- Email: [email protected]
Poster 217 thromboembolism and seizure after administration of intrathecal baclofen: A case series. Michael A. Ludwig, MD (Univ Washington, Seattle, WA); Ib R. Odderson, MD; Michael Hatzakis Jr, MD, e-mail: [email protected]
2004 Academy Annual Assembly Abstracts deficits at discharge. During the first year postinjury, his neuropsychologic status improved in certain areas (eg, language), but he continued to have severe memory impairment impacting daily activities. After extensive neuropsychologic testing was completed at 14mo postinjury, 5mg of donepezil hydrochloride (Aricept) was initiated daily and increased to 10mg after 1mo. Assessment/ Results: After medication initiation, his parents reported improvement in his memory, including better ability to remember daily events and increased utilization of compensatory strategies. Neuropsychologic testing 3mo after medication introduction revealed memory and processing speed improvements. Though memory was still below average for his age, performance improved on measures of everyday memory, verbal recognition, and nonverbal recall. Discussion: This is the first reported case, to our knowledge, of the use of donepezil in a child with brain injury. After introduction of medication, parent reports of improved memory functioning were corroborated by neuropsychologic testing. Practice effects might account for some of his improved performance, although it would be unlikely to account entirely for improvements. Of note, even on donepezil, the patient continued to display significant neuropsychologic problems, including memory difficulties, indicating an ameliorative rather than curative treatment effect. Conclusions: This case of a child with a severe anoxic brain injury whose memory functioning improved while on medication is intriguing and suggests that this or similar medications could be used to help treat memory problems after diffuse brain injuries in childhood. Research is critical to evaluate the efficacy of this medication. Key Words: Brain injuries; Pediatrics; Rehabilitation.
Poster 214 Injected Contrast Study Fails to Demonstrate Catheter-Pump Connector Tear: A Case Report. Linda E. Krach, MD (Gillette Children’s Specialty Healthcare, St. Paul, MN); Michael D. Partington, MD, e-mail: [email protected]. Disclosure: L.E. Krach, research grant from Medtronic, consulting fees from Medtronic, speakers bureau for Medtronic; M.D. Partington, None. Setting: Regional children’s specialty hospital. Patient: 11-yo boy with a history of quadriparetic cerebral palsy, shunted hydrocephalus, and continuous infusion of intrathecal baclofen (ITB) to treat hypertonicity. Case Description: The patient presented for a second opinion after experiencing 3wk of increased tone treated by shunt revision 3 times after 2 studies injecting contrast into the ITB pump catheter via the catheter access port did not demonstrate any extravasation of contrast material. Parents reported that there was little change in his lower-extremity tightness. His speech showed increased dysarthria during this time, and he had unusual difficulty handling food. On evaluation, the patient had severely increased muscle tone. He also was noted to have palpable fluid in his pump pocket. Review of the radiographs that accompanied the patient revealed findings that caused us to be suspicious of a tear of the sleeve that is part of the mechanism connecting the intrathecal catheter to the pump. A 100g bolus of ITB was administered, which did result in some relaxation. Assessment/Results: The patient underwent surgery at which time a torn pump-catheter connector was confirmed and replaced with a different type of connector. His symptoms resolved and he required a lower dose of ITB than on admission for significantly better tone control. Discussion: Patients typically reach a stable dose of ITB and if they develop a need for increasing dose later, most frequently a catheter problem exists. Also, if there is fluid in the pump pocket, one should have a high index of suspicion for this type of catheter and/or pump connector tear. Conclusions: In this case, careful evaluation of plain radiographs coupled with careful history taking, including the patient’s response to interventions, was all that was necessary to make an accurate diagnosis. Key Words: Baclofen; Muscle spasticity; Rehabilitation.
Poster 215: Refer to Abstract 56 in Pediatrics Poster Grand Rounds for full abstract. e-mail: [email protected].
