Our second case presents with a chief complain of back spasm.
So the first thing we think in the ER when we hear back spasm should be, back spasms. They are a very common complaint and they can be painful enough to bring someone into the ER. But let’s not forget that it’s our job to think outside of the box. Lots of things can cause back spasms from electrolyte imbalances, trauma, to something as foreign as tetanus. You need to keep your differential broad, but that was last week’s lesson.
This week’s lesson is to trust but verify. So it’s a busy shift. A patient has been brought in for hypotension with a pressure of 72/45. I’m busy in the resuscitation bay working to get her blood pressure up. We have an IV in place but it’s not running quickly enough and given how tenuous the patient’s blood pressure is we’ve decided to start a central line. As the nurses are helping me gather supplies I quickly logged in to the computer and placed orders on this patient and signed up for other patients to make sure we keep the flow of the ER going. It’s a seemingly benign reason the patient is here. A 52-year-old man presenting for back spasm. That’s what the tracking board tells me. Oh, and he’s been placed in the exact opposite corner of the ER.
So back to the central line, the Right IJ, the big vein in the right side of the patient’s neck, is proving difficult to cannulate and takes longer than expected. The X-ray techs are standing outside the resuscitation bay waiting to come in and shoot the film showing that we’ve put the line in the correct location and haven’t inadvertently dropped a lung. While all of this is going on I run down the hall to see the guy with a back spasm to quickly take a history and write for some muscle relaxants.
I get to his room and introduce myself and tell him, “So I hear you’re having a back spasm?” and he tells me yes. He goes on to give me the whole story. Turns out he was putting up wallpaper when he suddenly felt his low back spasm, this happens to him a lot for the past two years since a car accident, but the pain became so great that he blacked out and fell to the floor. When he woke up he felt funny and couldn’t feel anything at all on the left side of his body. He can’t feel anything from the top of his head to the tip of his toes on the front or back of his body. I realize that I have opened an entirely different can of worms than I anticipated. You need to trust that the history you see on the board is accurate but patients do not always tell the triage nurse the whole story.
So having walked into a patient who has total sensory loss on one side of his body I realize this is a much bigger issue than giving a medication for back spasm. My differential is no longer electrolyte imbalance or tetanus now I’m worried about something in the brain. I do a quick physical exam and it’s very strange. He has full movement of his left side. His strength in his right and left arms and legs are the same. He has no dysdiadochokinesia, fancy doctor work for he can flip his hands over back and forth in his lap without one side slowing down. Here watch this, https://www.youtube.com/watch?v=2EZqnmxWyAY. He has normal finger-to-nose testing meaning he can move his pointer finger from his nose to my finger without missing. These are all signs that his cerebellum is intact. He is able to answer all of the questions I ask him correctly and has no slurred speech. He is completely normal, except for the fact that when I poke him on his left side with the pointy end of a broken off q-tip he doesn’t flinch, he has no idea I’m touching him.
People are taught to look for the signs of a stroke. Slurred speech, facial droop, dragging a side of their body, but what is much less common is a pure sensory stroke, a condition where patients lose total sensation to some part of their body. The brain is a very mysterious thing, I tell the patients with neurologic complaints and their families that we are still in the dark ages of medicine when it comes to the brain. We’ve made great strides but we don’t know nearly as much as we someday will. Long story short, this guy needs a CT scan. Now.
The reason that early identification of a stroke is paramount is that we have a medication called TPA. This is a drug you’ve probably heard of as “the clot-buster drug”. Recently on a show called 911, there was a situation where the Paramedics determined someone was having a stroke based on vague symptoms and administered this medication in the field. The reality of the situation is that there are very hard rules for who can have TPA, there are inclusion and exclusion criteria and timing is very important.
INCLUSION/EXCLUSION CRITERIA
One of the most important rules is that the patient has to have a CT scan of the head before getting the drug. The thing about TPA is that it is a very powerful blood thinner that is nearly impossible to reverse. We always look at pictures from inside the skull to make sure that the patient’s symptoms aren’t due to a head bleed because if they were then you can’t give TPA.
So how does this fit in with our guy? The CT of his negative for a bleed. CT or CAT scans, you can use them interchangeably, are great at seeing bone and can show you bleeding. They are not good at telling you about soft tissue injuries unless they’re massive. If someone has symptoms of a stroke but no sign of bleeding then that’s one of the inclusion criteria for giving TPA.
With the negative CT in hand, I immediately get on the phone with our hospital’s neurology consulting service. We have a very fancy robot that allows for the neurologist to “telemedicine” in to assess the patient himself. If you’ve watched “The Big Bang Theory”, think of when Sheldon used a robot to go to work. Pretty much the same thing. So the neurologist is able to see this guy and make recommendations. Our guy has pure sensory findings with no trouble with strength or speech. His head CT was negative for a bleed. He has also relayed to me that these symptoms have happened before but never on a whole side of his body or been so profound. The neurologist agrees with me on withholding TPA in this situation. Interestingly, he says that he is concerned about this possibly being due to Multiple Sclerosis as that can present with symptoms such as spasms and odd numbness and tingling. He recommends giving the patient an aspirin and admitting him to the hospital for an MRI and MRA. MRIs look at the soft tissue, MRA looks at the vasculature. Basically, the guy needs a full work up.
So I give him an aspirin and admit him to the hospital. He is seen the following day by the neurology service who interpret the images with the help of radiology and find nothing out of the ordinary. When someone is having an MS flare there are findings of inflammation, this is why patients with MS get high doses of steroids. The neurologist felt that the patient’s symptoms were likely secondary to conversion disorder.
Conversion disorder is a fancy way to say that the patient’s symptoms exist in mind only. This is sometimes called La belle indifference because the French have much prettier ways of saying things. You typically see this in adolescent girls who will refuse to use an entire limb and be seemingly unaware of what is going on. The patient in our story was lucky enough to get a full workup and his symptoms resolved.
The takeaways this week are to always trust what you hear from your nurses and the rest of the staff but verify by getting your own history and doing a good physical exam.
When you don’t know what’s going on, consult an expert. The specialists who are “on call” are there to help you. If after talking to them it’s still not clear what’s going on it is always best to admit the patient. Scary things do happen, even if they are uncommon they can occur.
By Timothy Hanley DO
Reviewed by Hope Ring MD