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Poster 453 Paraparesis After Spinal Cord Stimulator Trial and Placement in 2 Patients: A Case Report
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abrupt pain; progressive loss of strength or sensation; or bowel, bladder, or sexual dysfunction. Diagnosis is made by MRI of the spine. Treatment options include open surgical ligation or resection of the malformation, endovascular occlusion, spinal radiation, or a combination of these techniques. Conclusions: We present a rare case of a patient with a thoracic spinal arteriovenous malformation. Clinicians should be aware of this entity and should consider further imaging of the spine in patients presenting with lower extremity weakness and a normal lumbar MRI.
Poster 452 Paraplegia After Bilateral Iliac Stent Occlusion: Ischemic Myelopathy or Plexopathy? A Case Report. Diane Mortimer, MD, MSN (Ohio State University Medical Center, Columbus, OH, United States); Sharon K. McDowell, MD. Disclosures: D. Mortimer, none. Patients or Programs: A 50-year-old woman with peripheral arterial disease who developed paraplegia of uncertain etiology. Program Description: Three weeks after placement of bilateral iliac stents, the patient presented with severe progressive leg pain. Several hours later, she reported intense abdominal and low back pain associated with paraplegia and sensory loss. A computed tomography angiogram demonstrated occlusions in bilateral iliac stents. Emergent iliofemoral thrombectomies with stenting and angioplasty failed to reverse her sensorimotor impairments. She also developed rhabdomyolysis and compartment syndrome. Examination revealed absence of motor or sensory function below the 12th thoracic level except for voluntary anal contraction and anal sensation. She had urinary retention. Her examination was unchanged except for partial hip extensor strength recovery during hospitalization. Setting: Tertiary care hospital. Results: The differential diagnosis for the etiology of her paraplegia included ischemic myelopathy from occlusion of one or more anterior spinal arteries, lumbosacral plexopathy, rhabdomyolysis, and peripheral nerve ischemia. After extensive workup, the patient was determined to have bilateral lumbosacral plexopathy, which was attributable to her ischemic episode. Discussion: Paraplegia that results from ischemic plexopathy is a rare complication of iliac stent occlusion. This unlikely phenomenon has not been extensively described. This case also highlights the complexity associated with diagnosing lumbosacral plexopathy acutely. There is an expected delay before development of findings on electrodiagnostic studies. Available imaging tests, including diffusion-weighted magnetic resonance imaging, have no definitive ability to visualize plexus injuries and limited sensitivity for detecting lumbar ischemia. In this case, somatosensory evoked potentials were uninformative due to severe lower extremity edema. Plexopathy was later confirmed with serial electrodiagnosis. Conclusions: Patients with peripheral arterial disease are at risk for developing thrombosed arteries and stents. Occluded bilateral iliac stents can result in ischemic lumbosacral plexopathy and, in extreme cases, irreversible paraplegia.
PRESENTATIONS
Poster 453 Paraparesis After Spinal Cord Stimulator Trial and Placement in 2 Patients: A Case Report. Naimish Baxi, MD (The Mount Sinai, New York, NY, United States); David Spinner, DO. Disclosures: N. Baxi, none. Patients or Programs: Patient 1: A 56-year-old man after spinal cord stimulator placement. Patient 2: A 51-year-old man after spinal cord stimulator trial. Program Description: Patient 1 underwent spinal cord stimulator placement for chronic low back pain. Four days after the procedure, he fell after sudden onset of bilateral lower extremity weakness. Magnetic resonance imaging revealed an epidural hematoma that spanned from T8-T10, and the patient underwent evacuation and decompression by neurosurgery the following day. On admission to the spinal cord rehabilitation unit, the patient was found to have American Spinal Injury Association Score (ASIA) of T10 AIS (ASIA impairment scale) C, with neurogenic bowel and bladder. Patient 2 underwent a spinal cord stimulator trial for failed back syndrome. Immediately after the procedure, the patient awoke from minimal sedation feeling numb and weak from the chest down, and incontinent of bowel and bladder. Computed tomographic myelogram revealed unobstructed cerebrospinal fluid flow and a screw, from prior surgery, displacing the thecal sac at T7. On admission to the spinal cord rehabilitation unit, results of a physical examination were consistent with C8 AIS D spinal cord injury. Assessment: Patient 1 was discharged from rehabilitation after becoming modified independent at the manual wheelchair level. Patient 2 was discharged after becoming ambulatory, walking 50 ft with minimum assistance, with bilateral knee-ankle-foot orthotics and rolling walker. Setting: Inpatient acute rehabilitation center. Results: Patient 1 was discharged from rehabilitation after becoming modified independent at the manual wheelchair level. Patient 2 was discharged after becoming ambulatory, walking 50 ft with minimum assistance with bilateral knee-ankle-foot orthotics and a rolling walker. Discussion: There is extremely limited literature regarding serious and permanent complications associated with spinal cord stimulators. Conclusions: Spinal cord stimulators have been used increasingly since the late 1960s for chronic pain syndromes. Although considered a relatively safe procedure, serious complications, for example, spinal cord injury that results in paraparesis, may occur.
Poster 454 A Patient With Spinal Epidural Mass Effect Refusing Surgical Intervention: A Case Report. David J. Chen, MD (University of Pennsylvania, Philadelphia, PA, United States); Franklin E. Caldera, DO, MBA. Disclosures: D. J. Chen, none. Patients or Programs: A 46-year-old man with a history of stab wound to the left neck in 1982, with resultant left-sided upper and lower extremity weakness, atrophy, and sensory impairment as well as RLE proprioception impairment, who presented with worsened right lower extremity weakness and shooting pain for 1 month. Program Description: Here, we described a patient who elected a conservative method to return toward his prior functional level.
abrupt pain; progressive loss of strength or sensation; or bowel, bladder, or sexual dysfunction. Diagnosis is made by MRI of the spine. Treatment options include open surgical ligation or resection of the malformation, endovascular occlusion, spinal radiation, or a combination of these techniques. Conclusions: We present a rare case of a patient with a thoracic spinal arteriovenous malformation. Clinicians should be aware of this entity and should consider further imaging of the spine in patients presenting with lower extremity weakness and a normal lumbar MRI.
