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Poster 281: Arteriovenous Malformation Presenting as Transverse Myelitis: A Case Report
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ACADEMY ANNUAL ASSEMBLY ABSTRACTS
trial. Setting: Hospital affiliated with university. Participants: 32 patients with SCI were divided into the incomplete injury group (n⫽16) and the complete injury group (n⫽16). Interventions: All patients had rehabilitation training 5 days a week for 6 months. SEP studies were recorded before and 6 months after rehabilitation training. The short latency and amplitude of waves in SEP studies were measured. American Spinal Injury Association (ASIA) motor score and sensory score were also measured before and 6 months after rehabilitation training. Main Outcome Measures: ASIA motor score, ASIA sensory score, and parameters of SEP studies were analyzed and compared between the 2 groups before and after training. Results: ASIA motor score and ASIA sensory score improved in the incomplete group after training (P⬍.05), but not in the complete injury group. The latencies were significantly shorter in SEP studies after training in the incomplete injury group (P⬍.05), but not in the complete injury group. The amplitudes of waves were significantly increased in SEP studies after training in the incomplete injury group (P⬍.05), but not in the complete injury group. In the incomplete injury group, the improvement of SEP studies after training was related to the improvement of ASIA motor score (P⬍.05) and the improvement of ASIA sensory score (P⬍.05). Conclusions: The parameters of SEP studies were improved following functional improvement in patients with incomplete SCI. Our finding suggests that the latency and amplitude of SEP studies could be among the useful diagnostic methods for assessment of functional improvement in patients with incomplete SCI. Key Words: Rehabilitation; Somatosensory evoked potentials; Spinal cord injuries. Poster 280 Elevated N-Telopeptide in Inpatients With Spinal Cord Injury Who Develop Acute Heterotrophic Ossification. Zhaohui Yang, MD, PhD (Boston Medical Ctr, Boston, MA); Kristin Gustafson, DO; Leslie Morse, MD; Yelena Giorfinkel; Steve Williams, MD. Disclosure: Z. Yang, None; K. Gustafson, None; L. Morse, None; Y. Giorfinkel, None; S. Williams, None. Objective: To evaluate the relationship between urinary N-telopeptide with spinal cord injury (SCI) severity and the development of heterotopic ossification (HO). Design: Retrospective study. Setting: Acute Model Spinal Cord Injury System inpatient rehabilitation service. Participants: SCI patients admitted to acute rehabilitation. Interventions: Chart review was performed for 19 patients admitted between February 3, 2006, and December 27, 2006, with a diagnosis of acute SCI. Main Outcome Measures: American Spinal Injury Association classification of SCI, urine N-telopeptide, and blood creatinine testing was performed on admission, and clinically significant HO confirmed by triple-phase bone scans. Results: N-telopeptide and creatinine ratio was significantly higher in the HO group (311.52⫾193.53 vs 141.78⫾132.69, P⫽.04) and in those with complete injury (245.34⫾191.53 vs 105.47⫾61.98, P⫽.04). Conclusions: Based on preliminary data, N-telopeptide and creatinine ratio show some promise as a clinically useful indicator for HO in the acute phase of SCI. It may show utility as an index for early prevention of HO formation in SCI patients. N-telopeptide is also higher in the subjects with complete SCI, suggesting bone resorption is greater in this group. Key Words: Ossification, heterotrophic; Rehabilitation; Spinal cord injuries. Poster 281 Arteriovenous Malformation Presenting as Transverse Myelitis: A Case Report. Brian F. White, DO (Kessler/UMDNJ, West Orange, NJ); Barbara Benevento, MD; Steven Kirshblum, MD. Disclosure: B.F. White, None; B. Benevento, None; S. Kirshblum, None. Arch Phys Med Rehabil Vol 88, September 2007
Setting: Acute inpatient rehabilitation hospital. Patient: A 59-yearold man with recurrent transverse myelitis. Case Description: Symptoms began acutely with leg weakness. Magnetic resonance imaging (MRI) revealed abnormal signal intensity from T8 to the conus. Additional workup was negative and treatment included steroids for a diagnosis of transverse myelitis. Following rehabilitation, he was community ambulating with a cane. 2 months later, neurologic progression led to treatment for a urinary tract infection; on discharge from rehabilitation he was ambulating using a walker. 