Physiatric Therapeutics Poster 216 Acute Intrathecal Baclofen Withdrawal Due to a Pharmaceutical Compounding Error: A Case Report. Maurice R. Bernaiche, DO (Michigan State Univ Coll Osteopathic Med, East Lansing, MI); Michael T. Andary, MD; Joel Bez, DO; J.J. Pysch, DO; Scott Kuhnert, MD, e-mail: [email protected]. Disclosure: M.R. Bernaiche, None; M.T. Andary, None; J. Bez, None; J.J. Pysch, None; S. Kuhnert, None. Setting: University-affiliated community hospital. Patient: A 39-yo woman with a history of stiff-man syndrome (SMS) with acute intrathecal baclofen (ITB) withdrawal secondary to a pharmaceutical compounding error. Case Description: The patient presented 3d after her regularly scheduled pump reservoir drug refill with worsening “stiffness, itching and headaches.” Complete medical management and pump interrogation enacted emergently revealed no apparent cause. The patient received a total of 100mg of intravenous diazepam, in separate 10-mg doses over several hours; she was monitored closely and worsened overnight. She later received a 100-mg bolus of ITB via lumbar puncture and was taken to surgery where the pump and catheter were removed and replaced with fresh instruments. With appropriate dosing of ITB, her withdrawal symptoms resolved. She survived and returned to exceptional functional baseline. A sample of the medication with the pump was sent to laboratory. Assessment/Results: The concentration of the ITB was found to be three quarters of the expected strength (1600g/mL vs 2000g/mL). Discussion: SMS and baclofen withdrawal were treated successfully with ITB. To our knowledge, this is the first reported case of a pharmaceutical compounding error leading to a subtherapeutic dosing of baclofen and baclofen withdrawal. Conclusions: Acute baclofen withdrawal can still occur despite the fact that the drug is present at three-quarter strength at its intended location. Inaccurate concentration of the medication must be considered in the differential diagnosis of baclofen withdrawal. Key Words: Baclofen; Rehabilitation; Stiff-man syndrome.
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Poster 217 Thromboembolism and Seizure After Administration of Intrathecal Baclofen: A Case Series. Michael A. Ludwig, MD (Univ Washington, Seattle, WA); Ib R. Odderson, MD; Michael Hatzakis Jr, MD, e-mail: [email protected]. Disclosure: M.A. Ludwig, None; I.R. Odderson, None; M. Hatzakis, None. Setting: Community and Veteran’s Affairs hospital. Patients: 2 patients with intractable lowerlimb spasticity. Case Descriptions: A 77-yo man with hemorrhagic stroke and left spastic hemiparesis (Ashworth Scale grade 4). He demonstrated an excellent clinical response to intrathecal baclofen (ITB) therapy with reduction of spasticity to Ashworth grade 1⫹ in the lower limbs. He presented with dyspnea 15d after the pump implantation with extensive acute thrombosis in his hemiparetic limb and multiple acute pulmonary emboli. In an effort to regain muscle tone and function in the hemiparetic limb, the ITB dose was reduced by 10%, and new onset seizures were seen within 24h. A 36-yo man with multiple sclerosis and spasticity in his plantarflexors (Ashworth grade 3) underwent ITB therapy with near complete loss of spasticity in the lower limbs. He suffered a fatal saddle embolus on postoperative day 1. Assessment/Results: The proposed mechanism was that of acute venous stasis due to the clinical loss of spasticity. Prophylactic therapy for deep venous thrombosis (DVT) prevention was not instituted in either case because of the chronicity of their impaired mobility. Discussion: We know of only 1 other reported case of documented acute thromboembolic events after administration of ITB. Conclusions: The sudden loss of muscle contraction seen with ITB therapy predisposes the patient to venous stasis and the sequelae of DVT and possibly fatal pulmonary embolism. We recommend that patients undergoing ITB therapy receive DVT prophylaxis, including medical and mechanical therapy. Second, when adjusting the ITB dose, proceed with caution, because seizure was seen with adjustments well below what has been considered a safe dosage adjustment. Key Words: Baclofen; Pulmonary embolus; Rehabilitation; Seizures; Venous thrombosis.
Poster 218 Catheter Migration After Intradiskal Procedure: A Case Report. Santhosh A. Thomas, DO (Cleveland Clin Foundation, Westlake, OH); R. Douglas Orr, MD, e-mail: sthomas315@ yahoo.com. Disclosure: S.A. Thomas, None; R.D. Orr, None. Setting: Multispecialty outpatient clinic. Patient: 45-yo woman originally presented with chief complaint of low back pain (LBP). Case Description: Patient initially presented to an outside pain management program. The patient underwent minimal conservative care including oral analgesic. No physical therapy was used to treat her pain. The patient subsequently underwent a diskogram and then intradiskal electrothermal therapy (IDET). During the procedure, the tip of a catheter broke off inside the disk. The patient reported increased back pain after the procedure and later developed left leg paresthesias. She presented to our institution and a computer tomography revealed that the catheter had migrated presumably to the extradural space. Multiple attempts to dissuade the patient from surgery failed and the patient insisted that the catheter be removed. Initially, a limited laminotomy was performed on the assumption that the catheter was extradural. The catheter tip was not found. A wide laminectomy was then performed and the catheter tip was still not visible. Intraoperative radiographs revealed that the catheter tip was in the midline and posterior to the foramen. A longitudinal durotomy was made and the catheter tip was inside the dural sac. Assessment/Results: 4mo postoperatively, the patient was still having some back pain but had improvement in her left lower-extremity radicular pain. Discussion: IDET has been advocated as a minimally invasive procedure for the treatment of diskogenic pain. Reasonable success with low complications has been reported. Conclusions: We report the first case of a catheter tip that broke off inside the disk during an IDET procedure subsequently migrating into the dural sac. In this case, removal of the tip led to reduction of the LBP and radicular pain but did not completely abolish the paresthesias. Key Words: Electrothermal therapy; Rehabilitation.
