Christopher Reger

Ultrasound Guidance for Technically Challenging Intrathecal Baclofen Pump Refill: Three Cases and Procedure Description.

ABSTRACTIntrathecal baclofen (ITB) therapy is a common treatment used to reduce spasticity due to neurologic disorders and injuries. A variety of factors can increase the difficulty of ITB pump refill. Excess subcutaneous fat overlying the pump, spasticity, suboptimal positioning, pump rotation or inversion, and scar formation over the reservoir fill port can create challenges during pump refill. As a result, multiple unsuccessful attempts at accessing the reservoir fill port can be painful and increase the risk of infection, particularly when repeat skin puncture is required. Blind attempts to refill a pump in challenging cases may also result in subcutaneous injection or pocket fill, resulting in a potentially fatal baclofen withdrawal syndrome. We describe 3 successful ITB pump refills in technically challenging cases when using ultrasound guidance. This represents an innovative approach to using ultrasound guidance to facilitate ITB refill in adults with intractable spasticity. We present these new clinical data with a literature review of potential complications related to inaccurate pump refill procedures and discuss the utility of ultrasound guidance for preventing such adverse events.

Poster 369: Bilateral Peroneal Compartment Syndrome in a Post-Partum Patient: A Case Report

right anterior choriodal infarction developed severe right hip pain 1 week after discharge to inpatient rehabilitation. Upon physical examination all provocative maneuvers of the right hip were negative except for reproducible pain on internal and external rotation as well as a positive scour test. The nature of the pain prompted plan radiographs to be obtained which showed only mild narrowing of the hip joint space as well as no presence of fractures. Days after initial evaluation she was found unresponsive with a hemoglobin and hematocrit of 4.2 and 13.1 respectively, prompting emergent blood transfusions and computed tomography (CT) of the abdomen and pelvis. Setting: Inpatient Academic Rehabilitation. Results: CT demonstrated a large atraumatic retroperitoneal hematoma which was successfully treated with embolization of the two branches of the superior gluteal artery by interventional radiology. After stabilization the patient was eventually restarted on antiplatelet therapy and was able to fully participate in the remainder of her inpatient rehabilitation stay. Discussion: Retroperitoneal hematoma is an accumulation of blood found in the retroperitoneal space most commonly secondary to a traumatic event. Although bleeding can occur post rt-PA administration, it commonly presents as intracerebral hemorrhage with retroperitoneal hematoma rarely being mentioned in the literature, represented in 2% of documented systemic hemorrhage. Patients should initially be managed in a higher acuity setting or intensive care unit with careful monitoring, fluid resuscitation, blood transfusion, normalization of coagulation factors, and arterial embolization of the site of bleeding. Conclusions: Although a rare occurrence, retroperitoneal hematoma should be considered in the differential of patients presenting with acute hip pain especially receiving anticoagulation or thrombolytic therapy. Furthermore, it should be highly suspected in patients who quickly decompensate after rt-PA therapy as it can lead to severe morbidity and possible mortality. Level of Evidence: Level V

Long-Term Dosing of Intrathecal Baclofen in the Treatment of Spasticity After Acquired Brain Injury

Intrathecal baclofen (ITB) often is used to treat severe spasticity of cerebral origin. Although literature exists regarding the efficacy of ITB, there has been minimal investigation related to dosing in the adult‐acquired brain injury population, particularly at long‐term duration.

Poster 294: Concurrent Tetraparesis and Cranial Nerve VI Palsy Secondary to Adenovirus Infection: A Case Report

