- Email: [email protected]
Poster 191
ACADEMY ANNUAL ASSEMBLY ABSTRACTS (acute and rehabilitation length of stay [LOS], hospital charges, FIM™ instrument motor efficiency changes, discharge disposition). Results: Persons in the early surgery group were more likely (P⬍.01) to be women, have an SCI because of a motor vehicle collision, and have shorter acute and rehabilitation LOS. No differences between groups were found for changes in neurologic levels, FIM motor efficiency, American Spinal Injury Association motor index, or discharge disposition. Both surgical groups had an increased acute care incidence of pneumonia and DVT and PE. Conclusion: Although shorter LOSs were shown, this study did not support the benefits of early spinal surgery for enhancing neurologic or functional outcome. Key Words: Rehabilitation; Spinal cord injuries; Surgery. Poster 186 Degenerative Versus Traumatic Spinal Cord Injury: An Inpatient Rehabilitation Comparison. Erin C. Peterson, DO (Mayo Clinic, Rochester, MN); Ronald K. Reeves, MD; Aaron B. Rindflesch, PT, MPT, e-mail: [email protected]. Disclosure: None. Objective: To compare nontraumatic spinal cord injury (SCI) due to musculoskeletal degenerative causes such as spinal stenosis to traumatic SCI. Design: Retrospective chart and database review. Setting: Tertiary care inpatient rehabilitation unit. Participants: 191 consecutive persons with traumatic SCI and 125 consecutive persons with degenerative SCI dismissed from a tertiary care inpatient rehabilitation unit between January 1, 1995, and December 31, 2001. Interventions: Not applicable. Main Outcome Measures: Demographics; level and completeness of injury; rehabilitation length of stay (LOS); admission and discharge FIM™ scores; FIM change; and discharge location. Results: Overall, the etiology of SCI was 31% motor vehicle collision (MVC), 14% falls, 4% sports, 11% other accidents, and 40% degenerative disease. When compared with traumatic SCI, persons with degenerative SCI were older (median age, 72.4y vs 38.8y; P⬍.0001). Gender distribution was similar for both groups (70% men). Comparison of marital status between the groups nearly reached statistical significance (P⫽.052). Degenerative SCI admission FIM scores (71 vs 51, P⬍.0001) and discharge FIM scores (100 vs 84, P⬍.0001) were significantly higher than those for traumatic SCI. FIM change (23–24 points) was similar for both groups. Neurologic level of injury was similar between the 2 groups. However, incomplete SCI was more common among persons with degenerative SCI etiologies (P⬍.0001). Median rehabilitation LOS was significantly shorter for degenerative SCI than traumatic SCI (14d vs 31d, P⬍.0001). Discharge location did not differ between the groups. Conclusions: Persons with degenerative SCI differed significantly from those with traumatic SCI. However, they experienced significant improvement in function during inpatient rehabilitation, comparable to that seen in traumatic SCI. Key Words: Outcome assessment (health care); Rehabilitation; Spinal cord injuries.
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later demonstrated patchy increased T2 and short TI inversion recovery signal in the cervical cord from the odontoid to C4-5. Assessment/Results: The patient suffered an incomplete American Spinal Injury Association class C spinal cord injury after diffuse vascular infarct to cervical cord. Discussion: This report is one of a few reported cases of spinal cord infarction after cervical epidural injections. No direct cord trauma occurred. Previously discussed risk factors of spinal infarction, such as hypotension and large volumes of injectate, were noncontributory in this case. Conclusions: Cervical epidural injections, despite careful localization, carry a risk of vascular infarction to the spinal cord, even in the absence of direct cord trauma. Etiology of these infarctions and identifying those patients at risk remain uncertain. Key Words: Injections, epidural; Rehabilitation; Spinal cord injuries. Poster 189 Use of Telemedicine in the Management of Spinal Cord Injury Patients With Pressure Ulcers. Moshe Lewis, MD (Tufts New England Medical Center, Boston, MA); Howard Choi, MD, MPH; Maura Boushell, BSN; Paula Barsanti, BSN; Marge Alquist; Sunil Sabharwal, MD, e-mail: [email protected]. Disclosure: None. Objectives: To determine the utilization of telemedicine in the management of pressure ulcers in patients with spinal cord injury (SCI) and to evaluate