- Email: [email protected]
Poster 228
E44
2005 ACADEMY ANNUAL ASSEMBLY ABSTRACTS
Poster 225 Heterotopic Ossification With Normal Serum Alkaline Phosphatase Levels: A Case Series. Divakara Kedlaya, MD (Loma Linda University Medical Center, Loma Linda, CA); Cid Nazir, MD, e-mail: [email protected]. Disclosure: None. Setting: Acute rehabilitation unit. Patients: A 28-year-old man with T12 American Spinal Injury Association (ASIA) grade C paraplegia due to gunshot wound, a 20-year-old man with T5 ASIA grade A paraplegia due to motor vehicle collision (MVC), and a 36-year-old man with C7-8 ASIA grade A tetraplegia due to MVC. Case Descriptions: The first patient had worsening pain, swelling, and decreased range of motion (ROM) of the left knee 5 weeks after the injury. Radiographs and triple-phase bone scan showed immature heterotopic ossification (HO) in medial condyle and epicondyle of left femur. Serum alkaline phosphatase (SAP) level was normal. Follow-up SAP a month later was also normal. The second patient had decreased ROM and a palpable callus of the right hip 14 weeks after the injury. He had history of fracture of right subtrochanteric right femur, which was treated with intramedullary rod. Hip radiograph showed HO in the soft tissues of right hip. Serial SAP levels were normal. On day 18 postinjury, the third patient began spiking high-grade fevers (⬎39°C) for the next 30 days. An extensive workup revealed no source of fever. 3 weeks later, he developed swelling and limited ROM in the left hip. Further workup was negative for deep venous thrombosis, and a triple-phase bone scan revealed HO in both hips. Serial SAP levels were normal. Discussion: In these 3 cases with documented HO, serum alkaline phosphatase levels were normal. We like to question the sensitivity of SAP as a marker for HO in its early diagnosis. Further studies need to be done to evaluate the sensitivity of SAP in the diagnosis of HO. Conclusions: Serial SAP levels may be normal in documented cases of HO. Key Words: Heterotopic ossification, Rehabilitation; Serum alkaline phosphatase; Spinal cord injuries.
Poster 226 A Proximate Cause of Heterotopic Ossification—Possible Implications for Parsing Etiologic Factors? A Case Report. Eric L. Altschuler, MD, PhD (Mt. Sinai School of Medicine, New York, NY); Brian Riordan, MD; Thomas N. Bryce, MD, e-mail: [email protected]. Disclosure: None. Setting: Acute rehabilitation facility. Patient: A 32-year-old man with a traumatic C6 complete spinal cord injury (SCI). Case Description: Before the SCI, the patient had a medical history only of kidney stones. Approximately 1.5 months post-SCI, the patient developed swelling in his right hip and groin area. Venous Doppler showed no evidence for deep vein thrombosis. Magnetic resonance imaging showed a fluid collection along the anterior aspect of the right quadriceps and accompanying inflammatory changes. Approximately 4 weeks later, the patient developed a solid mass in the right anterior thigh. Assessment/Results: Radiographs of the mass showed heterotopic ossification (HO) surrounding the right proximal femoral diaphysis. The HO was clinically significant causing some decreased hip range of motion. Discussion: This patient had a number of risk factors for developing HO: complete cervical SCI and a history of kidney stones. Interestingly, the patient only developed HO in the region with the fluid collection and inflammation, a locale with disruption of mesenchymal tissues. In this case, local injury and disruption of normal milieu were likely necessary etiologic factors in the development of the HO. By similar reasoning, cases of nonbrain or SCI patients who develop HO in the area of a joint that has been replaced, but not at other joints, may indicate the necessity of trauma to local mesenchymal tissue in the development of HO. Extremity trauma with obvious mesenchymal injury in patients with SCI may increase the risk for developing HO, potentially warranting HO prophylaxis (eg, with etidrium sodium) Conclusions: We demonstrate a case in which local trauma and tissue disruption was most likely a necessary factor in the development of HO. Controlled studies of treating patients with obvious extremity mesenchymal injury and SCI to prevent HO may be warranted. Key Words: Etiology; Heterotopic ossification; Rehabilitation; Spinal cord injuries; Trauma.