3 months later, he again developed progressive weakness and was diagnosed with exacerbation of transverse myelitis secondary to a sinus infection. Additional workup included MRI and magnetic resonance angiography and led to a diagnosis of arteriovenous malformation (AVM). Ultimately, he underwent spinal angiography and surgical repair of the thoracic AVM. He was discharged to rehabilitation using a wheelchair and has not returned to independent ambulation. Assessment/Results: During his 18-month course, he suffered multiple flairs of lowerextremity weakness and varied neurologic deficit. Following surgical repair of the AVM, his motor deficit remains stable although long-term prognosis for motor improvement is currently uncertain. Discussion: Several case reports of spinal AVMs are noted in the literature. This case displays a varying and protracted course with multiple diagnosis of transverse myelitis. Once the diagnosis was made, surgical correction was performed. However, the paucity of recovery following surgical correction may be in part due to the time elapsed between onset and diagnosis, thus delaying definitive treatment, and serves to support a high index of suspicion for a spinal AVM in such cases. Conclusions: AVMs are an uncommon, but not rare, cause of neurologic deficit. As such, they should be included in the differential for neurologic deficit without definitive etiology, especially in cases with recurrent episodes. Key Words: Arteriovenous malformations; Myelitis, transverse; Rehabilitation. Poster 282 Unstable Jefferson Fracture as an Etiology for Persistent Dysphagia and Dysphasia in a Tetraplegic Patient: A Case Report. Franz J. Macedo, DO (University of Wisconsin, Middleton, WI); J. George Thomas, MD; Kelly Logan, DO; Eric Kozfkay, DO. Disclosure: F.J. Macedo, None; J.G. Thomas, None; K. Logan, None; E. Kozfkay, None. Setting: University hospital, rehabilitation ward. Patient: A 37year-old C4 tetraplegic, 1 month postinjury, with persistent dysphagia and dysphasia. Case Description: The patient was admitted following a motorcycle crash, with resultant C4 complete tetraplegia. Immediately postinjury, prior to intubation, the patient was vocalizing. Injuries included: stable Jefferson (C1) fracture, C2 complex fracture, C5 fracture and small frontal subdural hematoma. Operative management included C5 corpectomy and C4-7 anteroposterior fusion. Tracheostomy was placed 3 weeks postinjury for ventilatory dependence. There was glottic swelling post tracheostomy, treated with intravenous dexamethasone, with good results. The patient was transferred to the rehabilitation ward at 6 weeks. At that time the patient had dysphagia, hypophonia, and lingual weakness. Over the next 4 weeks, there was no appreciable improvement in vocalization, swallow function, or lingual weakness. Videofluoroscopic swallow evaluation showed lingual weakness and resolution of glottic edema. Magnetic resonance imaging of the head and neck, to evaluate the brainstem for injury, showed unstable Jefferson fracture with resultant basilar invagination and development of high T2-signal intensity within the lower brainstem and upper cervical cord. The orthopedic spine service placed the patient in cervical traction to decompress the brainstem. Subsequently, cervical fusion with halo placement was performed. 2 weeks after decompression and fusion, tongue weakness improved and vocaliza-
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
trial. Setting: Hospital affiliated with university. Participants: 32 patients with SCI were divided into the incomplete injury group (n⫽16) and the complete injury group (n⫽16). Interventions: All patients had rehabilitation training 5 days a week for 6 months. SEP studies were recorded before and 6 months after rehabilitation training. The short latency and amplitude of waves in SEP studies were measured. American Spinal Injury Association (ASIA) motor score and sensory score were also measured before and 6 months after rehabilitation training. Main Outcome Measures: ASIA motor score, ASIA sensory score, and parameters of SEP studies were analyzed and compared between the 2 groups before and after training. Results: ASIA motor score and ASIA sensory score improved in the incomplete group after training (P⬍.05), but not in the complete injury group. The latencies were significantly shorter in SEP studies after training in the incomplete injury group (P⬍.05), but not in the complete injury group. The amplitudes of waves were significantly increased in SEP studies after training in the incomplete injury group (P⬍.05), but not in the complete injury group. In the incomplete injury group, the improvement of SEP studies after training was related to the improvement of ASIA motor score (P⬍.05) and the improvement of ASIA sensory score (P⬍.05). Conclusions: The parameters of SEP studies were improved following functional improvement in patients with incomplete SCI. Our finding suggests that the latency and amplitude of SEP studies could be among the useful diagnostic methods for assessment of functional improvement in patients with incomplete SCI. Key Words: Rehabilitation; Somatosensory evoked potentials; Spinal cord injuries. Poster 280 Elevated N-Telopeptide in Inpatients With Spinal Cord Injury Who Develop Acute Heterotrophic Ossification. Zhaohui Yang, MD, PhD (Boston Medical Ctr, Boston, MA); Kristin Gustafson, DO; Leslie Morse, MD; Yelena Giorfinkel; Steve Williams, MD. Disclosure: Z. Yang, None; K. Gustafson, None; L. Morse, None; Y. Giorfinkel, None; S. Williams, None. Objective: To evaluate the relationship between urinary N-telopeptide with spinal cord injury (SCI) severity and the development of heterotopic ossification (HO). Design: Retrospective study. Setting: Acute Model Spinal Cord Injury System inpatient rehabilitation service. Participants: SCI patients admitted to acute rehabilitation. Interventions: Chart review was performed for 19 