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Poster 181 Avascular necrosis in spinal cord injury
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
presence of a hematoma without any frank muscle tear, tumor, or bony deformity. The increased hip range of motion noticed on physical examination prompted further questioning, which revealed that the patient had recently changed to a vocation that required frequent car transfers. His car transfers demonstrated excessive abduction and internal rotation of the left leg when he exited on the passenger side and placed his wheelchair behind the seat. Repetitive stress on the hip, resulting in joint laxity and, ultimately, the shearing of blood vessels, was identified as the most likely cause of the thigh hematoma. Recommendations for car transfers were made. Physicians treating older patients with spinal cord injury are advised to pay careful attention to recent changes in lifestyle. Better understanding of musculoskeletal changes in aging patients with spinal cord injury may prevent secondary complications.
Poster 181 "Avascular Necrosis in Spinal Cord Injury." Stephen Kishner, MD
(Louisiana State University School of Medicine, New Orleans, LA); Robert L. Best, MD; Moshe Solomonow, PhD; Robert D'Ambrosia, MD. Avascular necrosis (AVN) has primarily been associated with patients who have been treated with glucocorticoids. Some of the steroid-treated conditions with the highest prevalence rates of AVN include systemic lupus erythematosis, renal transplant rejection, and rheumatoid arthritis. AVN has also been associated with many other disorders including trauma, diving, hemoglobinopathies, and Gaucher's disease. The association of AVN with spinal cord injury (SCI) has not been detailed in the literature. Fifty consecutive chronic spinal cord injured patients were evaluated. X-rays of the hips, knees, and ankles were performed on all patients. Five of the 50 patients had evidence of AVN, yielding a prevalence rate of 10%. The association of AVN with SCI may be related to the steroid treatment used during acute SCI.
Poster 182 "Tracheoesophageal Fistula Following Anterior Cervical Fusion." Donna M. DePhillips, MD (University of Medicine and Dentistry of New Jersey, Newark, NJ); Kevin C. O'Connor, MD; Harmeen K. Chawla, MD; Steven C. Kirshblum, MD. Tracheoesophageal fistulas are uncommon after neck surgery and have never been described as a complication after anterior cervical fusion. We report the case of a 20-year-old man with C4 ASIA A ventilator dependent tetraplegia following a diving accident. He underwent anterior cervical fusion with Synthes plating and bone graft and subsequently transferred to a spinal cord injury rehabilitation unit. Three months after surgery, undigested food was discovered draining from the tracheostomy site. Video fluoroscopic swallowing studies and a fistulogram showed a fistula beginning at the posterior hypopharynx and extending anterolaterally under the cervical strap muscles to communicate with the tracheostomy site. The course of this fistula is in contrast to previously described fistulas that connect the anterior esophagus with the posterior trachea. Although esophageal fistulas have been described as a complication in 10% to 28% of cases involving surgically repaired esphogeal wounds, they have not been previously described following anterior cervical fusion. Formation of the previously described fistulas include inadequate debridement, devascularization of the esophageal wall, closure under tension, or infection. The cause of the fistula is unknown but possibilities include surgical technique or postoperative infection. We discuss the diagnosis and treatment of this rare and unusual case.
Poster 183 "Transverse Myelitis Following Influenza Vaccination." Farrukh Hamid, MD (University of Texas Southwestern Medical Center, Dallas, TX); Henri V. Pelosof, MD; Gregory P. Dimas, MD. Cases of transverse myelitis are reported following vaccination for cholera, typhoid, polio and mumps. There are only 2 reported cases of acute transverse myelitis (ATM) following influenza vaccination. ATM is a neurological condition that presents with bilateral lower extremity weakness, sensory loss, and bladder and bowel dysfunction. Time of onset is variable, and recovery may be partial or complete and require months. Laboratory and radiographic evaluation may not be revealing. Magnetic resonance imaging (MRI) is not sensitive and MRI abnormality does not correlate with the cause, the extent of deficit, or the prognosis. Electromyography (EMG) may be used for diagnosis as well as for
1075
follow up in cases of ATM. We present a 73-year-old man who developed sensory, motor, bladder, and bowel symptoms 4 days after influenza vaccination. All laboratory investigations were negative, and the patient rapidly progressed to paraplegia. CT did not show any abnormality, and the patient refused MR/. EMG was performed 6 weeks after onset of the symptoms and revealed changes consistent with transverse myelitis. He gradually recovered completely from his illness, and follow-up EMG showed resolution of previous abnormalities.
