Cody's Case: Spinal Cord Injury, Neurological Assessment and Analysis

This assignment analyzes the case of Cody, a 19-year-old involved in a road traffic accident resulting in a spinal cord injury. The analysis begins with the immediate medical response, including the paramedics' actions, initial assessment, and transport to the hospital. It details the neurological examination, highlighting the absence of reflexes below a certain level, sensory loss, and vital sign changes. The assignment then addresses specific questions related to the scenario, such as the definition of movement terms (abduction and flexion), the plane of section in the provided images, and the features distinguishing cervical vertebrae. It explores the autonomic nervous system's role in vital functions, the impact of peripheral nerve damage on skin condition, and the nerves involved in respiration and pupillary light reflex. Furthermore, the assignment examines the significance of the Babinski sign, muscle fiber changes in relation to fatigue and endurance, and the muscles involved in shoulder movements. The case study provides an in-depth understanding of spinal cord injuries and their physiological implications.

A broken man!
Paramedics arrive at the scene of a road traffic accident to find 19 year-old Cody trapped
inside his smashed vehicle. Witnesses say he swerved to avoid a cat that ran out in the road
and crashed into a tree. He was not wearing a seatbelt and hit his head on the windscreen.
Cody is unable to move his limbs and complains of midline neck pain. He was awake, alert,
and oriented to time and place. There were no obvious signs of a head injury aside from a
cut forehead, and his pupils were equal and reactive to light. Cody’s blood pressure, heart
rate and respiration rate were all within normal ranges. The paramedics apply a cervical
collar, extricate him from the wreckage using a spine board, immobilize his head, cannulate
him and manage his pain with IV (intravenous) morphine. He is then taken to the nearest
major trauma hospital.
Upon examination at the hospital, Cody had very weak biceps stretch reflexes, but no triceps
or supinator reflexes, bilaterally. All other muscle stretch reflexes in the lower extremities
were absent. He had no perception of any sensory stimuli bilaterally below an imaginary line
drawn across his chest below the clavicle. He had some sensation in the outer parts of his
arms, but could not localize touch or describe texture with any consistency there. He was
able to raise and abduct his shoulders but had weak elbow flexion. His lower extremities
were flaccid, despite attempts to move them. Cody’s vital signs were taken again at the
hospital and blood pressure and heart rate were now decreased but his breathing rate was
elevated (with shallow breathing). His skin was warm and dry to the touch.
X-rays and CT scans taken upon arrival revealed a fracture dislocation of the C5/6 vertebra
which has damaged the spinal cord.
C-spine X-ray and CT scan images. The circled region in
x-ray shows a posterior fracture dislocation of the C5
vertebra. The CT scan confirms the damage to the C5
vertebra (short white arrow). Long white arrow indicates
the change in orientation of the vertebral canal.
A chest X-ray showed a decreased lung expansion upon inhalation. The neurosurgeons
immobilized his neck so that no further injury could occur. Cody was transferred to intensive
care and his condition was stabilized.
A physical examination a week later revealed normal vital signs but no change in Cody’s arm
strength or sensation. However, there was now marked muscular spasticity and exaggerated
stretch reflexes of the lower limbs. Cody had a Babinksi sign present in both feet. He also
suffered from urinary incontinence which required a Foley catheter to collect the urine. The
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doctor warn Cody that he may be dependent on a wheelchair for his mobility and that soon
he will be transferred to the rehabilitation ward to begin an inpatient program which will
address his physical function as well as his ability to complete daily activities in preparation
for leaving hospital and going home.
Answer the following questions in relation to the scenario (19 marks).
1. Explain the movement terms abduction and flexion with respect to the anatomical
plane (2 marks)
Abduction refers to the movement of the limbs or hands away from the anatomical plane
or spreading of toes or the fingers while flexion refers to anterior bending of either the
head or vertebral column or the arm or the thigh (Jarmey, 2018).
2. What plane of section is shown in the x-ray and CT image? (1 mark)
Sagittal section
3. What primary movements can be made by a typical cervical vertebra? (1 mark)
1. Flexion,
2. Extension,
3. Side bending and
4. Rotation.
4. Name four features of a typical cervical vertebra that distinguish it from other
vertebrae in the vertebral column (2 marks)
1. Triangular vertebral foramen
2. Bifid spinous process
3. Transverse foramina.
4. Presence of the costal facets
5. Which division of the nervous system is involved in control of breathing, blood
pressure and heart rate? Name its two main subdivisions. (2 marks)
The division of the nervous system that is involved in control of breathing, blood pressure
and heart rate is known as- Autonomic nervous system
Two main subdivisions of autonomic nervous system include:
1: Sympathetic nervous system and
2: Parasympathetic nervous system
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6. Briefly explain how damage to one subdivision of the peripheral nervous system
is responsible for Cody having warm dry skin? (1 mark)
A damage to one subdivision of the peripheral nervous system cause warm dry skin in
that the Schwann cells that insulates the nerve cells get damaged hence causing the
cells to loss heat continuously to the skin causing loss of moisture.
7. Which peripheral nerve innervates the primary muscle of respiration and state one
possible reason for weakness in Cody’s breathing after the accident? (2 marks)
The peripheral nerve that innervates the primary muscle of respiration, which is the
diaphragm, is the phrenic nerve. The main possible reason for weakness in Cody's
breathing after the incident, is that the innervation of the diaphragm muscle has been
interfered with, hence the diaphragm muscle does not function normally in the process of
breathing hence weakness in his breathing.
8. Name the cranial nerves involved in the pupillary light reflex response? (1 mark)
1. Optic and
2. Occulomotor nerves.
9. Describe a positive Babinski sign, how is it produced and its significance? (3
marks)
Positive Babinski sign refers to the occurrence of planter flexion and the adduction of the
toes during planter reflex (Maher, 2016). It is produced by stimulating the external portion
of the the sole, whereby the examiner begins the stimulation back at the heel and goes
forward to the base of the toes. Its clinical significance is that it reliably indicates
metabolic or structural abnormality in the corticospinal system upstream from the
segmental reflex.
10. Cody is asked to exercise his bicep muscles by lifting free weights strapped to
wrist. At first his endurance is poor, only being able to perform a few bicep curls
but within a month he improves significantly. How do changes in fast and slow
twitch muscle fibres contribute to overcoming muscle fatigue and improving
endurance? (3 marks)
A slow twitch fibre contracts slowly and releases energy gradually as required by the
body during steady state activity (Sherwood, 2015).. These fibres are efficient in using
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oxygen to generate energy (ATP), making them resistant to fatigue and endurance.
When the body is engaged in endurance-type activity, slow twitch fibres are used for
movement because they are more effective in meeting the immediate requirements of
the working muscles. Fast twitch fibres contract quickly and releases energy rapidly,
however they fatigue rapidly due to anaerobic metabolism providing the energy. They
use the elastic system (ATP-PC) and the lactic acid system for energy to perform
explosive movements that are short lasting. The body preferentially uses the fast twitch
fibres to perform explosive-type activities such as heavy weight lifting.
11. Name the two main muscles that are involved in raising and abducting the
shoulder joint (1 mark)
1. Subscapularis and
2. Supraspinatus
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References
Jarmey, C. (2018). The Pocket Atlas of Human Anatomy: A Reference for Students of
Physical Therapy, Medicine, Sports, and Bodywork. North Atlantic Books.
Maher, A. B. (2016). Neurological assessment. International journal of orthopaedic and
trauma nursing, 22, 44-53.
Sherwood, L. (2015). Human physiology: from cells to systems. Cengage learning
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