neurological deficits

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A 5 month old girl with alobar holoprosenceohaly. This condition was diagnosed prenatally in utero and understandably resulted in severe enlargement of the child’s head. The child was oriented to sound, able to move all extremities and responded to external stimuli, however the long term prognosis for this condition is poor as it is typically fatal in the neonatal period.

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Atlanto-axial Subluxation

Atlas - First Cervical Vertebrae 

Axis - Second Cervical Vertebrae

Atlanto-Axial Joint - The joint between the 1st and 2nd Cervical Vertebrae

This joint is unique compared to other vertebrae joints, in that there is no disc between the atlas and axis. Instead it is supported and stabilised by ligaments. The main purpose of this joint is to enable the patient to move their head from side to side. 

What is a AA subluxation?

AA subluxation is essentially a disruption in the alignment of the Atlas and Axis. This means that the joint becomes unstable and results in excessive movement of the neck.

What problems does this cause?

As a result of this type of subluxation the nerves that form the spinal cord, which runs through the vertebral column can become compressed resulting in neurological deficits and neck pain.

How does it occur?

Trauma to the neck such as forced flexion of the head causing ligament/vertebrae damage can result in this condition. However, it is often congenital and usually arises from an abnormality in the Axis either due to a issue with the supporting ligaments or because the Dens ( a projection of the Axis that fits with the Atlas) is malformed or absent. 

How common is this congenital abnormality?

This type of abnormality is most common in toy breeds such as: Yorkshire Terriers, Chihuahua’s, Pomeranians and Pekingese. It usually occurs within the first year of life.

What are the symptoms?

Neck pain - yelping and crying when lifted or touched in the neck/head region

Ridgity of the neck - A reluctance to flex the neck or move, eat and drink

Paraparesis/Paresis - Resulting in the patient being anything from non-ambulatory or ataxic

How is the condition diagnosed?

Radiographs - Lateral, Ventro-dorsal and Oblique views are recommended.

MRI - This will allow assessment of spinal cord damage. 

CT - This will allow visualisation of bone deformity in regards to the vertebrae. 

What are the treatment options?

Conservative - Often only offered to patients with mild clinical signs. It includes cage rest for 4-6 weeks and often the patients are put in a neck brace for this time to allow fibrous scar tissue to form and stabilise the joint. 

Surgical - The main aims of surgery are to relieve compression of the spinal cord and stabilise the joint permanently. If the dens is malformed or damaged, it may have to be removed. The recommended surgical approach is ventrally, as it allows arthrodesis (fusion) of the atlanto-axial joint. A cancellous bone graft is placed in the joint and pins or screws are placed across the joints. A head brace is then put in place and should remain on for 4-6weeks.

Nursing considerations

Avoid flexion of the neck - this will cause further compression of the spinal cord and may result in severe neurological issues.

Gentle Physiotherapy - Often these patients do not move either due to fear of pain or they are unable to because of the spinal cord compression. Therefore physiotherapy is important to maintain muscle tone and blood flow to the limbs

Feeding Tubes - Dependent of the neurological condition of the patient a feeding tube may be the best course of action to ensure they are maintaining hydration status and meeting their RER.

Supportive Bedding - Patients that have limited movement are prone to bed sores therefore padded supportive bedding is essential. The use of donut bandages around boney joints may be needed.

Prevention of Urine Scalding - Using inco pads to soak up urine and regular baths to get urine off skin will be needed.

Being aware of complications - Further displacement of the dens (as a result of surgical failure or neck flexion) into the spinal canal can lead to diaphram paralysis, respiratory failure and death. Thus monitoring of Res rate and effort is a must.

What is the prognosis? 

The prognosis depends on the degree of spinal cord trauma and neurological deficits present before treatment. Mild clinical signs result in a good prognosis whereas prognosis for dogs with paralysis is guarded, although recovery is possible with successful surgery.