patient and staff satisfaction with telemedicine on an outpatient basis for pressure ulcer management. Design: Retrospective chart review and satisfaction survey using Likert-type scales. Setting: Tertiary care hospital. Participants: 21 patients with SCI. Intervention: The records for 21 patients with SCI (comprising 24 admissions) were reviewed. Patients and staff completed satisfaction surveys using Likert-type scales. Main Outcome Measures: Descriptive statistics and satisfaction data. Results: All 21 patients were community-dwelling men; mean patient age was 69 years; 90% were white; 57% had paraplegia; and 43% had tetraplegia. The majority (76%) had American Spinal Injury Association class A SCI. 76% were living with a significant other or other primary caregiver; 24% lived alone; 82% had at least once-daily nursing care. The average distance from the patients’ homes to the regional SCI unit was 37.3 miles. Reasons for admission to the telemedicine program included recurrent pressure ulcers, frequent outpatient clinic utilization, or post-flap surgery. At admission, pressure ulcers were stages II (20%), III (20%), or IV (60%). Pressure ulcer locations were sacral (29%), ischial (40%), trochanteric (14%), lower limb (11%), or heel/foot (6%). Mean admission duration was 15.2 weeks. Survey data revealed that patients agreed (17%) or strongly agreed (78%) that the program alleviated the ordeal of traveling to the SCI center. Patients agreed (31%) or strongly agreed (58%) that the telemedicine equipment worked well and was easy to use. Staff either agreed (12%) or strongly agreed (88%) that the telemedicine program resulted in the identification of problems or recommendations for future care that may have otherwise been delayed. Conclusions: Data suggest that an outpatient SCI telemedicine program can have a positive impact on pressure ulcer management and patient satisfaction. Key Words: Pressure ulcers; Rehabilitation; Spinal cord injuries; Telemedicine.
Poster 187 Dysphagia After Anterior Cervical Spinal Surgery: Incidence, Treatment Strategies, and Outcomes. Vasilios Stambolis, MD (Marianjoy Rehabilitation Hospital, Wheaton, IL); Susan L. Brady, MS; Rhonda J. Miserendino, MS; Teresa Springer, MS; Donna Statkus, MHS; Mark Hakel, PhD, e-mail: [email protected]. Disclosure: None. Objective: To identify the incidence, characteristics, treatment strategies, and outcomes for dysphagia after anterior cervical spinal surgery (ACSS). Design: Retrospective, case-controlled. Setting: 2 free-standing rehabilitation hospitals. Participants: All patients admitted to 2 rehabilitation hospitals over 3 years after ACSS. Interventions: Not applicable. Main Outcome Measures: American Speech-Language-Hearing Association National Outcome Measurement System (NOMS) Swallowing Scale, results of instrumental assessment for aspiration, laryngeal penetration, pharyngeal residue, and length of dysphagia treatment. Results: 46 patients were included in this study. Group 1 (n⫽31) included patients who presented with dysphagia after ACSS. Group 2 (n⫽15) included patients who presented with no dysphagia after ACSS. Mean age for group 1 was 56.35 years and group 2 was 52.40 years. The difference in age between the 2 groups was not statistically significant (F⫽.49, P⫽.487). Traumatic injuries versus nontraumatic injuries were equally represented in each group. In group 1, 32% presented with a concomitant brain injury and in group 2, 22%. A tracheotomy was present in 26% of group 1 subjects as compared with 13% in group 2 subjects. In group 1, 29% had either the SOMI or halo-brace as compared with 6.6% in group 2. In group 1, 61% had a cervical collar as compared with 93% in group 2. In group 1, mean NOMS swallowing level for admission was 2.806 and for discharge was 4.968. Gains made were considered statistically significant (F⫽17.12, P⬍.0001). 84% of group 1 underwent either a fluoroscopic or endoscopic swallow evaluation, with 50% presenting with aspiration, 62% with laryngeal penetration, and 81% with pharyngeal residue. Length of treatment ranged from 2 to 71 days (mean, 17.68d). Conclusion: Dysphagia after ACSS was present in 67.4% of the patients who were admitted to the rehabilitation hospitals. Aspiration, laryngeal penetration, and pharyngeal residue were common findings. These patients demonstrated significant progress with their dysphagia treatment during inpatient rehabilitation. Key Words: Dysphagia; Rehabilitation; Spine.
