A rare spinal reflex in brain death: Bilateral plantar flexion in nuchal rigidity examination

Abstract

A 74-year-old female patient, who developed a hypoxic brain injury after cardiopulmonary arrest, was diagnosed with brain death on the 4th day of the clinical onset depending on the absence of brainstem reflexes and the intracranial blood circulation in magnetic resonance angiography, and positive apnea test. Bilateral plantar flexion response to the neck flexion was observed while lifting the head for the examination of oculocephalic reflex during the in-service nurse training. The plantar flexion response was observed every time the neck flexion was performed. This finding was interpreted primarily in favor of spinal reflex and the repeated brain death tests confirmed the diagnosis. Regarding the literature, spinal reflexes may emerge in patients with brain death and plantar flexion is among the most common reflexes. These reflexes are usually observed following painful stimuli, during the apnea test or when the patient is taken off the mechanical ventilation. Although the nuchal rigidity examination is not included in the routine diagnosis procedure of brain death, in this paper we report bilateral plantar flexion as a response to the neck flexion in a patient with brain death in the light of the studies found in the literature. We conclude that the introduction of the above-mentioned examination to the diagnosis of brain death will contribute to the improvement of the diagnosis procedure and prevent delays in the preparation of the potential donors.