Adam L. Schreiber

Spinal cord infarction secondary to cocaine use.

Schreiber AL, Formal CS: Spinal cord infarction secondary to cocaine use. Am J Phys Med Rehabil 2007;86:158–160. A 27-yr-old woman recreationally inhaled cocaine. Several hours later, she noted chest tightness, back and neck pain, and later bilateral upper-extremity weakness. Physical examination revealed flaccid paresis of the upper extremities. Spasticity at 2 mos after injury, but no detectable weakness, developed in the lower extremities. Cocaine was detected in her urine. Magnetic resonance imaging showed hyperintensity in the anterior cervicothoracic spinal cord. Electrodiagnostic studies of the upper extremities were consistent with anterior horn cell death. Cocaine abuse is associated with cerebrovascular events; spinal cord effects are rarely reported. The patient seems to have an infarct in the anterior spinal artery distribution, with clinical, imaging, and electrodiagnostic findings of upper-extremity lower–motor neuron injury, accompanied by spasticity of the lower extremities. Gray matter has increased susceptibility to ischemia compared with white matter, producing flaccid weakness in the cervical region with isolated arm weakness. Although uncommon, cocaine abuse can cause spinal cord infarction.

Carpal Tunnel Syndrome Diagnosis

Carpal tunnel syndrome (CTS) is a common median nerve compression syndrome and the most common peripheral mononeuropathy. The clinical syndrome is diagnosed by history and physical examination. Electrodiagnostic testing is the objective method used to measure median nerve dysfunction at the wrist and confirm the clinical diagnosis of CTS. Neuromuscular ultrasound imaging of the carpal tunnel provides supportive diagnostic information by revealing pathologic nerve swelling in CTS, and other anatomic anomalies that compress the median nerve. These tests cannot be used to make the diagnosis in the absence of history that includes CTS symptom criteria and excludes other causes.

Cervical epidural steroid injections and spinal cord injuries

BACKGROUND CONTEXT Cervical interlaminar and transforaminal epidural steroid injections have been increasingly performed as a medical interventional treatment for pain. PURPOSE This study aimed to examine if there was increasing proportion of cervical spinal cord injured acute rehabilitation hospital admissions related to cervical epidural injections because of increased use of the procedure. Additionally, this study aimed to determine risk factors that may have made these patients known higher risk premorbidly. STUDY DESIGN/SETTING A retrospective chart review was carried out. PATIENT SAMPLE The sample was from a 2001 to 2008 spinal cord-related injuries admitted to Magee Rehabilitation (2,770). A total of 1,343 patients were classified as having acute spinal cord injuries (SCIs). Of these patients, seven cases of SCI occurred after cervical epidural injections. OUTCOME MEASURES Chart data regarding characteristics of patients and proportion of SCI admissions to cervical epidural injections injuries were the outcome measures. METHODS Parameters analyzed included age, sex, American Spinal Injury Association Impairment Scale on admission, mechanism of injury, presenting symptoms, time of onset, and risk factors. Proportion of SCI admissions to cervical epidural injections injuries was also analyzed. RESULTS From the years 2001 to 2008, there were seven admissions for such injury with no change in the proportion of SCIs from cervical epidural injections relative to all SCIs. All were incomplete and mechanisms included anterior cord infarction (1), intraparenchymal injection (1), epidural abscess (2), contusion (1), epidural hematoma (1), and unknown (1). Presenting symptoms included hypotension, respiratory distress, chest pain, upper limb numbness, paresthesias, weakness, and fever. Symptom onset ranged from minutes to 72 hours after injection. CONCLUSIONS Although there is an increased use of interventional spine procedures to treat pain, this did not increase the proportion of cervical epidural-related SCI admissions. Additional research is needed to advocate reporting complications in all clinical settings.

Two Novel Nonsurgical Treatments of Carpal Tunnel Syndrome

This article describes 2 nonsurgical approaches to the treatment of carpal tunnel syndrome that are not routinely offered, probably due to a lack of awareness. Osteopathic manipulative treatment (OMT) is commonly used for many medical problems, including musculoskeletal issues. OMT of the carpal tunnel is well described and researched, and can be clinically used by a skilled practitioner. The second treatment strategy is a more recent development. The use of ultrasound for guidance of injection is established, but a newer technique using sonographically guided percutaneous needle release of the transverse carpal ligament has shown promising results.