Poster 190 Autonomic Dysreflexia Caused by an Imbedded Intrauterine Device in a Tetraplegic Woman: A Case Report. Michael Y. Lee, MD (University of North Carolina, Chapel Hill, NC); Hang-Won Lee, MD; Richard Kim, MD; John Lavelle, MD, e-mail: [email protected]. Disclosure: None. Setting: Tertiary care university medical center. Patient: A 46-year-old woman with traumatic right C5, left C6 incomplete tetraplegia (American Spinal Injury Association class C) for 14 years. Case Description: The patient presented to the clinic with a 1-month history of constant and sharp low back pain (LBP), which was exacerbated by sitting up and with onset of symptoms of headache, piloerection, diaphoresis, increased spasticity, and increased blood pressure. Her blood pressure would increase up to 140/90mmHg (baseline blood pressure, 110/60mmHg). Extensive work-up, including magnetic resonance imaging of the spine, ruled out compression fracture of the spine, lower-extremity fracture, urinary tract infection, and fecal impaction. Computerized tomography scan of the pelvis suggested a partially extrauterine intrauterine device (IUD) beyond the confines of the posterior uterine wall. Diagnostic and operative hysteroscopy was performed with the removal of the imbedded IUD. Assessment/Results: Patient’s LBP and symptoms of autonomic dysreflexia (AD), including spasticity and diaphoresis, immediately improved on removal of the imbedded IUD. She was able to sit in a wheelchair for a prolonged period and returned to her usual activities. Discussion: This is the first reported case, to our knowledge, of an imbedded IUD in a tetraplegic woman causing AD. Several etiologies of positionally induced AD have been suggested, including lesions of the lower spine and hips where AD symptoms were induced by sitting up. Conclusion: Complications with an IUD, including embedment, should be considered in the evaluation of SCI woman with AD. Key Words: Autonomic dysreflexia; Intrauterine device; Rehabilitation; Spinal cord injuries.
Poster 188 Spinal Cord Infarction After Cervical Transforaminal Epidural Injection: A Case Report. Michael A. Ludwig, MD (University of Washington, Seattle, WA); Stephen Burns, MD, e-mail: [email protected]. Disclosure: None. Setting: Private community hospital. Patient: A 53-year-old man with history of chronic cervical pain and multilevel degenerative disk disease with multiple posterior disk protrusions on cervical imaging. Case Description: The patient received a left C6 tranforaminal injection under fluoroscopic guidance for therapeutic pain relief. Needle localization was obtained with fluoroscopic confirmation of left C6 nerve root sheath spread of injectable contrast. Aspiration revealed no fluid return, and was followed with .75mL of .75% bupivacaine and .75mL of triamcinolone. Patient tolerated the procedure well and transferred to stretcher without assistance. Approximately 10 to 15 minutes postprocedure, the patient noted weakness in his left arm and bilateral lower limbs. Initial cervical magnetic resonance imaging revealed no cord signal change, but a follow-up study 24 hours
Poster 191 Rehabilitation Outcomes in Spinal Cord Injury: Persons in Isolation Versus Nonisolation. Alan P. Alfano, MD (University of Virginia, Charlottesville, VA); Jay S. Patel, MBBS, e-mail: [email protected]. Disclosure: None. Objective: To compare the rehabilitation outcomes of persons with spinal cord injury (SCI) on isolation precautions for antibiotic resistant organisms (for vancomycin-resistant Enterococcus faecium or methcillin-resistant Staphylococcus aureus) with patients who are not. Design: Retrospective chart review. Setting: Acute inpatient rehabilitation hospital. Participants: 58 consecutive admissions with SCI from January 1999 to December 1999, 11 in isolation (ISO) and 47 in nonisolation (non-ISO). Interventions: Not applicable. Main Outcome Measures: Length of stay (LOS), total charges, FIM™ instrument change, and FIM efficiency. Results: For the ISO and non-ISO groups, the mean of LOS ⫾ SD was 73.73⫾47.92 days and 24.57⫾21.78 days, respectively; total charges were $111,804.91⫾$74,980.83 and $28,682.20⫾$26,448.38, respectively; FIM
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later demonstrated patchy increased T2 and short TI inversion recovery signal in the cervical cord from the odontoid to C4-5. Assessment/Results: The patient suffered an incomplete American Spinal Injury Association class C spinal cord injury after diffuse vascular infarct to cervical cord. Discussion: This report is one of a few reported cases of spinal cord infarction after cervical epidural injections. No direct cord trauma occurred. Previously discussed risk factors of spinal infarction, such as hypotension and large volumes of injectate, were noncontributory in this case. Conclusions: Cervical epidural injections, despite careful localization, carry a risk of vascular infarction to the spinal cord, even in the absence of direct cord trauma. Etiology of these infarctions and identifying