Poster 184 "Spinal Myoclonus Complicating "Spasticity" in a Spinal Cord Injury: A Case Study." Michael T. Andary, MD (Michigan State University, College of Osteopathic Medicine, East Lansing, MI); Donald Green, MS; Verne D. Hnice, PhD; Joseph J. Pysh, DO, PhD. We present the first case of spinal myoclonus that complicates spasticity management. A 37-year-old man with a C6 American Spinal Injury Association classification B spinal cord injury was referred for treatment of spasticity. He had failed previous treatments with Baclofen and Dantrium but was relatively relieved by Valium. However, the side effects of Valium were unacceptable. Further evaluation, including simultaneous EEG, video taping, and EMG of the quadriceps, anterior tibialis, posterior tibialis, and medial hamstring, suggested myoclonic jerks that initiated episodes of unsustained clonus. There was no EEG evidence of cortical myoclonus corresponding with the myoclonic jerks. During the worst episodes each myoclonic jerk came once every 16 to 22 seconds and persisted for 4 to 5 hours. Each episode of clonus lasted about 4 to 6 seconds. Treatment with anticonvulsants greatly diminished the frequency of myoclonic jerks. Functionally, the patient was much less fatigued and better able to maintain his full-time employment. The methods of diagnosis of spinal myoclonus, the various treatment regimens, and functional implications of this unusual presentation of spasticity will be discussed.
Poster 185 "Herpetic Tracheobronchitis in Quadriplegia." David H. Kim, MD (Thomas Jefferson University, Philadelphia, PA); Raymond B. Attolino, DO. Herpetic tracheobronchitis is an uncommon clinical entity. There are only a few case reports in the literature. We present the first documented case report (to our knowledge) of herpetic tracbeobronchitis in quadriplegia. An 80-year-old man with C4, ASIA A quadriplegia sustained a fall. Blood-tinged secretions were noted on day 1 after admission. On day 2, thick tan secretions were noted that persisted along with lowgrade temperatures. On day 7, a bronehoscopy was performed, and 2 days later, herpes simplex was diagnosed by viral culture. A 10-day course of Acyclovir was started on day 9. The patient continued with tan secretions which were moderate to large, and he had low grade temperatures during treatment. Bronchoscopies performed on days 12 and 13 showed erythema and ulceration in the left main stem bronchus. On day 19, a bronchoscopy showed resolution of herpetic tracheobronchitis. Acyclovir was discontinued. On day 20, secretions were yellow. On day 23, secretions were white. This case illustrates the clinical course, diagnosis, and management of herpetic tracheobronchitis in quadriplegia.
Poster 186 "Rehabilitation Outcome in Patients with Spinal Cord Infarction." Snnil Sabharwal, MD (Medical College of Wisconsin, Milwaukee, WI); Richard Saltzstein, MD. Ischemic myelopathy from complications of aortic disease or surgery of the aorta is an increasingly important cause of spinal cord injury (SCI) because of an aging population and greater survival after the acute event. Although acute mortality and morbidity statistics exist, there is no literature on the rehabilitation outcome of these patients. This report presents the course and functional outcome of patients admitted to a comprehensive rehabilitation program with spinal cord infarction developing after aortic surgery for vascular disease. Complications of the underlying vascular disorder slowed progress during inpatient rehabilitation and, in many cases, had a direct impact on functional outcome. The mean length of stay was 50 days in the acute setting and 114 days in the rehabilitation facility. However, a significant improvement in function occurred during the rehabilitation stay as measured by the Modified Barthel Index (MBI), with a mean MBI of 29.4 at rehabilitation
Arch Phys Med Rehabil Vol 76, November 1995
presence of a hematoma without any frank muscle tear, tumor, or bony deformity. The increased hip range of motion noticed on physical examination prompted further questioning, which revealed that the patient had recently changed to a vocation that required frequent car transfers. His car transfers demonstrated excessive abduction and internal rotation of the left leg when he exited on the passenger side and placed his wheelchair behind the seat. Repetitive stress on the hip, resulting in joint laxity and, ultimately, the shearing of blood vessels, was identified as the most likely cause of the thigh hematoma. Recommendations for car transfers were made. Physicians treating older patients with spinal cord injury are advised to pay careful attention to recent changes in lifestyle. Better understanding of musculoskeletal changes in aging patients with spinal cord injury may prevent secondary complications.
