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  • c5 burst fracture and vertebral artery dissection

    On July 9, my 50 yr old boyfriend had a surfing accident and suffered a c5 burst fracture and vertebral artery dissection. He also fractured c4 and c6. He is not paralysed nor is there any brain damage.
    He was flown to Yale on a Sat night.

    We were told that the fracture is very bad + bone pieces are dangerously close to the SC, and there is a possibility it could slice the SC.
    He was originally scheduled for surgery Sun morning until it was discovered that in the artery that ruptured there is a clot.

    So he was put in a full halo and surgery was postponed 1 week.

    After the 7 days more studies were done, and the clot remained a "catastrophic risk" to surgery, so he was discharged (!) to home for 2 weeks, for further studies. After 2 weeks, he returned for a 3rd MRI/MRA and the Neuro guy said "Clots still there. Go home and rest, and come back in 30 days and we'll see if we can proceed at that time"

    we are way confused. So many contradicting opinions between Neuro and Ortho surgeons.

    Example: Ortho has stated all along that surgery is "an emergent issue" and they are not concerned about the clot. Neuro will not allow surgery to happen.
    Another contradiction: Ortho says the clot is not 100% occluding the artery and that that small amount of blood flow is what is keeping him alive. They put him on aspirin therapy in order to reduce the clot size, in a managed and controlled manner (as opposed to using blood thinners or clot busters) Neuro on the other hand, says the clot 100% occludes the artery, AND that the goal is not to dissolve or reduce the clot. The goal is to wait, and allow it to mature, to become thicker and more stable.

    meanwhile, his neck is healing in a "less than optimal manner". The ortho guy said that, and that without surgery he will have deformity and problems. And that the eventual surgery will be that much more difficult, because they will need to rebreak his bones.

    So, here is the latest and the reason I am asking for any experience, insight or advice:

    yesterday, after all this urgency to get the surgery, his ortho guy told him that he might not even need surgery, and to wait another 30 days in the halo, after which he can go to a soft collar, and rehab. He said that yes, there will likely be deformity and weakness but, that ought to be acceptable.

    i was floored.

    This is not acceptable at all, and I am concerned that maybe the standard of care is being lowered because he was uninsured so is now on state assistance.

    Suggestions? thoughts are welcome
    thanks!
    Last edited by careprovider; 08-11-2011, 10:28 PM.

  • #2
    Originally posted by careprovider View Post
    On July 9, my 50 yr old boyfriend had a surfing accident and suffered a c5 burst fracture and vertebral artery dissection. He also fractured c4 and c6. He is not paralysed nor is there any brain damage.
    He was flown to Yale on a Sat night.

    We were told that the fracture is very bad + bone pieces are dangerously close to the SC, and there is a possibility it could slice the SC.
    He was originally scheduled for surgery Sun morning until it was discovered that in the artery that ruptured there is a clot.

    So he was put in a full halo and surgery was postponed 1 week.

    After the 7 days more studies were done, and the clot remained a "catastrophic risk" to surgery, so he was discharged (!) to home for 2 weeks, for further studies. After 2 weeks, he returned for a 3rd MRI/MRA and the Neuro guy said "Clots still there. Go home and rest, and come back in 30 days and we'll see if we can proceed at that time"

    we are way confused. So many contradicting opinions between Neuro and Ortho surgeons.

    Example: Ortho has stated all along that surgery is "an emergent issue" and they are not concerned about the clot. Neuro will not allow surgery to happen.
    Another contradiction: Ortho says the clot is not 100% occluding the artery and that that small amount of blood flow is what is keeping him alive. They put him on aspirin therapy in order to reduce the clot size, in a managed and controlled manner (as opposed to using blood thinners or clot busters) Neuro on the other hand, says the clot 100% occludes the artery, AND that the goal is not to dissolve or reduce the clot. The goal is to wait, and allow it to mature, to become thicker and more stable.

    meanwhile, his neck is healing in a "less than optimal manner". The ortho guy said that, and that without surgery he will have deformity and problems. And that the eventual surgery will be that much more difficult, because they will need to rebreak his bones.

    So, here is the latest and the reason I am asking for any experience, insight or advice:

    yesterday, after all this urgency to get the surgery, his ortho guy told him that he might not even need surgery, and to wait another 30 days in the halo, after which he can go to a soft collar, and rehab. He said that yes, there will likely be deformity and weakness but, that ought to be acceptable.

    i was floored.

    This is not acceptable at all, and I am concerned that maybe the standard of care is being lowered because he was uninsured so is now on state assistance.

    Suggestions? thoughts are welcome
    thanks!
    I am so sorry that your friend and you are going through this. Based on your description, I was initially puzzled by the decisions that were being made. While there are often disagreements between orthopedic and neurosurgeons, I was surprised by the recommendations until I read what you wrote carefully.