those patients at risk remain uncertain. Key Words: Injections, epidural; Rehabilitation; Spinal cord injuries. Poster 189 Use of Telemedicine in the Management of Spinal Cord Injury Patients With Pressure Ulcers. Moshe Lewis, MD (Tufts New England Medical Center, Boston, MA); Howard Choi, MD, MPH; Maura Boushell, BSN; Paula Barsanti, BSN; Marge Alquist; Sunil Sabharwal, MD, e-mail: [email protected]. Disclosure: None. Objectives: To determine the utilization of telemedicine in the management of pressure ulcers in patients with spinal cord injury (SCI) and to evaluate patient and staff satisfaction with telemedicine on an outpatient basis for pressure ulcer management. Design: Retrospective chart review and satisfaction survey using Likert-type scales. Setting: Tertiary care hospital. Participants: 21 patients with SCI. Intervention: The records for 21 patients with SCI (comprising 24 admissions) were reviewed. Patients and staff completed satisfaction surveys using Likert-type scales. Main Outcome Measures: Descriptive statistics and satisfaction data. Results: All 21 patients were community-dwelling men; mean patient age was 69 years; 90% were white; 57% had paraplegia; and 43% had tetraplegia. The majority (76%) had American Spinal Injury Association class A SCI. 76% were living with a significant other or other primary caregiver; 24% lived alone; 82% had at least once-daily nursing care. The average distance from the patients’ homes to the regional SCI unit was 37.3 miles. Reasons for admission to the telemedicine program included recurrent pressure ulcers, frequent outpatient clinic utilization, or post-flap surgery. At admission, pressure ulcers were stages II (20%), III (20%), or IV (60%). Pressure ulcer locations were sacral (29%), ischial (40%), trochanteric (14%), lower limb (11%), or heel/foot (6%). Mean admission duration was 15.2 weeks. Survey data revealed that patients agreed (17%) or strongly agreed (78%) that the program alleviated the ordeal of traveling to the SCI center. Patients agreed (31%) or strongly agreed (58%) that the telemedicine equipment worked well and was easy to use. Staff either agreed (12%) or strongly agreed (88%) that the telemedicine program resulted in the identification of problems or recommendations for future care that may have otherwise been delayed. Conclusions: Data suggest that an outpatient SCI telemedicine program can have a positive impact on pressure ulcer management and patient satisfaction. Key Words: Pressure ulcers; Rehabilitation; Spinal cord injuries; Telemedicine.
Poster 187 Dysphagia After Anterior Cervical Spinal Surgery: Incidence, Treatment Strategies, and Outcomes. Vasilios Stambolis, MD (Marianjoy Rehabilitation Hospital, Wheaton, IL); Susan L. Brady, MS; Rhonda J. Miserendino, MS; Teresa Springer, MS; Donna Statkus, MHS; Mark Hakel, PhD, e-mail: [email protected]. Disclosure: None. Objective: To identify the incidence, characteristics, treatment strategies, and outcomes for dysphagia after anterior cervical spinal surgery (ACSS). Design: Retrospective, case-controlled. Setting: 2 free-standing rehabilitation hospitals. Participants: All patients admitted to 2 rehabilitation hospitals over 3 years after ACSS. Interventions: Not applicable. Main Outcome Measures: American Speech-Language-Hearing Association National Outcome Measurement System (NOMS) Swallowing Scale, results of instrumental assessment for aspiration, laryngeal penetration, pharyngeal residue, and length of dysphagia treatment. Results: 46 patients were included in this study. Group 1 (n⫽31) included patients who presented with dysphagia after ACSS. Group 2 (n⫽15) included patients who presented with no dysphagia after ACSS. Mean age for group 1 was 56.35 years and group 2 was 52.40 years. The difference in age between the 2 groups was not statistically significant (F⫽.49, P⫽.487). Traumatic injuries versus nontraumatic injuries were equally represented in each group. In group 1, 32% presented with a concomitant brain injury and in group 2, 22%. A tracheotomy was present in 26% of group 1 subjects as compared with 13% in group 2 subjects. In group 1, 29% had either the SOMI or halo-brace as compared with 6.6% in group 2. In group 1, 61% had a cervical collar as compared with 93% in group 2. In group 1, mean NOMS swallowing level for admission was 2.806 and for discharge was 4.968. Gains made were considered statistically significant (F⫽17.12, P⬍.0001). 84% of group 1 underwent either a fluoroscopic or endoscopic swallow evaluation, with 50% presenting with aspiration, 62% with laryngeal penetration, and 81% with pharyngeal residue. Length of treatment ranged from 2 to 71 days (mean, 17.68d). Conclusion: Dysphagia after ACSS was present in 67.4% of the patients who were admitted to the rehabilitation hospitals. Aspiration, laryngeal penetration, and pharyngeal residue were common findings. These patients demonstrated significant progress with their dysphagia treatment during inpatient rehabilitation. Key Words: Dysphagia; Rehabilitation; Spine.