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Middle aged man, walking with an open pocket knife, trips on a wire, and inadvertently impale himself with the knife. Alert, oriented, no neurological deficits, small amount of venous bleeding (blood in the picture is clotted). Trauma system entry straight to OR. The knife was found to be penetrating 13 mm into the temporal lobe. Missed any major structures and vasculature. 45 minute surgery. Got to see him the day after, and he is walking, talking, absolutely no neurological deficits. He is one lucky son of a bitch.

theatlantic.com
Why Some Companies Are Trying to Hire More People on the Autism Spectrum
The majority of those with autism are unemployed, but new pilot programs at big companies, such as EY and Microsoft, are discovering unexpected benefits from having "neurodiverse" colleagues.
By Bourree Lam

Found a great comment on this article by Laney Chandler. It’s wasted in a comments section, so I’m sharing it here.

So now imagine what it is like for an autistic person to work with neurotypicals. Our nervous system is structured completely differently. The challenges we face apply to essentially everyone around us.

People expect us to read non-verbal communication, but we have a neurological deficit that prevents this and yet people are not shy about chastising or rejecting us for our disability, so we are operating from a place of anxiety all the time.

The way we dress is based on sensory challenges. Many of us cannot “tune out” tactile information, so while you may put on a pair of woolly socks and find them scratchy, you soon forget about it. For many of us, when we wear certain materials, cuts, or something, we have the equivalent of someone following us, beeping loudly in our ear all day. It becomes excruciatingly painful.

People around us say one thing with their words and another with their faces - which we often cannot read. We need to verbalize things, and we are direct. We are susceptible to lies and manipulation because we have challenges in reading certain non-verbal aspects of social communication. It means we are abused and exploited many, many times, and yet, most of us continue to try and show up. Only to be told we are “too direct”.

Repetitive behaviors can have several causes. Tic disorders are extremely common, which means that many of us have repetitive movements that are of neurological origin that cannot be controlled. You think it is annoying to see someone shake or roll their head? It is much harder to endure the social scrutiny that follows an involuntary movement, not to mention pain from repetitive strain.

In other cases, repetitive movements are a natural form of self-regulation in response to a vastly different sensory system. Some people have hyposensitivities, which creates anxiety. Thus rocking may be an effort to feel where one’s body is in 3D space. We also routinely take in 2-4 times as much sensory information through the 5 standards senses, which means the world is intense and chaotic. Repetitive movement helps to ease the neurological pain we experience from that. The only analogous experience in neurotypicals is physical pain.

We generally cannot filter sensory input either, and cannot multitask. Our cognitive functioning is different - we have to focus deeply. It is how we are wired. If you startle a person on the spectrum while they are focusing, it can be extremely painful. So what you dismiss as behavior is actually an acutely difficult experience.

Temple Grandin is not the archetype for what autism is. What Grandin does is pass, whcih means that, even though she has sensory needs and experiences pain, she has learned to pass as neurotypical (as close as she can manage), by making her own needs and pain subordinate to the needs and expectations of neurotypicals. It doesn’t change her disabilities - it just hides them from your view. Many autistics do this out of fear of social punishment, rejection, etc. But that does not make it right - the problem here is that no room is made for someone with different neurological needs. Not all of us CAN pass, and the damage from passing is cumulative and devastating. Imagine having to hide who you are and sweat bullets because you are in agony in every single social encounter just so you will not be punished. It damages self-esteem. Fundamentally.

If neurotypicals can bother to learn about the differences and at least meet autistics half way in communication, a lot of the challenges would be avoided, including what you call “trouble with men.” What is actually happening is that autistics - the people with significant neurological challenges and disabilities - are being asked to shoulder the entire burden of bridging the communication gap. They are being asked to mask who they are and live in pain so that neurotypicals, already in the majority, can have a seamless experience of the world.

In terms of providing accommodation for a disability. autistics are being asked to accommodate neurotypicals far more than neurotypicals are being asked to accommodate autistics.

So in terms of having a “thick skin”, autistics are absorbing the rougher end of that. It is worth remembering that. Because they endure the challenge of dealing with difference in 99% of the people they meet. Likely all of their work colleagues (if they are lucky enough to get a job). And they struggle with this for their entire lives, feeling like an alien species and shut out of most of social life. A little compassion in place of a zoological taxonomy would go a long way.

I super hate when people think that attention deficits and neurological problems could be solved by “trying harder to focus” or w/e

Like, I feel like some people literally can’t comprehend that hey!!! other people’s brains? They’re not like yours!! They work!! Differently!! And your experience does not apply to everyone!! Wow!