with Molly Stevens, Johns Hopkins, on the Hot Seat
The Case
“C1-C7 are visualized, T1 is obscured by soft tissues. No definite abnormalities identified, however the imaging of C1 C2 is suboptimal.”
The patient’s exam on that call-back visit remained unchanged – A happy, playful 3yo M who keeps his neck in a slightly left-turned and very mildly flexed position. He was unwilling to turn head to the left or right, flex or extend his head due to pain. He points to the c-spine to explain region of pain, but cannot localize further. The remainder of the exam, including a full neuro exam was intact. The patient was sent home with motrin and instructions to follow up with the PCP.
The patient is now returning, 6 days after the original fall and initial visits, to see you in the ER. He is back because he has not improved.
VS – T 37.9 HR 139 RR 28 BP 103/72 RA
General – happy, playful, articulate 3yo M
Neck – slightly left-turned and mildly flexed position. Unwilling to turn head to left or right (turns with trunk); unwilling to flex or extend head – points to neck/c-spine and explains he won’t move “because his neck hurts”. Minimal wince/grimace when palpation of midline c-spine.
The remainder of his exam, including a full neuro exam, is intact.
Questions for you (click on "Submit" to send your answers and see what others said)
You decide to obtain a c-spine CT. There is no fracture visualized. You decide to try some PO valium to see if this will help relax his muscle spasm/torticollis. This is entirely unsuccessful, and the patient continues to refuse to move his neck.
You decide to keep the patient in a Miami J, continue motrin around the clock and have the patient follow up with neurosurgery (appointment made for 2 days from now).
The next day, you are discussing this interesting case with a colleague and you come across the official read of that c-spine CT from last night:
“Craniocervical malalignment, could be positional in nature. No definite findings of fixed rotatory subluxation. No acute dislocation or fracture. Upper cervical prevertebral soft tissue thickening, normalized by C5.”
You call your patient at home to get an update. His parents report they have been giving motrin around the clock and he is still in his collar, like you advised. He might be moving his neck a little more, but it is hard to tell in the collar. He has not had any fevers.
One more question for you:
Click here to read the denouement for this case.
About the Hot Seat. Hot Seat cases are written by PEM fellows at Children's National, Inova Fairfax, and Johns Hopkins. The Hot Seat Attending is a selected faculty member who comments on the case without knowing the outcome. Emily Willner is the faculty mentor for the series but she is on a well-deserved leave. During July, August, and September guest faculty from Children's National, Inova Fairfax, and Johns Hopkins will serve as case mentors. Paul Mullan, Children's National, edited this case.
Your exam is really important here. You want to assess: the sternocleidomastoid muscle, eyes, retropharynx, and cervical spine in addition to routine ROM. You need to differentiate what the kid doesn't want to do from what the kid is unable to do.
ReplyDeleteThe story is pretty classic for atlantoaxial rotary subluxation, right? A little young. But fixed torticollis after a minor trauma with limited ROM is kinda classic. You don't have to have trisomy 21 to get this. The sternocleidomastoid is often tight on the opposite side from the tilt, which differs from classic torticollis which is the same side. Now kids can get muscular injury of the neck that mimics this, but in those you can passively move the neck (with heat packs and NSAIDs) and there shouldn't be a problem with flexion and extension which is a big red flag here.
If the kid just doesn't want to move his neck, that's really different and it would make me think of other stuff....intracranial tumor, ocular strabismus, etc. but that's very different than what's described.
Trust your clinical judgement. If you think this kid has rotary subluxation (which you should) then try to prove it with CT imaging. Get an attending to read the films. Then have a neurosurgeon evaluate the patient and the films and confirm an outpatient plan. This is not routine "my neck hurts" and i have a negative CT and i should go home in a collar and take motrin. Do that when the neck is in good alignment and there is tenderness in the neck with negative imaging. And i'd be quite reluctant do it in a 3yo. The kid would rip off the collar in 2 seconds. I have no idea if an MRI would be additionally helpful here, but i don't think it would. We're not looking for spinal cord disease although could assess for ligamentous injury which would be quite uncommon in a 3 yo. and perhaps better identify neck positioning. But a sedated MRI isn't something i'd do unless a consultant really thought this was necessary.
My first questions for this not uncommon presentation are usually answered by HX and PE. Is there trauma or concerns of infection/inflammation, and any evidence of CNS involvement? Since we see the common things most commonly, I would expect to find knowing only the age and chief complaint that it’s due to either minor trauma (muscle strain or a fx like clavicle) vs common infections (cervical adenitis, and if sicker meningitis or peritonsillar/retropharyngeal cellulitis or abscess). More rarely are the infrequent presentations of those more scary things: c-spine fxs or subluxations, head and neck tumors, bleeds, or bony or intracranial infections/abscesses (congenital and rheumatologic rarities would come up later).