patients admitted between February 3, 2006, and December 27, 2006, with a diagnosis of acute SCI. Main Outcome Measures: American Spinal Injury Association classification of SCI, urine N-telopeptide, and blood creatinine testing was performed on admission, and clinically significant HO confirmed by triple-phase bone scans. Results: N-telopeptide and creatinine ratio was significantly higher in the HO group (311.52⫾193.53 vs 141.78⫾132.69, P⫽.04) and in those with complete injury (245.34⫾191.53 vs 105.47⫾61.98, P⫽.04). Conclusions: Based on preliminary data, N-telopeptide and creatinine ratio show some promise as a clinically useful indicator for HO in the acute phase of SCI. It may show utility as an index for early prevention of HO formation in SCI patients. N-telopeptide is also higher in the subjects with complete SCI, suggesting bone resorption is greater in this group. Key Words: Ossification, heterotrophic; Rehabilitation; Spinal cord injuries. Poster 281 Arteriovenous Malformation Presenting as Transverse Myelitis: A Case Report. Brian F. White, DO (Kessler/UMDNJ, West Orange, NJ); Barbara Benevento, MD; Steven Kirshblum, MD. Disclosure: B.F. White, None; B. Benevento, None; S. Kirshblum, None. Arch Phys Med Rehabil Vol 88, September 2007
Setting: Acute inpatient rehabilitation hospital. Patient: A 59-yearold man with recurrent transverse myelitis. Case Description: Symptoms began acutely with leg weakness. Magnetic resonance imaging (MRI) revealed abnormal signal intensity from T8 to the conus. Additional workup was negative and treatment included steroids for a diagnosis of transverse myelitis. Following rehabilitation, he was community ambulating with a cane. 2 months later, neurologic progression led to treatment for a urinary tract infection; on discharge from rehabilitation he was ambulating using a walker. 3 months later, he again developed progressive weakness and was diagnosed with exacerbation of transverse myelitis secondary to a sinus infection. Additional workup included MRI and magnetic resonance angiography and led to a diagnosis of arteriovenous malformation (AVM). Ultimately, he underwent spinal angiography and surgical repair of the thoracic AVM. He was discharged to rehabilitation using a wheelchair and has not returned to independent ambulation. Assessment/Results: During his 18-month course, he suffered multiple flairs of lowerextremity weakness and varied neurologic deficit. Following surgical repair of the AVM, his motor deficit remains stable although long-term prognosis for motor improvement is currently uncertain. Discussion: Several case reports of spinal AVMs are noted in the literature. This case displays a varying and protracted course with multiple diagnosis of transverse myelitis. Once the diagnosis was made, surgical correction was performed. However, the paucity of recovery following surgical correction may be in part due to the time elapsed between onset and diagnosis, thus delaying definitive treatment, and serves to support a high index of suspicion for a spinal AVM in such cases. Conclusions: AVMs are an uncommon, but not rare, cause of neurologic deficit. As such, they should be included in the differential for neurologic deficit without definitive etiology, especially in cases with recurrent episodes. Key Words: Arteriovenous malformations; Myelitis, transverse; Rehabilitation. Poster 282 Unstable Jefferson Fracture as an Etiology for Persistent Dysphagia and Dysphasia in a Tetraplegic Patient: A Case Report. Franz J. Macedo, DO (University of Wisconsin, Middleton, WI); J. George Thomas, MD; Kelly Logan, DO; Eric Kozfkay, DO. Disclosure: F.J. Macedo, None; J.G. Thomas, None; K. Logan, None; E. Kozfkay, None. Setting: University hospital, rehabilitation ward. Patient: A 37year-old C4 tetraplegic, 1 month postinjury, with persistent dysphagia and dysphasia. Case Description: The patient was admitted following a motorcycle crash, with resultant C4 complete tetraplegia. Immediately postinjury, prior to intubation, the patient was vocalizing. Injuries included: stable Jefferson (C1) fracture, C2 complex fracture, C5 fracture and small frontal subdural hematoma. Operative management included C5 corpectomy and C4-7 anteroposterior fusion. Tracheostomy was placed 3 weeks postinjury for ventilatory dependence. There was glottic swelling post tracheostomy, treated with intravenous dexamethasone, with good results. The patient was transferred to the rehabilitation ward at 6 weeks. At that time the patient had dysphagia, hypophonia, and lingual weakness. Over the next 4 weeks, there was no appreciable improvement in vocalization, swallow function, or lingual weakness. Videofluoroscopic swallow evaluation showed lingual weakness and resolution of glottic edema. Magnetic resonance imaging of the head and neck, to evaluate the brainstem for injury, showed unstable Jefferson fracture with resultant basilar invagination and development of high T2-signal intensity within the lower brainstem and upper cervical cord. The orthopedic spine service placed the patient in cervical traction to decompress the brainstem. Subsequently, cervical fusion with halo placement was performed. 2 weeks after decompression and fusion, tongue weakness improved and vocaliza-