Poster 227 An Unusual Etiology for a Floppy Infant: A Case Report. Marioara Bodea, MD (East Carolina University, Brody School of Medicine, Greenville, NC); David Epperson, MD; Daniel P. Moore, MD, e-mail: [email protected]. Disclosure: None. Setting: Tertiary care hospital, in- and outpatient pediatric rehabilitation units. Patient: White male with hypotonia at birth, followed until 3 years of age. Case Description: This white male was born at 35 weeks of gestation, 3000gm, via C-section secondary to failure to progress and preeclampsia. History included a weak cry, poor respiratory effort, and quadriplegia. A physical exam revealed axial hypotonia, quadriplegia, absent deep tendon, palmar and plantar grasp, clonus, and Moro reflexes. Differential diagnosis initially included central nervous system disorders (congenital, genetic, metabolic, infectious, vascular, traumatic), motoneuron disorders (eg, Werdnig-Hoffman disease), neuromuscular junction disorders, congenital myopathies, congenital muscular dystrophy, and myotonia congenita. Assessment/Results: Complete blood count, serum electrolytes, and head and neck computed tomography were unremarkable. Creatine phosphokinase was 349. The workup for Werdnig-Hoffman disease, myotonia congenita, and myasthenia gravis was negative. With negative initial workup, a referral was made and a magnetic resonance imaging (MRI) of the spine was performed. It revealed abnormal T1 and T2 signal within the spinal cord extending from the cervicothoracic junction to the conus, consistent with ischemia and/or intramedullary hemorrhage. Coagulopathy workup was negative. At the 3-year follow-up, the patient had some antigravity strength in the upper extremities and 0/5 strength in the lower extremities. The cognitive development was appropriate for his age, and the patient was able to use a manual wheelchair. A repeat MRI revealed intramedullary central cord mass, possibly a lipoma spanning T6-12, and a tethered cord. Discussion: Intramedullary spinal cord hemorrhage in a neonate is unusual. Other locations of hemorrhage such as subarachnoid, subdural, or epidural are more commonly seen. A systematic approach to the floppy infant is important. Conclusions: This is a rare case of intramedullary cord hemorrhage at birth with hypotonia. It demonstrates the need to consider SCI in the differential diagnosis. Key Words: Muscle hypotonia; Rehabilitation; Spinal cord diseases.
Arch Phys Med Rehabil Vol 86, September 2005
Poster 228 Use of Bladder Irrigation To Treat Bacteriuria in Persons With Neurogenic Bladder Dysfunction. Ken B. Waites, MD; Kay C. Kanupp, MSN, CRNP; James F. Roper, MD; Yuying Chen, MD, PhD (University of Alabama, Birmingham, AL); Susan M. Camp, CRNP, e-mail: [email protected]. Disclosure: None. Objective: To evaluate the potential value of bladder irrigation to treat bacteriuria in persons with neurogenic bladders. Design: Double-blind randomized controlled trial. Setting: Rehabilitation center. Participants: 52 community-residing men and women with neurogenic bladders managed with an indwelling Foley catheter or suprapubic tube. Intervention: Subjects were randomized to irrigate their bladders twice daily for 8 weeks with 30mL of: sterile saline, acetic acid, or neomycin-polymixin. Main Outcome Measures: Urinalysis and cultures were performed at baseline and weeks 2, 4, and 8 to determine the extent to which each of the solutions affected bacterial numbers, pH, urinary leukocytes, and generation of antimicrobial-resistant organisms. Results: Bladder irrigation was well tolerated with the exception of 3 subjects who had bladder spasms and could not participate further. All participants had bacteriuria with ⱖ100,000 colonies/mL at baseline. None of the 3 irrigants had a detectable effect on the degree of bacteriuria, pyuria, or urinary pH. There was no significant increase in the occurrence of oxacillin-resistant Staphylococcus aureus or multidrug resistant gram-negative bacilli in any of the 3 groups, although the baseline rates of resistance were high. No significant development of resistance to oral antimicrobials among gram-negative bacilli beyond what was observed at baseline was detected. Conclusions: Bladder irrigation was generally well tolerated for 8 weeks. No advantages were detected for neomycin-polymixin or acetic acid over saline in terms of reducing the urinary bacterial load and inflammation. We cannot recommend bladder irrigation as an alternative to systemic antibiotics for treatment of bacteriuria. Key Words: Bacteriuria; Bladder, Neurogenic; Rehabilitation; Urinary tract infections.