Manifestations of Rheumatoid Arthritis: Epidural Pannus and Atlantoaxial Subluxation Resulting in Basilar Invagination

Atlantoaxial instability results from cartilaginous destruction, periarticular erosions, and ligament and tendon attenuation. Instability affects 19%-70% of patients, and basilar invagination from vertical odontoid subluxation through the foramen magnum occurs in 38% of patients. This phenomenon occurs twice as often in women than men, whose age at diagnosis typically ranges from 30-50 years. Along with bony compression, the pannus further decreases the space available for the cord by 3 mm or more in approximately 66% of patients (Figures 1-7). The earliest and most common symptom of cervical subluxation is pain radiating up into the occiput with associated headaches. Episodes of medullary dysfunction that represent severe but less common patterns of progressive myelopathic symptoms provide an even more grim prognosis. When cervical myelopathy is established, 50% of these patients die within 1 year. The incidence of sudden death from the combination of basilar impression and atlantoaxial instability is 10%. Preoperative neurological deficits provide a guarded prognosis, and basilar impression is associated with poorer recovery of function [1,2]. McRorie et al [3] researchedsurgicaloutcomesandfoundthatnoclearfactorsemergedtopredictthegreatest risk of operative mortality. Neurological compromise did not correlate with immediate perioperative death, and early surgery to correct symptomatic atlantoaxial subluxation may prevent the progression of instability.

Demographic Characteristics of 38 Patients Injured in Motor Vehicle Accidents Referred by Chiropractors to Physiatrists

OBJECTIVE The purpose of this study is to describe the demographic profile of patients in the New Jersey area who are involved in motor vehicle personal injury lawsuits and who are referred from chiropractors to physiatrists. METHODS The study design was a prospective chart review of patients (N = 38) referred to a private physiatric practice from 5 chiropractic practices. Patient data collected at initial consultation included age, employment status, emergency department consultation, time since accident, visual analog score, neck pain and back pain, review of systems, and functional limitations. RESULTS The average patient was 37.1 years old, with male-to-female ratio nearly 1:1, and presenting 4.5 months after the accident; 81.6% were employed before the accident, 25.8% of which stopped working. The average pain score was 6.6 on a visual analog scale. Neck and back pain were common at 84.2% and 89.5%, respectively. Other complaints included headaches, sleeping difficulties, dizziness, depression, and anxiety. Limitations in function was reported in most patients. CONCLUSIONS In this study, patients referred to a physiatrist from doctors of chiropractic had neck and low back pain not requiring hospital admission. Patients referred tended to have complicated cases with a variety of medical, legal, and psychological factors that are associated with delayed recovery. Physiatrists may be uniquely suited to assist chiropractors in management of complicated patients who have been involved in motor vehicle personal injury lawsuits and who have multidisciplinary needs.

Rehabilitation of Neuromyelitis Optica (Devic Syndrome) Three Case Reports

Schreiber AL, Fried GW, Formal CS, DeSouza BX: Rehabilitation of neuromyelitis optica (Devic syndrome): three case reports. Am J Phys Med Rehabil 2008;87:144–148.We describe the inpatient clinical rehabilitation course of three patients with neuromyelitis optica (NMO; Devic syndrome). These patients had varying functional deficits. Each patient improved in several functional independence measures (FIM domains) but had minimal to no progress in other domains after acute rehabilitation stays between 1 and 1.5 mos. NMO is a severe central nervous system demyelinating syndrome distinct from MS, characterized by optic neuritis, myelitis, and at least two of three criteria: longitudinally extensive cord lesion, MRI nondiagnostic for multiple sclerosis, or NMO-IgG seropositivity. Persons with NMO may demonstrate improved function with rehabilitation efforts; though gains may be lost to relapse. Future immunomodulatory intervention may augment the benefits of rehabilitation.