    I assume that your friend has an epidural hemorrhage (outside the dura). This is typically what happens with vertebral artery hemorrhage. Epidural hematomas that are compressing on the spinal cord are usually considered surgical emergencies. A laminectomy and evacuation of epidural hematoma is a relatively safe procedure. So, I don't understand why the presence of a clot would be a contraindication for decompression and stabilization surgery if the spinal cord is compressed and the spinal fracture is unstable.

    My conclusion is that your friend does not have spinal cord compression, his spinal fracture is stable, and the clot must be small. If so, this would explain the conservative approach recommended by the neurosurgeon. From that perspective, I both understand and agree with the decision not to operate. If there is no neurological loss, the spinal cord is not compressed, fracture is stable, and the vertebral column is in reasonable alignment, it is better to let it heal.

    I am surprised by the language being used to describe the fracture, i.e. "fracture is very bad + bone pieces are dangerously close to the SC, and there is a possibility it could slice the SC". Are you sure that this was told to you by a doctor? Bone fragments cannot slice the spinal cord. The fact that the bone is "close" suggest that it is not touching the spinal cord. So, there is no compression. This is good news. The fact that the surgeons sent him home indicates that they think the fracture is stable. The rest is hyperbole.

    The brain is supplied by four arteries: two carotid and two vertebral arteries. The two vertebral arteries join together to form the basilar artery. The carotids and the basilar artery feed the Circle of Willis which distributes arterial blood to both sides of the brain. Occlusion of one vertebral arteries typically will not endanger the blood supply to the brain, brainstem, or spinal cord. So, there is no reason to operate or to do anti-coagulation. The latter may in fact aggravate the hemorrhage. It is likely that the vertebral artery will recanalize or collateralize.

    Your friend is extremely lucky and should be able to surf again.

    Wise.

    Comment


    • #3
      thank you so much. your insight is a comfort and helps to ground us.

      what remains scary to us is the clot. How does that work itself out? will there always be a risk of it breaking loose and causing sudden death? are there any activities or considerations that increase danger of stroke after the halo and collar come off?

      Is emotion linked to stroke? i ask because my friend has been having panic & anxiety attacks in his halo which is very hard to watch as it seems it would raise Bp.

      Comment


      • #4
        The clot slowly is broken down by the body and reabsorbed, but this does take time.

        Panic attacks related to confinement in a halo are not that unusual, but can raise his blood pressure. He needs to speak to his physician, and see a good counselor who can help him manage his anxiety and panic attacks. Anti-anxiety edications can help, but are also sedating and may cause him to have poor balance and be a fall risk...definately something he does not want to occur in a halo. Most often the halo will need to be on for 3-4 months, so he needs to learn how to deal with this for a while yet.

        (KLD)
        The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.

        Comment


        • #5
          okay, I did not know that, about the 3-4 months. we've been told to wait 30 more days which will total 60 days, at which point he was told hed go into a soft collar.

          he began counseling and is on anxiety meds.

          thank you...so glad I found this site!

          Comment


          • #6
            pain, spasms and medication questions

            This is in reference to my boyfriend with the C5 burst fracture/Vertebral Artery Dissection, dated july 9 2011.

            He has been taking both Dilaudid 2mg and Valium. He went down from 2 Dilaudid 2mg every 4-6 hours to 1 Dilaudid 2mg every 12 hours. But, due to increased anxiety from having to wait in his halo for 60 days in hopes the blood clot will mature sufficiently to allow surgery, he has (under Doctor's advice) increased the Valium from 5mg to 10mg 3 times per day.

            Although it is not an issue I wanted to ask for advice about weaning off both of these drugs safely. How do I taper him down and what is the best medication for long term pain, spasms and cramping that he feels in both shoulders and arms, constantly?

            Comment


            • #7
              Has he seen a pain specialist or a physiatrist?? They would be more expert at managing this type of pain.

              Neuropathic pain is usually treated best with drugs like Neurontin or Lyrica. Orthopedic pain generally does better with NSAIDS or Cox2 inhibiters, sometimes combined with an opioid. Spasticity is not well treated with opioids, but instead with either skeletal muscle relaxers (for spasm due to muscle strain) like Robaxin or Flexeril, or if due to central nervous system damage, baclofen or tizanadine.

              Benzos should be tapered down to stop if the person has been taking a high dose for 3 or more months. Generally this is done by decreasing the dose by 10% weekly. Opioids can be decreased more rapidly: generally by 25% weekly.

              (KLD)
              The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.

              Comment


              • #8
                No, he has not seen a pain mgmt person or physiatrist. We meet with his Ortho surgeon next week and I will ask abt those meds you mentioned, in hopes of getting away from opioids.

                thanks!

                Comment


                • #9
                  so, today he was prescribed neurontin 3X day.

                  Since I have had no experience or knowlegde of this medication, I am hoping it will be safe for the arterial thrombus situation. It is, I understand, an anti convulsive drug and it does somehow work for neuropathic pain.

                  Does anyone here have any feedback or input regarding the safety of taking neurontin with a high-risk brain blood clot ?