Poster 219 Changes in the Motoneuron Excitability With Passive Exercise Using a Robotic Arm in Healthy Subjects. Jeffery Ho, DO (Greater Los Angeles VA Healthcare Syst, Los Angeles, CA); Sheila Patel, DO; Raji Kumar, MD; Khang Lai, DO; Brian Ahangar, MD; A.M. Erika Scremin, MD, e-mail: [email protected]. Disclosure: J. Ho, None; S. Patel, None; R. Kumar, None; K. Lai, None; B. Ahangar, None; A. Scremin, None. Objective: To assess the influence of passive exercise on the spinal motoneuron excitability, Hoffman reflex (H-reflex), and motor response (M response) in healthy subjects. Design: Casecontrol prospective study. Setting: Physical medicine and rehabilitation outpatient clinic at an urban tertiary veteran association medical center. Participants: 19 healthy subjects (16 men, 3 women; average age, 65.7⫾8.7y). Interventions: Patients sat in a wheelchair with their right arm secured to the robotic arm. A standardized passive exercise program was performed for 20min using the robotic arm. Nerve conduction study was done before and within 3min after the exercise. The median nerve was stimulated at the elbow with the recording electrode placed over the flexor carpi radialis muscle. Care was taken to prevent displacement of the recording electrodes throughout the study. Maximum onset to peak amplitude of the H-reflex (Hmax) and M response wave (Mmax) were recorded. The Hmax/Mmax ratio was calculated. Main Outcome Measure: Hmax/Mmax ratio. Results: The pre- and postexercise Hmax average values were 1.26⫾1.10 and 1.02⫾0.77, respectively. The pre- and postexercise Mmax average values were 4.57⫾2.62 and 4.84⫾2.57, respectively. The average Hmax/Mmax ratio preexercise was .39⫾.41 and the postexercise was .27⫾.24. There were no significant differences in pre- and postexercise H-reflex (P⫽.47). However, there was a significant reduction in the pre- and postexercise M response (P⬍.03) and Hmax/Mmax ratio (P⬍.049). Conclusions: In healthy subjects, passive exercise causes an immediate and significant postexercise depression in motoneuron excitability. Although there was a depression of the H-reflex, the facilitation of the M response was more significant. These postexercise changes may play a role in strengthening exercise programs. Key Words: Exercise; H-reflex; Rehabilitation.
Arch Phys Med Rehabil Vol 85, September 2004
Poster 214 Injected Contrast Study Fails to Demonstrate Catheter-Pump Connector Tear: A Case Report. Linda E. Krach, MD (Gillette Children’s Specialty Healthcare, St. Paul, MN); Michael D. Partington, MD, e-mail: [email protected]. Disclosure: L.E. Krach, research grant from Medtronic, consulting fees from Medtronic, speakers bureau for Medtronic; M.D. Partington, None. Setting: Regional children’s specialty hospital. Patient: 11-yo boy with a history of quadriparetic cerebral palsy, shunted hydrocephalus, and continuous infusion of intrathecal baclofen (ITB) to treat hypertonicity. Case Description: The patient presented for a second opinion after experiencing 3wk of increased tone treated by shunt revision 3 times after 2 studies injecting contrast into the ITB pump catheter via the catheter access port did not demonstrate any extravasation of contrast material. Parents reported that there was little change in his lower-extremity tightness. His speech showed increased dysarthria during this time, and he had unusual difficulty handling food. On evaluation, the patient had severely increased muscle tone. He also was noted to have palpable fluid in his pump pocket. Review of the radiographs that accompanied the patient revealed findings that caused us to be suspicious of a tear of the sleeve that is part of the mechanism connecting the intrathecal catheter to the pump. A 100g bolus of ITB was administered, which did result in some relaxation. Assessment/Results: The patient underwent surgery at which time a torn pump-catheter connector was confirmed and replaced with a different type of connector. His symptoms resolved and he required a lower dose of ITB than on admission for significantly better tone control. Discussion: Patients typically reach a stable dose of ITB and if they develop a need for increasing dose later, most frequently a catheter problem exists. Also, if there is fluid in the pump pocket, one should have a high index of suspicion for this type of catheter and/or pump connector tear. Conclusions: In this case, careful evaluation of plain radiographs coupled with careful history taking, including the patient’s response to interventions, was all that was necessary to make an accurate diagnosis. Key Words: Baclofen; Muscle spasticity; Rehabilitation.
Poster 215: Refer to Abstract 56 in Pediatrics Poster Grand Rounds for full abstract. e-mail: [email protected].
Physiatric Therapeutics Poster 216 Acute Intrathecal Baclofen Withdrawal Due to a Pharmaceutical Compounding Error: A Case Report. Maurice R. Bernaiche, DO (Michigan State Univ Coll Osteopathic Med, East Lansing, MI); Michael T. Andary, MD; Joel Bez, DO; J.J. Pysch, DO; Scott Kuhnert, MD, e-mail: [email protected]. Disclosure: M.R. Bernaiche, None; M.T. Andary, None; J. Bez, None; J.J. Pysch, None; S. Kuhnert, None. Setting: University-affiliated community hospital. Patient: A 39-yo woman with a history of stiff-man syndrome (SMS) with acute intrathecal baclofen (ITB) withdrawal secondary to a pharmaceutical compounding error. Case Description: The patient presented 3d after her regularly scheduled pump reservoir drug refill with worsening “stiffness, itching and headaches.” Complete medical management and pump interrogation enacted emergently revealed no apparent cause. The patient received a total of 100mg of intravenous diazepam, in separate 10-mg doses over several hours; she was monitored closely and worsened overnight. She later received a 100-mg bolus of ITB via lumbar puncture and was taken to surgery where the pump and catheter were removed and replaced with fresh instruments. With appropriate dosing of ITB, her withdrawal symptoms resolved. She survived and returned to exceptional functional baseline. A sample of the medication with the pump was sent to laboratory. Assessment/Results: The concentration of the ITB was found to be three quarters of the expected strength (1600g/mL vs 2000g/mL). Discussion: SMS and baclofen withdrawal were treated successfully with ITB. To our knowledge, this is the first reported case of a pharmaceutical compounding error leading to a subtherapeutic dosing of baclofen and baclofen withdrawal. Conclusions: Acute baclofen withdrawal can still occur despite the fact that the drug is present at three-quarter strength at its intended location. Inaccurate concentration of the medication must be considered in the differential diagnosis of baclofen withdrawal. Key Words: Baclofen; Rehabilitation; Stiff-man syndrome.
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Poster 217 Thromboembolism and Seizure After Administration of Intrathecal Baclofen: A Case Series. Michael A. Ludwig, MD (Univ Washington, Seattle, WA); Ib R. Odderson, MD; Michael Hatzakis Jr, MD, e-mail: [email protected]. Disclosure: M.A. Ludwig, None; I.R. Odderson, None; M. Hatzakis, None. Setting: Community and Veteran’s Affairs hospital. Patients: 2 patients with intractable lowerlimb spasticity. Case Descriptions: A 77-yo man with hemorrhagic stroke and left spastic hemiparesis (Ashworth Scale grade 4). He demonstrated an excellent clinical response to intrathecal baclofen (ITB) therapy with reduction of spasticity to Ashworth grade 1⫹ in the lower limbs. He presented with dyspnea 15d after the pump implantation with extensive acute thrombosis in his hemiparetic limb and multiple acute pulmonary emboli. In an effort to regain muscle tone and function in the hemiparetic limb, the ITB dose was reduced by 10%, and new onset seizures were seen within 24h. A 36-yo man with multiple sclerosis and spasticity in his plantarflexors (Ashworth grade 3) underwent ITB therapy with near complete loss of spasticity in the lower limbs. He suffered a fatal saddle embolus on postoperative day 1. Assessment/Results: The proposed mechanism was that of acute venous stasis due to the clinical loss of spasticity. Prophylactic therapy for deep venous thrombosis (DVT) prevention was not instituted in either case because of the chronicity of their impaired mobility. Discussion: We know of only 1 other reported case of documented acute thromboembolic events after administration of ITB. Conclusions: The sudden loss of muscle contraction seen with ITB therapy predisposes the patient to venous stasis and the sequelae of DVT and possibly fatal pulmonary embolism. We recommend that patients undergoing ITB therapy receive DVT prophylaxis, including medical and mechanical therapy. Second, when adjusting the ITB dose, proceed with caution, because seizure was seen with adjustments well below what has been considered a safe dosage adjustment. Key Words: Baclofen; Pulmonary embolus; Rehabilitation; Seizures; Venous thrombosis.
