Alberto Panero

The emerging use of platelet-rich plasma in musculoskeletal medicine.

Platelet-rich plasma (PRP) is one of many new developments within the expanding field of regenerative medicine. Specialists in areas such as orthopedics, physical medicine and rehabilitation, and rheumatology have been exploring the benefits of this novel therapy. Although PRP therapy remains controversial and has minimal clinical trial support, the use of orthobiologics such as PRP continues to advance as patients seek nonsurgical approaches to acute and chronic musculoskeletal injury and disease. However, academic acceptance as well as insurance reimbursement remain reliant on solid and repeatable positive results from large clinical trials. The authors summarize the evolution of PRP therapy and report on its status.

Poster 14 Efficacy and Safety of Frontal & Occipital Nerve Blocks in Post-Traumatic Headache: A Retrospective Study

nitisinone. Design: Prospective randomized treatment study. Setting: Biomedical research facility. Participants: 40 subjects with alkaptonuria (27 male and 13 female). Baseline 38 years old to 65 years old (mean age 51). Interventions: Nitisinone (IND 71780). Main Outcome Measures: Human activity profile (HAP), a measure of physical activity, SF-36, Health Assessment Questionnaire (HAQ), a measure of ADL and health status, Pain Disability Index (PDI), Wisconsin Brief Pain questionnaire (BP), the fatigue assessment instrument (FAI). Results: On the HAP adjusted activity score (AAS) over 3 years, the treatment group (TG) had 3 fewer subjects in the impaired category, 1 more subject in the moderately active group, and gained 2 subjects in the active group. The control group (CG) had 1 more subject in the impaired category, 1 fewer subject in the moderately active group, and no change in the active group. In controlling for the subjects’ homogentisic acid, the TG significantly increased its AAS and HAP maximum activity score (MAS) in the 3rd year (P .040 and P .032, respectively). In the TG, the AAS increased from 56.50-61.61 and the CG decreased from 64.06-63.87. In the TG, the average MAS increased from 71.22 to 73.11 and the CG average decreased from 78.44 to 76.19. On the HAQ, the TG had 2 more subjects with no functional limitations and 2 fewer with moderate limitations; the CG had 3 more with mild limitations and 3 fewer with moderated limitations. The TG and CG are associated with increased SF-36 physical composite score (PCS) (P .045 and P .043, respectively). The CG is associated with increased SF-36 mental composite score (MCS) (P .009). In the 1st year, the TG is associated with lower BP right now pain level (BPRN) (P .015) then at 3 years, both groups have lower BPRN (P .015 (TG) and P .026 (CG)). Conclusions: In a 3-year follow up of this alkaptonuria cohort, the TG is associated with an increase in maximum and average activity level. However, the TG and the CG have improvement in physical disability. Both groups have a lower pain level at 3 years but the TG had a significant earlier reduction in pain. Further long-term treatment studies are warranted to determine if nitisinone treatment is associated with improvement in activity, pain, and disability over time.

Poster 313 How a Seemingly Minimal Physical Examination Finding Unveiled a More Serious Condition: A Case Report

Results or Clinical Course: Upon 9 week follow up, the patient recovered fully with no motor or sensory deficits other than mild numbness at the site of lumbar fasciotomies. Discussion: Acute compartment syndrome (ACS) is commonly reported in the extremities. However, increased compartmental pressure can compromise perfusion of any fascial compartment. The muscular hypertrophy that occurs over time with chronic exercise reduces the volume available within the fascial compartment and contributes to compartment non-compliance. ACS involving the thigh has a reported incidence of 0.027%, and there have been few case reports describing acute paraspinal muscle compartment syndrome. Conclusion: Compartment syndrome is a life threatening condition that places the patient at risk for multi-organ failure without prompt intervention and early recognition of the diagnosis. Few cases of ACS have been reported in the literature regarding the thigh or lumbar paraspinals. However, to the authors’ knowledge this is the first reported case of combined paraspinal muscle and posterior thigh exercise induced ACS.

