Don't let this misguide you!

Whenever you assess a patient with no history of trauma you don't expect him to have any trauma injury or fracture nor dislocation in most cases. Ok, you might say there are patients, who develops pathological fractures without a high energy impact source and you are right, but even so, this cases usually complaints of pain related to the fracture and so on and so forth.

What about a pediatric case, whose main complaint is frontal bossing, the mother also refers "there is a soft prominence at the back of the neck", and after MRI you see non-obstructive hydrocephalus (HCP), so, very easy, it is a straightforward case, no need for further workup. You might say the next step is shunt.

However, the background of the patient is broad, he is 1 yo, mucopolisacaridosys type 6 carrier along with some morbidities related to it, with no history of tx. The prior primary care provider assessed him and discharged him on grounds compensated HCP.

After few months, the pt returned to ER. By then, the pediatrician referred the pt to ophtalmology, whom diagnosed him with bilateral papilledema. HE requested you for immediately shunt.

I, -in my experience I've been related to neurosurgery as a trainee and consultant for more than 10 years and I haven't seen this so far, assessed the pt comprehensible, then I waited for the relative to bring the prior brain MRI, later on, I agreed with the prior Neurosurgeon diagnosis, but only this time the pt needs emergent shunt.

Notwithstanding, I have the compulsion to see every view available and suddenly I noticed that the odontoid is out place (sagittal view), not only that, but also the C1 spinal canal space is narrow,- The spence rule of thirds is not there, so, the patient has an anterior C1-occipital subluxation, along with pseudomeningocele and symptomatic HCP. All the sudden the possible management changed, you must fixed the cervical spine to the skull first, later on reassess the need of shunt. In the meantime I put him on a hard neck collar.

I have seen case like this in webinars and videos, but not at work. 

I want your comments regarding such a case!, what would you do?

 

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