Poster 190 Autonomic Dysreflexia Caused by an Imbedded Intrauterine Device in a Tetraplegic Woman: A Case Report. Michael Y. Lee, MD (University of North Carolina, Chapel Hill, NC); Hang-Won Lee, MD; Richard Kim, MD; John Lavelle, MD, e-mail: [email protected]. Disclosure: None. Setting: Tertiary care university medical center. Patient: A 46-year-old woman with traumatic right C5, left C6 incomplete tetraplegia (American Spinal Injury Association class C) for 14 years. Case Description: The patient presented to the clinic with a 1-month history of constant and sharp low back pain (LBP), which was exacerbated by sitting up and with onset of symptoms of headache, piloerection, diaphoresis, increased spasticity, and increased blood pressure. Her blood pressure would increase up to 140/90mmHg (baseline blood pressure, 110/60mmHg). Extensive work-up, including magnetic resonance imaging of the spine, ruled out compression fracture of the spine, lower-extremity fracture, urinary tract infection, and fecal impaction. Computerized tomography scan of the pelvis suggested a partially extrauterine intrauterine device (IUD) beyond the confines of the posterior uterine wall. Diagnostic and operative hysteroscopy was performed with the removal of the imbedded IUD. Assessment/Results: Patient’s LBP and symptoms of autonomic dysreflexia (AD), including spasticity and diaphoresis, immediately improved on removal of the imbedded IUD. She was able to sit in a wheelchair for a prolonged period and returned to her usual activities. Discussion: This is the first reported case, to our knowledge, of an imbedded IUD in a tetraplegic woman causing AD. Several etiologies of positionally induced AD have been suggested, including lesions of the lower spine and hips where AD symptoms were induced by sitting up. Conclusion: Complications with an IUD, including embedment, should be considered in the evaluation of SCI woman with AD. Key Words: Autonomic dysreflexia; Intrauterine device; Rehabilitation; Spinal cord injuries.
Poster 188 Spinal Cord Infarction After Cervical Transforaminal Epidural Injection: A Case Report. Michael A. Ludwig, MD (University of Washington, Seattle, WA); Stephen Burns, MD, e-mail: [email protected]. Disclosure: None. Setting: Private community hospital. Patient: A 53-year-old man with history of chronic cervical pain and multilevel degenerative disk disease with multiple posterior disk protrusions on cervical imaging. Case Description: The patient received a left C6 tranforaminal injection under fluoroscopic guidance for therapeutic pain relief. Needle localization was obtained with fluoroscopic confirmation of left C6 nerve root sheath spread of injectable contrast. Aspiration revealed no fluid return, and was followed with .75mL of .75% bupivacaine and .75mL of triamcinolone. Patient tolerated the procedure well and transferred to stretcher without assistance. Approximately 10 to 15 minutes postprocedure, the patient noted weakness in his left arm and bilateral lower limbs. Initial cervical magnetic resonance imaging revealed no cord signal change, but a follow-up study 24 hours
Poster 191 Rehabilitation Outcomes in Spinal Cord Injury: Persons in Isolation Versus Nonisolation. Alan P. Alfano, MD (University of Virginia, Charlottesville, VA); Jay S. Patel, MBBS, e-mail: [email protected]. Disclosure: None. Objective: To compare the rehabilitation outcomes of persons with spinal cord injury (SCI) on isolation precautions for antibiotic resistant organisms (for vancomycin-resistant Enterococcus faecium or methcillin-resistant Staphylococcus aureus) with patients who are not. Design: Retrospective chart review. Setting: Acute inpatient rehabilitation hospital. Participants: 58 consecutive admissions with SCI from January 1999 to December 1999, 11 in isolation (ISO) and 47 in nonisolation (non-ISO). Interventions: Not applicable. Main Outcome Measures: Length of stay (LOS), total charges, FIM™ instrument change, and FIM efficiency. Results: For the ISO and non-ISO groups, the mean of LOS ⫾ SD was 73.73⫾47.92 days and 24.57⫾21.78 days, respectively; total charges were $111,804.91⫾$74,980.83 and $28,682.20⫾$26,448.38, respectively; FIM
Arch Phys Med Rehabil Vol 84, September 2003