                  Comment


                  • #10
                    It was first used for seizures but found to help neuropathic pain also and that is what it is most used for. It also can help spasiticty or increased tone. Start with low dose and can slowly build up.
                    Totally biased- but to me- always listen to neurosurgeons first- the vertebral artery also feeds the spinal cord and the back part of the brain. Very important not to mess it up!
                    CWO
                    The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.

                    Comment


                    • #11
                      but you think its safe in this case? He doesnt see the neuro til August 31st...
                      should I call his office and run it by him?

                      Comment


                      • #12
                        Thanks SCI-Nurse.

                        I must be very slow taking everything in, but just now I have a new curiosity:its about the vertebral artery.

                        July 2011 Left side VA was dissected with a clot, with 100% occlusion.
                        Oct 2011, the neurosurgeons decided it is mature enough for ortho surgery to proceed.

                        You mentioned that this artery feeds the spinal cord and the back of the brain. What are the functions of the back of the brain? what are the repercussions, long term of blockage of arterial flow to the Spinal cord?

                        Comment


                        • #13
                          The vertebral arteries join together at the base of the brain to form the basilar artery, which supplies the brain stem, pons, cerebellum, and then joins up with the Circle of Willis (where most of the other brain arteries join together to supply the upper parts of the brain. Right before the two arteries join, they send off a branch each which join to form the anterior spinal artery. This single artery then travels done the front side of the spinal cord, supplying the front 2/3 of the spinal cord.





                          Loss of blood flow completely in the basilar artery can result in profound disability or death due to infarction of the vital centers in the brain stem that control breathing, blood pressure, temperature, and heart rate. Loss of blood flow in the anterior spinal artery usually results in paralysis and loss of temperature, pain, and touch sensation below the level where the blood flow is stopped.

                          (KLD)
                          The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.

                          Comment


                          • #14
                            this seems pretty critical to understand.
                            My 4 main questions:

                            1.Does the fact that there is 100% occlusion (via thrombus) in the Left vertebral artery, mean that there is now or potentially will be in the future, loss of blood flow to the basilar artery? Causing the effects you outlined?

                            2. what exactly is meant when the neurosurgeon tells us that the blood clot has "matured"? He seems to speak in circles and contradictions. we feel confused.
                            On the one hand, up til 2 weeks ago, the clot in the Left VA presented a "catastrophic risk" against orthopedic surgery, but, now, he says the risk has lesssened somewhat due to the fact the clot has now matured and he is comfortable enough to defer the decision for surgery to the orthopedic man.

                            3. Are there things we should be aware of while living with an untreated clot in the vertebral artery as well as in the event that we do not have the fusion surgery? Are there movement restrictions? weight restrictions? Nobody is educationg us on these topics.

                            4.Does the Vertebral artery blockage constitute a brain injury? Should we seek a brain doctor?

                            Comment


                            • #15
                              Originally posted by careprovider View Post
                              this seems pretty critical to understand.
                              My 4 main questions:

                              1.Does the fact that there is 100% occlusion (via thrombus) in the Left vertebral artery, mean that there is now or potentially will be in the future, loss of blood flow to the basilar artery? Causing the effects you outlined?
                              No, not necessarily. The reason you have two is as a back-up. Many people loose flow in one of the two vertebral arteries due to trauma or disease and continue to have perfectly acceptable flow into both the anterior spinal arteries and their basilar artery. Loss of both vertebrals is the problem.

                              Originally posted by careprovider View Post
                              2. what exactly is meant when the neurosurgeon tells us that the blood clot has "matured"? He seems to speak in circles and contradictions. we feel confused.
                              On the one hand, up til 2 weeks ago, the clot in the Left VA presented a "catastrophic risk" against orthopedic surgery, but, now, he says the risk has lesssened somewhat due to the fact the clot has now matured and he is comfortable enough to defer the decision for surgery to the orthopedic man.
                              Generally this means that the clot is no longer growing in size, and may actually have started calcifying somewhat. This makes it less likely to break off and form an ebolus with any manipulation of the artery area.

                              Originally posted by careprovider View Post
                              3. Are there things we should be aware of while living with an untreated clot in the vertebral artery as well as in the event that we do not have the fusion surgery? Are there movement restrictions? weight restrictions? Nobody is educationg us on these topics.
                              Once you have been given a clearance by the vascular surgeon, generally not. Until then, it is important to avoid straining (valsalva) and any radical movements of the head or neck (extremes of rotation, flexion or extension). Lifting is generally limited more for any fracture precautions than with the vascular issues, but heavy lifting ususally does include some straining and valsalva, so we would limit that until OK'd by the vascular surgeon.

                              Originally posted by careprovider View Post
                              4.Does the Vertebral artery blockage constitute a brain injury? Should we seek a brain doctor?
                              No, unless there are signs or symptoms that the clot has extended up into the basilar artery itself, or higher, or if the person has brain stem symptoms (blurred vision, respiratory distress, speech problems, etc.) which cannot be explained by SCI only.

                              (KLD)
                              The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.

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