ReplyDeleteLet’s go through this visit. We have a previously normal child with 6 days of “not improving”, not wanting to move his neck, but “happy and playful” (before and currently) after initially being stiff “like a robot”. He has a hx of trauma “earlier in the day” (trauma we assume to be minor as it was not the primary initiator of the visit).
Initial VS catch my attention for a high heart rate for age, which makes me delay over his temp of 37.9, especially knowing about his ”motrin around the clock”. Is it pain or masked fever? This needs a repeat check, and maybe repeat temp check if it’s getting over 6 hours since the last ibuprofen. That keeps infection on my list with trauma for now.
He is still “happy and playful”. For hx, I would want to confirm that he’s had no fever, nor s/s of illness, particularly is eating/drinking normally without vomiting or drooling, has had no HA, and is doing his normal activities at home (ie has no hx concerning for spinal cord or intracranial ‘badness’ and no hx concerning for an infection). His exam is normal except for being unwilling to move neck and having tenderness on palpation of his c-spine. I want to confirm his normal neuro exam, no other findings of trauma, and that he has no PE evidence of infection (rash, adenopathy, drooling, normal retropharynx, etc).
We have his initial c-spine images X2; notable for being suboptimal at C1C2 (are they seeing something that draws their attention this area?).
We have a CT with next day attending read of “craniocervical malalignment, could be positional…no definitive...rotary subluxation…no fx or dislocation. Upper cervical prevertebral soft tissue thickening”.
At home he still has no fever, no new neuro findings, and is in his collar.
2 things top my differential. First: rotary atlantoaxial subluxation (more common than fractures in this age group, and can happen with relatively minor injury, manifests with torticollis and neck pain (with SCM spasm and fixed head rotation both on the same side), would have a tender C-spine on palpation, is not definitively diagnosed by CT (needs dynamic CT study for definitive dx), and can have prevertebral ST swelling. Fits pretty well.
One of the things I do on my PE when I’m thinking of AA rotary subluxation is to give motrin or diazepam, give it time to work, then examine the patient lying flat. With the head fully supported, I ask if they can “let the chin fall over to this side”, then the other. Movement past midline (I use 45 degrees past) towards each side pretty well rules out jumped C1C2 facets and makes me comfortable with not chasing a rotary subluxation.
Second on the differential is retropharyngeal cellulitis or abscess. This pt has no hx of fevers, but has been on ibuprofen RTC. Not wanting to extend or rotate the neck and the widening of the retropharyngeal ST goes with retropharyngeal cellulitis/abscess, but this child being well-appearing, drinking normally, not drooling, goes against it.
At yesterday’s visit, I may have gotten a CBC and inflammatory markers and done the ibuprofen/valium trick above. These done prior to his CT might have helped me decide if his CT should include a dynamic component after negative for fx (because I was concerned about rotary subluxation) vs with contrast (for a concern for cellulitis/abscess).
Already 2 very extensive comments. Thank you! I don't have much to add, except maybe including neurosurgery consult early on as part of the return visit a week later!
ReplyDeleteAlso, one thing I've learnt, especially with CT scans: If you have a clinical concern, don't trust the prelim resident read. Get the attending to read it before you dispo the child.
I agree, very well thought out responses. Similar to the last Hot Seat, I am nervous about sending home a child with a week of concerning symptoms that have not responded to the interventions prescribed and now on the third assessment by a provider (both clinically and by radiology). How many times can we be satisfied by the abnormal radiology findings due to position? The comment on soft tissue thickening raises my eye brow as well as the tachycardia and 37.9 temp. (This mainly raises my eyebrow because it is a week away from the initial presentation and this child is no better despite the recommended motrin -- these points could be missed or explained away on an initial visit, but by the third time, we are using a fine tooth comb here).
ReplyDeleteI like the idea of lab work as mentioned by Molly. I agree the child appears well, but the magic of Motrin can keep things just simmering enough to not make the diagnosis more obvious. AS Molly noted, RPA is definitely higher on my differential at this third visit after that CT. You've already committed him to a CT -- would I do another one with contrast to look for an RPA?? Hmmm... would talk to Radiology and use a CBC/CRP to guide me in the direction of infectious etiology. If it is clear cut from labs that there is something infectious, I would treat, admit and let ENT know. If not apparently infectious, then maybe more radiographic investigation and get NSGY consult as mentioned by Dave.