Surrogate Decision Making in the Case of a Pregnant Woman Newly Disabled With Brain Injury

Brain injuries are never planned. Brain injuries also disproportionately affect young dults who are busy with young adult tasks such as school, selecting careers, dating, hoosing whom to marry, and whether to become parents. Young adults have rarely pent much time thinking about advance directives or wills, and almost never have left uidance for decision making in the event of brain injury. Thus, brain injuries often ose some of the most difficult dilemmas in medicine and certainly for those who must ake decisions on behalf of the person with brain injury, specifically, the family and ealth care team. Many of these dilemmas have received exhaustive attention, particuarly when the legal and moral issues involve questions of starting and stopping ife-sustaining treatments [1-4]. I am grateful that Alberto J. Panero, DO, chief resident at the Department of Rehabilitation Medicine, University of Miami and Jackson Memorial Hospital, brought to my attention the following case that raises questions not only about how best to make decisions on behalf of a woman with a new brain injury but also her fetus. Next to brain injuries, maternal-fetal conflicts and discussions of indications for pregnancy terminations pose some of the most difficult and emotional dilemmas in medicine.

Poster 360 Epidural Hematoma and Paraplegia After Spinal Cord Stimulator Removal: A Case Report

Setting: Urban, academic physical medicine and rehabilitation residency program. Participants: Physical medicine and rehabilitation residents (n 17), control group (n 8) and treatment group (n 9). Interventions: All residents were given an examination of neuroanatomy that included a multiple choice portion (written) and a plexus labeling portion (drawing) at baseline and at 5 weeks. Residents in the control group received only lecture notes. Residents in treatment group received lecture notes as well as four interactive neuroanatomy lectures including visual aids, such as plexus drawings, supplemented with pneumonic devices given over a 5-week period. Main Outcome Measures: Post-test performance on the total exam score (max 80), written exam score (max 20), and drawing exam score (max 60) adjusted for baseline scores. Results: Both the treatment and control groups improved in the total exam score (32.6 11.0 and 22.4 20.6, respectively) and drawing exam score (30.7 10.7 and 23.1 19.1, respectively). The treatment group improved in the written exam (1.9 2.6) whereas the control group performed worse at follow-up ( 0.8 3.3). At 5 weeks, there was no significant difference between treatment group verses control group in the total exam score (P .2) or the drawing exam score (P .6), but there was a significant difference in the written exam score (P .03). Conclusions: The interactive neuroanatomy lecture series was associated with higher written exam scores at 5 weeks than those for residents who received lecture notes only. The interactive neuroanatomy lectures were associated with non-significantly higher scores in drawing exam score and the total exam score.

Poster 489 Unilateral C5 Nerve Root Palsy in a C3 Incomplete Tetraplegic Patient: A Case Report

Disclosures: J. Cohen, No Disclosures. Case Description: The patient is a 76-year-old man who sustained a cervical spinal cord injury secondary to a fall, which resulted in complete tetraplegia at the C4 level. He underwent a cervical laminectomy and fusion with no post-operative complications and was transferred to the inpatient spinal cord injury unit 1 month after the injury. On the first day of rehab, the patient was unable to tolerate therapy secondary to light-headedness attributed to orthostatic hypotension; his blood pressure dropped from 100/60 to 80/45 with less than 30 degrees of vertical elevation. The symptoms of orthostatic hypotension persisted for 1 week with no improvement despite the use of both midodrine and fludrocortisone. At the same time, his serum sodium was noted to be 132-133 so he was placed on a free water fluid restriction for the treatment of syndrome of inappropriate antidiuretic hormone hypersecretion (SIADH). Setting: Academic tertiary care hospital inpatient rehabilitation unit. Results or Clinical Course: As the patient’s serum sodium level began to rise, so did his tolerance during therapy while sitting at a greater vertical degree. Once the serum sodium reached 135 at the beginning of the second week, the signs and symptoms of his orthostatic hypotension had diminished. Discussion: The prevalence of hyponatremia in acute spinal cord injury has been documented to be much higher than in the general patient population and usually occurs within the first 2 weeks after the injury. The important correlation between hyponatremia and orthostatic hypotension in cervical spinal cord injury patients, to our knowledge, has not been emphasized in rehabilitation literature. Conclusions: Successfully treating hyponatremia in cervical spinal cord injury patients in the setting of orthostatic hypotension is essential to improve outcomes in therapy as demonstrated in this unique case.

