Hot Seat #212: Just in the Neck of Time
Posted on: August 9, 2023, by : Brandon Ho
Case by Mohamed Masouma MD, INOVA PEM Fellow
A 3-year-old otherwise healthy male presents after he and his father had a fall about 2 hours PTA. They were reportedly outdoors with the patient on Dad’s shoulders when Dad slipped on a rock causing them both to fall. Dad was not sure how the boy landed on the ground. The patient had no significant LOC or focal neuro deficits. He had no signs of trauma per his parents’ report. He was his normal, playful self after the fall. Mom denies any instances of vomiting, lethargy, vision changes, or complaints of pain. Past medical history is noncontributory.
Temp: 98.8 °F (37.1 °C), Heart Rate: 168, BP: 95/60, Resp Rate: 24, SpO2: 97 %
Head: Bruise to L occiput
Ears: TM wnl b/l
Nose: Nose normal. No septal hematoma
Mouth: Mucous membranes are moist. No evidence of intraoral trauma.
Pharynx: No oropharyngeal exudate or posterior oropharyngeal erythema.
Neck: no central midline tenderness, full ROM
Derm: Skin is warm and dry, CRT 2 seconds, one small abrasion to R knee.
CV: Tachycardic, Normal S1/S2, no murmurs
Resp: CTAB B/l
Abdomen: Soft, non-tender, no organomegaly
Back: No midline tenderness, no step-off or deformity.
Neurological:
- Mental Status: Awake and alert and answering age-appropriate questions. Follows commands. Speech is clear without evidence of aphasia.
- Cranial Nerves: Pupils 3 mm equal round and reactive to light. CNII-XII grossly intact.
- Motor: Muscle tone normal without spasticity or flaccidity. No atrophy. Moves all 4 extremities antigravity and symmetrically.
- Sensory: Light touch intact throughout
- Reflexes: No Clonus bilaterally, Babinski: none
- Coordination: not tested
- Gait: Normal
Patient was discharged home with return precautions of change in behavior, altered mental status, persistent headaches, or any other concerns.
The patient was brought in 3 days later. Per parents, the patient is not moving his neck fully. Upon further enquiry: parents reported that the patient started to c/o neck pain later that day, the day of the fall. The pain has not been severe over the last few days, but he cannot turn his neck fully when asked.
They brought the patient to the ED out of precaution and deny any changes in the patient’s mental status, activity level, or baseline function.
Exam was unchanged apart from:
Patient has no central midline tenderness, step off nor deformity. Patient with left sided neck tenderness and restriction in ROM due to pain.
Patient received pain meds which helped briefly but then pain recurred. The patient underwent cervical spine x-ray and CT with no evidence of fractures nor dislocation.
MRI was done and showed…
Obviously it’s something which is why it’s here but in real life likely would not have ordered stat mri
Phew – this is a tough case! The things I would be worried about most in a patient with persistent post-traumatic neck pain despite a negative neck CT would be central cord syndrome or some sort of ligamentous injury. I was torn as to whether to recommend an outpatient MRI or to try to get an MRI done during the ED visit. However, if I’m impressed by the severity of the pain, and taking into account that this is already a return visit to the ED, I might at least speak to the radiology team to check on the feasibility of a sedated MRI that day.