Poster 181 "Avascular Necrosis in Spinal Cord Injury." Stephen Kishner, MD
(Louisiana State University School of Medicine, New Orleans, LA); Robert L. Best, MD; Moshe Solomonow, PhD; Robert D'Ambrosia, MD. Avascular necrosis (AVN) has primarily been associated with patients who have been treated with glucocorticoids. Some of the steroid-treated conditions with the highest prevalence rates of AVN include systemic lupus erythematosis, renal transplant rejection, and rheumatoid arthritis. AVN has also been associated with many other disorders including trauma, diving, hemoglobinopathies, and Gaucher's disease. The association of AVN with spinal cord injury (SCI) has not been detailed in the literature. Fifty consecutive chronic spinal cord injured patients were evaluated. X-rays of the hips, knees, and ankles were performed on all patients. Five of the 50 patients had evidence of AVN, yielding a prevalence rate of 10%. The association of AVN with SCI may be related to the steroid treatment used during acute SCI.
Poster 182 "Tracheoesophageal Fistula Following Anterior Cervical Fusion." Donna M. DePhillips, MD (University of Medicine and Dentistry of New Jersey, Newark, NJ); Kevin C. O'Connor, MD; Harmeen K. Chawla, MD; Steven C. Kirshblum, MD. Tracheoesophageal fistulas are uncommon after neck surgery and have never been described as a complication after anterior cervical fusion. We report the case of a 20-year-old man with C4 ASIA A ventilator dependent tetraplegia following a diving accident. He underwent anterior cervical fusion with Synthes plating and bone graft and subsequently transferred to a spinal cord injury rehabilitation unit. Three months after surgery, undigested food was discovered draining from the tracheostomy site. Video fluoroscopic swallowing studies and a fistulogram showed a fistula beginning at the posterior hypopharynx and extending anterolaterally under the cervical strap muscles to communicate with the tracheostomy site. The course of this fistula is in contrast to previously described fistulas that connect the anterior esophagus with the posterior trachea. Although esophageal fistulas have been described as a complication in 10% to 28% of cases involving surgically repaired esphogeal wounds, they have not been previously described following anterior cervical fusion. Formation of the previously described fistulas include inadequate debridement, devascularization of the esophageal wall, closure under tension, or infection. The cause of the fistula is unknown but possibilities include surgical technique or postoperative infection. We discuss the diagnosis and treatment of this rare and unusual case.
Poster 183 "Transverse Myelitis Following Influenza Vaccination." Farrukh Hamid, MD (University of Texas Southwestern Medical Center, Dallas, TX); Henri V. Pelosof, MD; Gregory P. Dimas, MD. Cases of transverse myelitis are reported following vaccination for cholera, typhoid, polio and mumps. There are only 2 reported cases of acute transverse myelitis (ATM) following influenza vaccination. ATM is a neurological condition that presents with bilateral lower extremity weakness, sensory loss, and bladder and bowel dysfunction. Time of onset is variable, and recovery may be partial or complete and require months. Laboratory and radiographic evaluation may not be revealing. Magnetic resonance imaging (MRI) is not sensitive and MRI abnormality does not correlate with the cause, the extent of deficit, or the prognosis. Electromyography (EMG) may be used for diagnosis as well as for
1075
follow up in cases of ATM. We present a 73-year-old man who developed sensory, motor, bladder, and bowel symptoms 4 days after influenza vaccination. All laboratory investigations were negative, and the patient rapidly progressed to paraplegia. CT did not show any abnormality, and the patient refused MR/. EMG was performed 6 weeks after onset of the symptoms and revealed changes consistent with transverse myelitis. He gradually recovered completely from his illness, and follow-up EMG showed resolution of previous abnormalities.