Poster 452 Paraplegia After Bilateral Iliac Stent Occlusion: Ischemic Myelopathy or Plexopathy? A Case Report. Diane Mortimer, MD, MSN (Ohio State University Medical Center, Columbus, OH, United States); Sharon K. McDowell, MD. Disclosures: D. Mortimer, none. Patients or Programs: A 50-year-old woman with peripheral arterial disease who developed paraplegia of uncertain etiology. Program Description: Three weeks after placement of bilateral iliac stents, the patient presented with severe progressive leg pain. Several hours later, she reported intense abdominal and low back pain associated with paraplegia and sensory loss. A computed tomography angiogram demonstrated occlusions in bilateral iliac stents. Emergent iliofemoral thrombectomies with stenting and angioplasty failed to reverse her sensorimotor impairments. She also developed rhabdomyolysis and compartment syndrome. Examination revealed absence of motor or sensory function below the 12th thoracic level except for voluntary anal contraction and anal sensation. She had urinary retention. Her examination was unchanged except for partial hip extensor strength recovery during hospitalization. Setting: Tertiary care hospital. Results: The differential diagnosis for the etiology of her paraplegia included ischemic myelopathy from occlusion of one or more anterior spinal arteries, lumbosacral plexopathy, rhabdomyolysis, and peripheral nerve ischemia. After extensive workup, the patient was determined to have bilateral lumbosacral plexopathy, which was attributable to her ischemic episode. Discussion: Paraplegia that results from ischemic plexopathy is a rare complication of iliac stent occlusion. This unlikely phenomenon has not been extensively described. This case also highlights the complexity associated with diagnosing lumbosacral plexopathy acutely. There is an expected delay before development of findings on electrodiagnostic studies. Available imaging tests, including diffusion-weighted magnetic resonance imaging, have no definitive ability to visualize plexus injuries and limited sensitivity for detecting lumbar ischemia. In this case, somatosensory evoked potentials were uninformative due to severe lower extremity edema. Plexopathy was later confirmed with serial electrodiagnosis. Conclusions: Patients with peripheral arterial disease are at risk for developing thrombosed arteries and stents. Occluded bilateral iliac stents can result in ischemic lumbosacral plexopathy and, in extreme cases, irreversible paraplegia.
PRESENTATIONS
Poster 453 Paraparesis After Spinal Cord Stimulator Trial and Placement in 2 Patients: A Case Report. Naimish Baxi, MD (The Mount Sinai, New York, NY, United States); David Spinner, DO. Disclosures: N. Baxi, none. Patients or Programs: Patient 1: A 56-year-old man after spinal cord stimulator placement. Patient 2: A 51-year-old man after spinal cord stimulator trial. Program Description: Patient 1 underwent spinal cord stimulator placement for chronic low back pain. Four days after the procedure, he fell after sudden onset of bilateral lower extremity weakness. Magnetic resonance imaging revealed an epidural hematoma that spanned from T8-T10, and the patient underwent evacuation and decompression by neurosurgery the following day. On admission to the spinal cord rehabilitation unit, the patient was found to have American Spinal Injury Association Score (ASIA) of T10 AIS (ASIA impairment scale) C, with neurogenic bowel and bladder. Patient 2 underwent a spinal cord stimulator trial for failed back syndrome. Immediately after the procedure, the patient awoke from minimal sedation feeling numb and weak from the chest down, and incontinent of bowel and bladder. Computed tomographic myelogram revealed unobstructed cerebrospinal fluid flow and a screw, from prior surgery, displacing the thecal sac at T7. On admission to the spinal cord rehabilitation unit, results of a physical examination were consistent with C8 AIS D spinal cord injury. Assessment: Patient 1 was discharged from rehabilitation after becoming modified independent at the manual wheelchair level. Patient 2 was discharged after becoming ambulatory, walking 50 ft with minimum assistance, with bilateral knee-ankle-foot orthotics and rolling walker. Setting: Inpatient acute rehabilitation center. Results: Patient 1 was discharged from rehabilitation after becoming modified independent at the manual wheelchair level. Patient 2 was discharged after becoming ambulatory, walking 50 ft with minimum assistance with bilateral knee-ankle-foot orthotics and a rolling walker. Discussion: There is extremely limited literature regarding serious and permanent complications associated with spinal cord stimulators. Conclusions: Spinal cord stimulators have been used increasingly since the late 1960s for chronic pain syndromes. Although considered a relatively safe procedure, serious complications, for example, spinal cord injury that results in paraparesis, may occur.
Poster 454 A Patient With Spinal Epidural Mass Effect Refusing Surgical Intervention: A Case Report. David J. Chen, MD (University of Pennsylvania, Philadelphia, PA, United States); Franklin E. Caldera, DO, MBA. Disclosures: D. J. Chen, none. Patients or Programs: A 46-year-old man with a history of stab wound to the left neck in 1982, with resultant left-sided upper and lower extremity weakness, atrophy, and sensory impairment as well as RLE proprioception impairment, who presented with worsened right lower extremity weakness and shooting pain for 1 month. Program Description: Here, we described a patient who elected a conservative method to return toward his prior functional level.