Traumatic cervical spinal cord injury with “negative” cervical spine CT scan

A 46-year-old man fell four steps, striking his neck and having associated neck pain and discomfort. He was evaluated at a local emergency department and reported no neurological deficit but focal mid cervical tenderness. Radiographs and computed tomography (CT) scan were “negative” for cervical spine fracture, dislocation or pre-vertebral soft tissue swelling. He was discharged home in a cervical collar with a scheduled outpatient follow-up. Over the proceeding hours neurologic deterioration occurred, including hand and lower limb weakness with the inability to urinate. The patient returned to the local emergency room and was transferred to a tertiary care hospital where examination revealed C5ASIAB deficits. Repeat high resolution CT scan of the cervical spine with reformatted images was unremarkable for osseous fractures except some loss of definition in the posterior cervical musculature. Emergency magnetic resonance imaging MRI revealed a subluxation of C5/6 right facet (not evident on CT) with disruption of the posterior longitudinal ligament, ligamentum flavum, and disc space with abnormal T2 weighted spinal cord hyperintense signal at C5/6. He underwent emergency C5–C6 anterior and posterior decompression and fusion. One week later an examination showed improved C5ASIAD. This case reveals the difficulty of assessing the cervical spine for instability and potential limitations of current management schemes.

New Phenotype of Parsonage-Turner Syndrome involving Radial and Proximal Median Nerve: A Case Report

HISTORY A 74-year-old woman developed sudden severe left shoulder, arm, and forearm pain that suddenly developed. This pain lasted approximately 2 months. Approximately 1-2 months after the resolution of the first pain she developed a different type of pain which she described as a tingling, burning, pins and needle sensation that radiated from her shoulder past her elbow into the dorsal and palmar aspect of her hand in the thumb, index, and long fingers. Additionally, she developed numbness in her hand along the palmar thumb, index, and long fingers. Two months following the onset of the initial type of pain, she developed left hand weakness that progressively worsened.

The Appropriateness of Long-term Opioids to Treat Chronic Back Pain

A 55-year-old man presents to a pain clinic upon referral from his primary care physician. His symptom is axial low back pain. His pain started approximately 1 year earlier without a specific inciting event. He denies radiation of pain into the lower extremities. There is no bowel or bladder involvement. There is no directional preference. He reports pain “all the time,” with minimal specific exacerbating or relieving factors. There is no medical-legal involvement. His medical history is significant for hypertension, hypercholesterolemia, obesity, and sleep apnea. He is a divorced father of 2 adult children. He is self-employed local truck driver, and his job also involves some loading and unloading of boxes, although he describes the weight of the boxes as “light.” He notes a decreased capacity to complete job-related activities but states that the pain medication (sustained-release oxycodone, 80 mg twice a day) allows him to work with minimal discomfort. The physical examination is notable for diffusely limited lumbar range of motion without a directional preference for pain reduction. Strength examination demonstrates pain-limited weakness in the proximal bilateral lower extremities. There is no abnormality of sensation or deep tendon reflexes. He has diffuse tenderness over the lumbar paraspinal, quadratus lumborum laborum, gluteal, and piriformis muscles. There is no tenderness over the sacroiliac joints. Gaenslen, flexion abduction external rotation (FABER), slump, and straight-leg raising testing is negative. He is 5 ft, 11 in. tall and weighs 230 lb. His primary care physician ordered magnetic resonance imaging of the lumbar spine, which demonstrated mild degeneration of multiple intervertebral disks without nerve root compression. He has tried physical therapy, nonsteroidal anti-inflammatory drugs, and cyclobenzaprine, without sustained relief. He has had bilateral lumbar selective nerve root injections at L5 and S1 as well as bilateral facet injections at L4-5 and L5-S1 without improvement. The primary care physician notes that the patient appears to have done well on the sustained-release oxycodone, but the physician feels uncomfortable with continuing to manage the pain with high doses of opioid pain medication. The physician believes that the patient is taking the medication appropriately, but he concedes that he does not have a formal program in place to help ensure that there is no medication diversion. He also is concerned about the appropriateness of having his patient taking high doses of opioid medications because his primary job task is driving. What is your treatment recommendation, and how do you specifically plan to address the issues related to long-term opioid use? Guest Discussants: