Neuro Clinical Reasoning Problem for you

Had an interesting case during the Neuro placement which brought up an intriguing clinical reasoning problem - you can have a read and see if you would crack the nut yourself.

The patient was a 68 year old gent with transverse myelitis and a PMH of R MCA stroke.

Transverse myelitis (TM) itself is interesting in that it is similar to Guillan Barré, but presents like an incomplete spinal cord injury (SCI). Specifically, TM involves demyelination (like Guillan Barré) of the spinal cord across a specific spinal cord level (so there is partial or complete loss of motor control below a segment, like an SCI).

The clinical course is similar to Guillan Barré in that there is an extremely rapid decline followed by long, slow recovery. However, the prognosis is not as good as Guillan Barré: 1/3 of patients recover with a mild to moderate disability; 1/3 of patients recover with a moderate to severe disability; and 1/3 of patients don't recover appreciably. Thankfully for our patient, people with TM who show early signs of some recovery (as he did) are much less likely to fall into the last group.

Another positive aspect is that, unlike Guillan Barré, TM leaves with patients with wholly intact function above the affected level of the spinal cord. Our patient was a C7 TM case, so he had complete control of triceps, etc. - but not the best finger grip for pens, etc.

This brings up the clinical reasoning question. Our patient was starting to lose ROM for wrist flexion. The questions was: do we stretch out the long finger flexors to retain muscle length & avoid a flexion contracture; or do we leave it alone so that he will still have a tenodesis grip?

What would you do?

We debated the question before asking our clinical supervisor. The answer she came up with was: Consider the likely clinical course... While there is any chance for recovery, we should try to aim for optimal function and not go for compensations - which is what a tenodesis grip is. We therefore instituted a 'HEP' stretching program so that the patient could maintain his wrist ROM.