Poster 229 Compliance With Guidelines for Preventing Pressure Ulcers Following Spinal Cord Injury. Sunil Sabharwal, MD (VA New England Healthcare System/ Harvard Medical School, Boston, MA); Dan Berlowitz, MD, MPH; Elaine Czarnowski, RN; Elaine Hickey, RN, e-mail: [email protected]. Disclosure: None. Objectives: To measure current compliance with the pressure ulcer prevention guidelines (Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury, published by the Consortium for Spinal Cord Medicine) and to define determinants of variation from guideline recommendations and identify compliance barriers and facilitators. Design: (1) Review of 100 randomly selected medical records using a chart abstraction tool developed for abstracting information regarding compliance with pressure ulcer prevention. Inclusion criteria were SCI diagnostic ICD-9 codes and clinic visit or hospitalization at a study site in fiscal year 2003. (2) Provider focus groups conducted to identify perceived facilitators and barriers to guideline adherence. Setting: VA spinal cord injury (SCI) system of care including an SCI center and 5 SCI clinics. Interventions: Not applicable. Main Outcome Measures: Overall and facility-specific adherence rates to 14 pressure ulcer prevention guidelines. Records with outpatient visits only were analyzed separately from those with inpatient hospitalizations. Results: Guideline adherence was lower in the outpatient than inpatient group. For example, 90% of inpatients had documented pressure ulcer risk factor assessment versus 5% of outpatients. Guideline adherence varied considerably between sites. For example, nutritional status documentation varied from 15% to 85% within outpatient sites and documented pressure relief regimen ranged from 5% to 65%. Adherence was better for some guidelines than others. For example, for the outpatient group, wheelchair cushion assessment was documented in 60%, but ⬍5% documented bed support surfaces used. Focus groups indicated that standardized templates incorporating guidelines would improve documentation and also serve as a reminder checklist. The greatest perceived barrier to guideline adherence was patient compliance. Conclusions: Knowledge generated by this study has prompted development of interventions especially with outpatient focus, including standardized templates for pressure ulcer specific periodic evaluation, and patient educational material to promote compliance. Key Words: Clinical practice guidelines; Spinal cord injuries; Pressure ulcer; Rehabilitation.
Poster 230 Incidence and Outcomes of Spinal Cord Injury Clinical Syndromes. Katia Santos, MD (Virginia Commonwealth University, Richmond, VA); William McKinley, MD; Michelle Meade, PhD; Karen L. Brooke, e-mail: [email protected]. Disclosure: None. Objective: To examine and compare demographics and functional outcomes for individuals with spinal cord injury (SCI) clinical syndromes, including central cord (CCS), Brown-Sequard (BSS), anterior cord (ACS), posterior cord (PCS), cauda equina (CES), and conus medullaris (CMS). Design: Retrospective review. Setting: Tertiary care, level I trauma center inpatient rehabilitation unit. Participants: 848 consecutive admissions with acute SCI. Interventions: Not applicable. Main Outcome Measures: FIM instrument, FIM subgroups (motor, self-care, cognitive), length of stay (LOS), and discharge disposition. Results: 176 (20.8%) patients were diagnosed with SCI clinical syndromes. CCS was the most common (44.3%), followed by CES (25.6%) and BSS (17.6%). Significant differences (Pⱕ.01) were found between groups with regard to age, race, etiology, total admission FIM, motor admission FIM, self-care admission and discharge FIM, and LOS. Statistical analysis between tetraplegic BSS and CCS revealed significant difference (Pⱕ.01) with respect to age (38.9 vs 53.2) and a trend toward significance (Pⱕ.05) with regard to total discharge FIM (97.0 vs 85.0), motor discharge FIM (64.5 vs 55.0), and self-care discharge FIM (29.0 vs 23.9). No significant differences (Pⱕ.01) were found when comparing CMS with CES. Conclusions: SCI clinical syndromes represent a significant proportion of admissions to acute SCI rehabilitation with CCS presenting most commonly and representing the oldest age group with the lowest admission functional level of all SCI clinical syndromes. Cervical BBS individuals seem to achieve higher functional improvement by discharge when compared with CCS patients. CMS and
