usually intact here |
Treatment Plan
Immediate / Emergency:
- Cervical spine immobilization — hard cervical collar / rigid collar; do not remove until injury excluded
- ABC stabilization — airway, breathing, circulation
- Urgent MRI cervical spine — to identify cord edema, contusion, ligamentous injury, disc herniation
- X-ray cervical spine — AP, lateral, and open-mouth odontoid views
- Admit to neurosurgery/neuro-ICU
- Foley catheter — monitor urine output; assess bladder function
- Maintain mean arterial pressure (MAP) ≥ 85 mmHg to optimize spinal cord perfusion
Medical Management:
| Drug | Rationale |
|---|---|
| Methylprednisolone | High-dose IV (controversial; NASCIS III protocol — 30 mg/kg bolus then 5.4 mg/kg/hr for 23–47 hrs) — only if within 8 hours of injury; discuss with neurosurgeon |
| Analgesics (IV paracetamol / opioids) | Pain control for neck and chest |
| Proton pump inhibitor | Stress ulcer prophylaxis |
| DVT prophylaxis | Low-molecular-weight heparin once cord injury is stabilized |
| Chest physiotherapy | For anterior chest wall pain — prevent atelectasis |
Note on methylprednisolone: Its use in acute SCI remains controversial. Most current guidelines do not recommend it as standard of care; the decision must be individualized.
Surgical Management:
- If MRI shows cord compression from disc herniation, fracture, or instability → surgical decompression and stabilization (anterior cervical discectomy and fusion, or posterior fixation)
Rehabilitation:
- Early physiotherapy once stable
- Occupational therapy
- Bladder and bowel training program
- Psychological support
Summary Table
| Mechanism | Axial loading + hyperflexion/hyperextension, head-to-roof impact |
| Diagnosis | Incomplete cervical cord injury (contusion) / SCIWORA |
| Level | Likely C3–C5 (UMN signs in all 4 limbs) |
| Key investigation | MRI cervical spine — urgent |
| UMN signs | Brisk DTR + increased tone + mild quadriparesis |
| Treatment | Immobilization → MRI → neuroprotection → surgical decision |
Key teaching point: Normal NCCT head does NOT exclude cervical cord injury. The cord is soft tissue and requires MRI. Brisk reflexes + increased tone + 4-limb weakness after a flexion–extension neck injury = cord injury until proven otherwise.
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