Poster 488 Hyponatremia in a Cervical Spinal Cord Injury Patient with Refractory Orthostatic Hypotension: A Case Report

Disclosures: J. Cohen, No Disclosures. Case Description: The patient is a 76-year-old man who sustained a cervical spinal cord injury secondary to a fall, which resulted in complete tetraplegia at the C4 level. He underwent a cervical laminectomy and fusion with no post-operative complications and was transferred to the inpatient spinal cord injury unit 1 month after the injury. On the first day of rehab, the patient was unable to tolerate therapy secondary to light-headedness attributed to orthostatic hypotension; his blood pressure dropped from 100/60 to 80/45 with less than 30 degrees of vertical elevation. The symptoms of orthostatic hypotension persisted for 1 week with no improvement despite the use of both midodrine and fludrocortisone. At the same time, his serum sodium was noted to be 132-133 so he was placed on a free water fluid restriction for the treatment of syndrome of inappropriate antidiuretic hormone hypersecretion (SIADH). Setting: Academic tertiary care hospital inpatient rehabilitation unit. Results or Clinical Course: As the patient’s serum sodium level began to rise, so did his tolerance during therapy while sitting at a greater vertical degree. Once the serum sodium reached 135 at the beginning of the second week, the signs and symptoms of his orthostatic hypotension had diminished. Discussion: The prevalence of hyponatremia in acute spinal cord injury has been documented to be much higher than in the general patient population and usually occurs within the first 2 weeks after the injury. The important correlation between hyponatremia and orthostatic hypotension in cervical spinal cord injury patients, to our knowledge, has not been emphasized in rehabilitation literature. Conclusions: Successfully treating hyponatremia in cervical spinal cord injury patients in the setting of orthostatic hypotension is essential to improve outcomes in therapy as demonstrated in this unique case.

Poster 491 A Large Multi-Level Lipoma Resulting in an SCI in a Patient With Juvenile Scoliosis: A Case Report

Disclosures: J. Bashir, No Disclosures. Case Description: Patient: A 40-year-old male T4 ASIA A SCI patient with a PMH of juvenile scoliosis. Patient presented to an Orthopedic Surgeon’s office in his native Romania after a meniscal tear to his right knee at age 21. PMH was remarkable for scoliosis diagnosed at age 9. The physician evaluating him became concerned when he found decreased sensations of pain typical with acute meniscal injury. Dermatomal testing at the time revealed pronounced sensory impairment on the right side of his body below the T4 distribution raising concern for possible neurological disease. Diagnostic MRI conducted by a local neurologist revealed an extensive lesion extending from the seventh cervical body to the tenth thoracic region. He sought treatment in the United States, undergoing a laminectomy from C7-T10 after which he remained ambulatory. Tumor pathology was performed at that time, with partial resection 3 years later during a surgical revision. Since the revision surgery he reports paraplegia with near complete paralysis of his bilateral lower extremities. Setting: Tertiary care hospital. Results or Clinical Course: Pathology revealed a spinal cord lipoma with acute inflammatory infiltrates. Discussion: The extensive size of this spinal cord lipoma in the setting of a history of juvenile scoliosis raises concern over screening protocols in at-risk children. This patient received no diagnostic imaging with either radiography or MRI in his native Romania at the time his scoliosis was first recognized. In the United States X-ray imaging in these cases is normal. However, MRI is not, thus preventing definitive identification of soft tissue masses as the underlying cause. Conclusions: The extremely rare presentation of a lipoma of this size resulting in possible vertebral body misalignment warrants discussion whether MRI screening should be done in children identified as having scoliosis. In the very least this case provides evidence of the necessity for serial complete neurological testing in these patients, which could identify possible spinal pathology early and thus minimize morbidity.