2005 ACADEMY ANNUAL ASSEMBLY ABSTRACTS
Poster 225 Heterotopic Ossification With Normal Serum Alkaline Phosphatase Levels: A Case Series. Divakara Kedlaya, MD (Loma Linda University Medical Center, Loma Linda, CA); Cid Nazir, MD, e-mail: [email protected]. Disclosure: None. Setting: Acute rehabilitation unit. Patients: A 28-year-old man with T12 American Spinal Injury Association (ASIA) grade C paraplegia due to gunshot wound, a 20-year-old man with T5 ASIA grade A paraplegia due to motor vehicle collision (MVC), and a 36-year-old man with C7-8 ASIA grade A tetraplegia due to MVC. Case Descriptions: The first patient had worsening pain, swelling, and decreased range of motion (ROM) of the left knee 5 weeks after the injury. Radiographs and triple-phase bone scan showed immature heterotopic ossification (HO) in medial condyle and epicondyle of left femur. Serum alkaline phosphatase (SAP) level was normal. Follow-up SAP a month later was also normal. The second patient had decreased ROM and a palpable callus of the right hip 14 weeks after the injury. He had history of fracture of right subtrochanteric right femur, which was treated with intramedullary rod. Hip radiograph showed HO in the soft tissues of right hip. Serial SAP levels were normal. On day 18 postinjury, the third patient began spiking high-grade fevers (⬎39°C) for the next 30 days. An extensive workup revealed no source of fever. 3 weeks later, he developed swelling and limited ROM in the left hip. Further workup was negative for deep venous thrombosis, and a triple-phase bone scan revealed HO in both hips. Serial SAP levels were normal. Discussion: In these 3 cases with documented HO, serum alkaline phosphatase levels were normal. We like to question the sensitivity of SAP as a marker for HO in its early diagnosis. Further studies need to be done to evaluate the sensitivity of SAP in the diagnosis of HO. Conclusions: Serial SAP levels may be normal in documented cases of HO. Key Words: Heterotopic ossification, Rehabilitation; Serum alkaline phosphatase; Spinal cord injuries.
Poster 226 A Proximate Cause of Heterotopic Ossification—Possible Implications for Parsing Etiologic Factors? A Case Report. Eric L. Altschuler, MD, PhD (Mt. Sinai School of Medicine, New York, NY); Brian Riordan, MD; Thomas N. Bryce, MD, e-mail: [email protected]. Disclosure: None. Setting: Acute rehabilitation facility. Patient: A 32-year-old man with a traumatic C6 complete spinal cord injury (SCI). Case Description: Before the SCI, the patient had a medical history only of kidney stones. Approximately 1.5 months post-SCI, the patient developed swelling in his right hip and groin area. Venous Doppler showed no evidence for deep vein thrombosis. Magnetic resonance imaging showed a fluid collection along the anterior aspect of the right quadriceps and accompanying inflammatory changes. Approximately 4 weeks later, the patient developed a solid mass in the right anterior thigh. Assessment/Results: Radiographs of the mass showed heterotopic ossification (HO) surrounding the right proximal femoral diaphysis. The HO was clinically significant causing some decreased hip range of motion. Discussion: This patient had a number of risk factors for developing HO: complete cervical SCI and a history of kidney stones. Interestingly, the patient only developed HO in the region with the fluid collection and inflammation, a locale with disruption of mesenchymal tissues. In this case, local injury and disruption of normal milieu were likely necessary etiologic factors in the development of the HO. By similar reasoning, cases of nonbrain or SCI patients who develop HO in the area of a joint that has been replaced, but not at other joints, may indicate the necessity of trauma to local mesenchymal tissue in the development of HO. Extremity trauma with obvious mesenchymal injury in patients with SCI may increase the risk for developing HO, potentially warranting HO prophylaxis (eg, with etidrium sodium) Conclusions: We demonstrate a case in which local trauma and tissue disruption was most likely a necessary factor in the development of HO. Controlled studies of treating patients with obvious extremity mesenchymal injury and SCI to prevent HO may be warranted. Key Words: Etiology; Heterotopic ossification; Rehabilitation; Spinal cord injuries; Trauma.
Poster 227 An Unusual Etiology for a Floppy Infant: A Case Report. Marioara Bodea, MD (East Carolina University, Brody School of Medicine, Greenville, NC); David Epperson, MD; Daniel P. Moore, MD, e-mail: [email protected]. Disclosure: None. Setting: Tertiary care hospital, in- and outpatient pediatric rehabilitation units. Patient: White male with hypotonia at birth, followed until 3 years of age. Case Description: This white male was born at 35 weeks of gestation, 3000gm, via C-section secondary to failure to progress and preeclampsia. History included a weak cry, poor respiratory effort, and quadriplegia. A physical exam revealed axial hypotonia, quadriplegia, absent deep tendon, palmar and plantar grasp, clonus, and Moro reflexes. Differential diagnosis initially included central nervous system disorders (congenital, genetic, metabolic, infectious, vascular, traumatic), motoneuron disorders (eg, Werdnig-Hoffman disease), neuromuscular junction disorders, congenital myopathies, congenital muscular dystrophy, and myotonia congenita. Assessment/Results: Complete blood count, serum electrolytes, and head and neck computed tomography were unremarkable. Creatine phosphokinase was 349. The workup for Werdnig-Hoffman disease, myotonia congenita, and myasthenia gravis was negative. With negative initial workup, a referral was made and a magnetic resonance imaging (MRI) of the spine was performed. It revealed abnormal T1 and T2 signal within the spinal cord extending from the cervicothoracic junction to the conus, consistent with ischemia and/or intramedullary hemorrhage. Coagulopathy workup was negative. At the 3-year follow-up, the patient had some antigravity strength in the upper extremities and 0/5 strength in the lower extremities. The cognitive development was appropriate for his age, and the patient was able to use a manual wheelchair. A repeat MRI revealed intramedullary central cord mass, possibly a lipoma spanning T6-12, and a tethered cord. Discussion: Intramedullary spinal cord hemorrhage in a neonate is unusual. Other locations of hemorrhage such as subarachnoid, subdural, or epidural are more commonly seen. A systematic approach to the floppy infant is important. Conclusions: This is a rare case of intramedullary cord hemorrhage at birth with hypotonia. It demonstrates the need to consider SCI in the differential diagnosis. Key Words: Muscle hypotonia; Rehabilitation; Spinal cord diseases.
Arch Phys Med Rehabil Vol 86, September 2005
Poster 228 Use of Bladder Irrigation To Treat Bacteriuria in Persons With Neurogenic Bladder Dysfunction. Ken B. Waites, MD; Kay C. Kanupp, MSN, CRNP; James F. Roper, MD; Yuying Chen, MD, PhD (University of Alabama, Birmingham, AL); Susan M. Camp, CRNP, e-mail: [email protected]. Disclosure: None. Objective: To evaluate the potential value of bladder irrigation to treat bacteriuria in persons with neurogenic bladders. Design: Double-blind randomized controlled trial. Setting: Rehabilitation center. Participants: 52 community-residing men and women with neurogenic bladders managed with an indwelling Foley catheter or suprapubic tube. Intervention: Subjects were randomized to irrigate their bladders twice daily for 8 weeks with 30mL of: sterile saline, acetic acid, or neomycin-polymixin. Main Outcome Measures: Urinalysis and cultures were performed at baseline and weeks 2, 4, and 8 to determine the extent to which each of the solutions affected bacterial numbers, pH, urinary leukocytes, and generation of antimicrobial-resistant organisms. Results: Bladder irrigation was well tolerated with the exception of 3 subjects who had bladder spasms and could not participate further. All participants had bacteriuria with ⱖ100,000 colonies/mL at baseline. None of the 3 irrigants had a detectable effect on the degree of bacteriuria, pyuria, or urinary pH. There was no significant increase in the occurrence of oxacillin-resistant Staphylococcus aureus or multidrug resistant gram-negative bacilli in any of the 3 groups, although the baseline rates of resistance were high. No significant development of resistance to oral antimicrobials among gram-negative bacilli beyond what was observed at baseline was detected. Conclusions: Bladder irrigation was generally well tolerated for 8 weeks. No advantages were detected for neomycin-polymixin or acetic acid over saline in terms of reducing the urinary bacterial load and inflammation. We cannot recommend bladder irrigation as an alternative to systemic antibiotics for treatment of bacteriuria. Key Words: Bacteriuria; Bladder, Neurogenic; Rehabilitation; Urinary tract infections.
Poster 229 Compliance With Guidelines for Preventing Pressure Ulcers Following Spinal Cord Injury. Sunil Sabharwal, MD (VA New England Healthcare System/ Harvard Medical School, Boston, MA); Dan Berlowitz, MD, MPH; Elaine Czarnowski, RN; Elaine Hickey, RN, e-mail: [email protected]. Disclosure: None. Objectives: To measure current compliance with the pressure ulcer prevention guidelines (Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury, published by the Consortium for Spinal Cord Medicine) and to define determinants of variation from guideline recommendations and identify compliance barriers and facilitators. Design: (1) Review of 100 randomly selected medical records using a chart abstraction tool developed for abstracting information regarding compliance with pressure ulcer prevention. Inclusion criteria were SCI diagnostic ICD-9 codes and clinic visit or hospitalization at a study site in fiscal year 2003. (2) Provider focus groups conducted to identify perceived facilitators and barriers to guideline adherence. Setting: VA spinal cord injury (SCI) system of care including an SCI center and 5 SCI clinics. Interventions: Not applicable. Main Outcome Measures: Overall and facility-specific adherence rates to 14 pressure ulcer prevention guidelines. Records with outpatient visits only were analyzed separately from those with inpatient hospitalizations. Results: Guideline adherence was lower in the outpatient than inpatient group. For example, 90% of inpatients had documented pressure ulcer risk factor assessment versus 5% of outpatients. Guideline adherence varied considerably between sites. For example, nutritional status documentation varied from 15% to 85% within outpatient sites and documented pressure relief regimen ranged from 5% to 65%. Adherence was better for some guidelines than others. For example, for the outpatient group, wheelchair cushion assessment was documented in 60%, but ⬍5% documented bed support surfaces used. Focus groups indicated that standardized templates incorporating guidelines would improve documentation and also serve as a reminder checklist. The greatest perceived barrier to guideline adherence was patient compliance. Conclusions: Knowledge generated by this study has prompted development of interventions especially with outpatient focus, including standardized templates for pressure ulcer specific periodic evaluation, and patient educational material to promote compliance. Key Words: Clinical practice guidelines; Spinal cord injuries; Pressure ulcer; Rehabilitation.
Poster 230 Incidence and Outcomes of Spinal Cord Injury Clinical Syndromes. Katia Santos, MD (Virginia Commonwealth University, Richmond, VA); William McKinley, MD; Michelle Meade, PhD; Karen L. Brooke, e-mail: [email protected]. Disclosure: None. Objective: To examine and compare demographics and functional outcomes for individuals with spinal cord injury (SCI) clinical syndromes, including central cord (CCS), Brown-Sequard (BSS), anterior cord (ACS), posterior cord (PCS), cauda equina (CES), and conus medullaris (CMS). Design: Retrospective review. Setting: Tertiary care, level I trauma center inpatient rehabilitation unit. Participants: 848 consecutive admissions with acute SCI. Interventions: Not applicable. Main Outcome Measures: FIM instrument, FIM subgroups (motor, self-care, cognitive), length of stay (LOS), and discharge disposition. Results: 176 (20.8%) patients were diagnosed with SCI clinical syndromes. CCS was the most common (44.3%), followed by CES (25.6%) and BSS (17.6%). Significant differences (Pⱕ.01) were found between groups with regard to age, race, etiology, total admission FIM, motor admission FIM, self-care admission and discharge FIM, and LOS. Statistical analysis between tetraplegic BSS and CCS revealed significant difference (Pⱕ.01) with respect to age (38.9 vs 53.2) and a trend toward significance (Pⱕ.05) with regard to total discharge FIM (97.0 vs 85.0), motor discharge FIM (64.5 vs 55.0), and self-care discharge FIM (29.0 vs 23.9). No significant differences (Pⱕ.01) were found when comparing CMS with CES. Conclusions: SCI clinical syndromes represent a significant proportion of admissions to acute SCI rehabilitation with CCS presenting most commonly and representing the oldest age group with the lowest admission functional level of all SCI clinical syndromes. Cervical BBS individuals seem to achieve higher functional improvement by discharge when compared with CCS patients. CMS and