Poster 184 "Spinal Myoclonus Complicating "Spasticity" in a Spinal Cord Injury: A Case Study." Michael T. Andary, MD (Michigan State University, College of Osteopathic Medicine, East Lansing, MI); Donald Green, MS; Verne D. Hnice, PhD; Joseph J. Pysh, DO, PhD. We present the first case of spinal myoclonus that complicates spasticity management. A 37-year-old man with a C6 American Spinal Injury Association classification B spinal cord injury was referred for treatment of spasticity. He had failed previous treatments with Baclofen and Dantrium but was relatively relieved by Valium. However, the side effects of Valium were unacceptable. Further evaluation, including simultaneous EEG, video taping, and EMG of the quadriceps, anterior tibialis, posterior tibialis, and medial hamstring, suggested myoclonic jerks that initiated episodes of unsustained clonus. There was no EEG evidence of cortical myoclonus corresponding with the myoclonic jerks. During the worst episodes each myoclonic jerk came once every 16 to 22 seconds and persisted for 4 to 5 hours. Each episode of clonus lasted about 4 to 6 seconds. Treatment with anticonvulsants greatly diminished the frequency of myoclonic jerks. Functionally, the patient was much less fatigued and better able to maintain his full-time employment. The methods of diagnosis of spinal myoclonus, the various treatment regimens, and functional implications of this unusual presentation of spasticity will be discussed.
Poster 185 "Herpetic Tracheobronchitis in Quadriplegia." David H. Kim, MD (Thomas Jefferson University, Philadelphia, PA); Raymond B. Attolino, DO. Herpetic tracheobronchitis is an uncommon clinical entity. There are only a few case reports in the literature. We present the first documented case report (to our knowledge) of herpetic tracbeobronchitis in quadriplegia. An 80-year-old man with C4, ASIA A quadriplegia sustained a fall. Blood-tinged secretions were noted on day 1 after admission. On day 2, thick tan secretions were noted that persisted along with lowgrade temperatures. On day 7, a bronehoscopy was performed, and 2 days later, herpes simplex was diagnosed by viral culture. A 10-day course of Acyclovir was started on day 9. The patient continued with tan secretions which were moderate to large, and he had low grade temperatures during treatment. Bronchoscopies performed on days 12 and 13 showed erythema and ulceration in the left main stem bronchus. On day 19, a bronchoscopy showed resolution of herpetic tracheobronchitis. Acyclovir was discontinued. On day 20, secretions were yellow. On day 23, secretions were white. This case illustrates the clinical course, diagnosis, and management of herpetic tracheobronchitis in quadriplegia.
Poster 186 "Rehabilitation Outcome in Patients with Spinal Cord Infarction." Snnil Sabharwal, MD (Medical College of Wisconsin, Milwaukee, WI); Richard Saltzstein, MD. Ischemic myelopathy from complications of aortic disease or surgery of the aorta is an increasingly important cause of spinal cord injury (SCI) because of an aging population and greater survival after the acute event. Although acute mortality and morbidity statistics exist, there is no literature on the rehabilitation outcome of these patients. This report presents the course and functional outcome of patients admitted to a comprehensive rehabilitation program with spinal cord infarction developing after aortic surgery for vascular disease. Complications of the underlying vascular disorder slowed progress during inpatient rehabilitation and, in many cases, had a direct impact on functional outcome. The mean length of stay was 50 days in the acute setting and 114 days in the rehabilitation facility. However, a significant improvement in function occurred during the rehabilitation stay as measured by the Modified Barthel Index (MBI), with a mean MBI of 29.4 at rehabilitation
Arch Phys Med Rehabil Vol 76, November 1995