Poster 218 Catheter Migration After Intradiskal Procedure: A Case Report. Santhosh A. Thomas, DO (Cleveland Clin Foundation, Westlake, OH); R. Douglas Orr, MD, e-mail: sthomas315@ yahoo.com. Disclosure: S.A. Thomas, None; R.D. Orr, None. Setting: Multispecialty outpatient clinic. Patient: 45-yo woman originally presented with chief complaint of low back pain (LBP). Case Description: Patient initially presented to an outside pain management program. The patient underwent minimal conservative care including oral analgesic. No physical therapy was used to treat her pain. The patient subsequently underwent a diskogram and then intradiskal electrothermal therapy (IDET). During the procedure, the tip of a catheter broke off inside the disk. The patient reported increased back pain after the procedure and later developed left leg paresthesias. She presented to our institution and a computer tomography revealed that the catheter had migrated presumably to the extradural space. Multiple attempts to dissuade the patient from surgery failed and the patient insisted that the catheter be removed. Initially, a limited laminotomy was performed on the assumption that the catheter was extradural. The catheter tip was not found. A wide laminectomy was then performed and the catheter tip was still not visible. Intraoperative radiographs revealed that the catheter tip was in the midline and posterior to the foramen. A longitudinal durotomy was made and the catheter tip was inside the dural sac. Assessment/Results: 4mo postoperatively, the patient was still having some back pain but had improvement in her left lower-extremity radicular pain. Discussion: IDET has been advocated as a minimally invasive procedure for the treatment of diskogenic pain. Reasonable success with low complications has been reported. Conclusions: We report the first case of a catheter tip that broke off inside the disk during an IDET procedure subsequently migrating into the dural sac. In this case, removal of the tip led to reduction of the LBP and radicular pain but did not completely abolish the paresthesias. Key Words: Electrothermal therapy; Rehabilitation.
Poster 219 Changes in the Motoneuron Excitability With Passive Exercise Using a Robotic Arm in Healthy Subjects. Jeffery Ho, DO (Greater Los Angeles VA Healthcare Syst, Los Angeles, CA); Sheila Patel, DO; Raji Kumar, MD; Khang Lai, DO; Brian Ahangar, MD; A.M. Erika Scremin, MD, e-mail: [email protected]. Disclosure: J. Ho, None; S. Patel, None; R. Kumar, None; K. Lai, None; B. Ahangar, None; A. Scremin, None. Objective: To assess the influence of passive exercise on the spinal motoneuron excitability, Hoffman reflex (H-reflex), and motor response (M response) in healthy subjects. Design: Casecontrol prospective study. Setting: Physical medicine and rehabilitation outpatient clinic at an urban tertiary veteran association medical center. Participants: 19 healthy subjects (16 men, 3 women; average age, 65.7⫾8.7y). Interventions: Patients sat in a wheelchair with their right arm secured to the robotic arm. A standardized passive exercise program was performed for 20min using the robotic arm. Nerve conduction study was done before and within 3min after the exercise. The median nerve was stimulated at the elbow with the recording electrode placed over the flexor carpi radialis muscle. Care was taken to prevent displacement of the recording electrodes throughout the study. Maximum onset to peak amplitude of the H-reflex (Hmax) and M response wave (Mmax) were recorded. The Hmax/Mmax ratio was calculated. Main Outcome Measure: Hmax/Mmax ratio. Results: The pre- and postexercise Hmax average values were 1.26⫾1.10 and 1.02⫾0.77, respectively. The pre- and postexercise Mmax average values were 4.57⫾2.62 and 4.84⫾2.57, respectively. The average Hmax/Mmax ratio preexercise was .39⫾.41 and the postexercise was .27⫾.24. There were no significant differences in pre- and postexercise H-reflex (P⫽.47). However, there was a significant reduction in the pre- and postexercise M response (P⬍.03) and Hmax/Mmax ratio (P⬍.049). Conclusions: In healthy subjects, passive exercise causes an immediate and significant postexercise depression in motoneuron excitability. Although there was a depression of the H-reflex, the facilitation of the M response was more significant. These postexercise changes may play a role in strengthening exercise programs. Key Words: Exercise; H-reflex; Rehabilitation.
Arch Phys Med Rehabil Vol 85, September 2004