Disclosures: Douglas Verrill: I Have No Relevant Financial Relationships To Disclose Case/Program Description: The patient was a 44-year-old man who initially presented with severe headaches, nausea and abdominal pain and was diagnosed with Syndrome of Inappropriate Antidiuretic hormone and non-ST-elevation myocardial infarction. During his hospitalization, he developed progressive tetraparesis with proximal greater than distal weakness, and a left lateral gaze deficit consistent with cranial nerve VI palsy. His weakness progressed and he required intubation for airway protection with eventual tracheostomy placement along with gastric tube placement for dysphagia. Electrodiagnostic testing was suggestive of critical illness myopathy and neuropathy. Extensive laboratory testing, including infectious disease testing, was significant for elevated serum adenovirus titers. A para-neoplastic work up was negative along with cerebrospinal fluid testing via lumbar punctures. Patient received Intravenous Immunoglobulin (IVIG) for a total of 5 days and high dose steroids with subsequent taper for suspected adenovirus axonopathy. Setting: Acute Inpatient Rehabilitation. Results: Patient had gradual improvement of his strength in all extremities after receiving IVIG and high dose steroids. His respiratory status also improved and his tracheostomy was able to be discontinued. He had persistent visual symptoms, predominately blurred vision, that was present at time of discharge from inpatient rehabilitation. Discussion: Adenovirus is a well-documented cause of both isolated weakness and cranial neuropathies. However, this is a rare case of concurrent gradual, progressive tetraparesis with cranial nerve VI palsy secondary to adenovirus infection that to our knowledge has only been seen and documented in a few isolated cases. Conclusions: Adenovirus infection can be a severely incapacitating infection with variable clinical presentations. It is important to consider that in rare cases it can cause concurrent weakness and cranial neuropathies and should be included on the differential diagnosis of patients who present with both limb weakness and cranial nerve VI palsy. Level of Evidence: Level V

Poster 372 Long-Term Intrathecal Baclofen Treatment for Spasticity after Acquired Brain Injury: Does Diagnosis Affect Dosing?

Disclosures: J€ org Wissel: Speakers bureau Allergan, Ipsen, Merz, Medtronic Objective: To assess the safety and efficacy of escalating incobotulinumtoxinA (Xeomin, Merz Pharmaceuticals GmbH) doses (400-800U) in patients with spasticity. Design: Prospective dose-escalation study (NCT01603459). Setting: 30 study sites worldwide. Participants: 155 adults (18-80 years) with spasticity due to cerebral causes deemed to require total body doses of incobotulinumtoxinA 800U. Interventions: 3 injection cycles (ICs) with escalating incobotulinumtoxinA doses (400U, 600U and 600-800U, respectively), each followed by 12-16-week observations. Main Outcome Measures: Ashworth Scale (AS) responder rate ( 1point improvement 4 weeks post-injection), Disability Assessment Scale (DAS), Functional Ambulatory Classification (FAC), Investigators Global Efficacy Assessment (IGEA), adverse events (AEs) and antibody testing. Results: Escalation of the total incobotulinumtoxinA dose enabled physicians to treat an increasing number of spasticity patterns in each patient. AS responses were achieved in 364/608 (59.9%) patterns treated in IC1 (155 patients), 431/743 (58.0%) patterns in IC2 (152 patients) and 537/811 (66.2%) patterns in IC3 (140 patients). There was increased reporting of “no”/“slight” disability for the principal target domain (DAS score 0 or 1) after each IC (baseline: 0.7%; study end: 42.9%). The proportion of ambulator-independent patients (FAC level 5) also improved throughout the study (baseline: 24.5%; study end: 40.6%). The proportion of “good”/“very good” IGEA assessments increased with escalating doses (IC1: 55.5%; IC2: 72.4%; IC3: 89.3%). Importantly, dose escalation did not increase the incidence of AEs (IC1: 36.1%; IC2: 37.5%; IC3: 25.7%) or treatment-related AEs (IC1: 4.5%; IC2: 5.3%; IC3: 2.9%). There were no treatment-related serious AEs or cases of clinical non-responsiveness due to antibodies. Conclusions: Increasing incobotulinumtoxinA doses (400-800U) allowed the effective treatment of a rising number of spasticity patterns for each patient while maintaining safety and tolerability. This enhanced efficacy was confirmed by improved muscle tone, favorable investigator global assessments, reduced upper-limb disability and greater ambulator independence. Level of Evidence: Level II

Poster 242 Ultrasound Guided and Doppler Verified Baclofen Pump Refill

Conclusions: SSFS is a potential complication following hemicraniectomy. It is important to quickly recognize in order to prevent potential catastrophic sequelae due to compressive forces on critical neurovascular structures. Additionally, expedited diagnosis and treatment can result in dramatic clinical improvement and increased functional outcome as demonstrated in this case. Level of Evidence: Level V

An Appropriate Population for Acute Inpatient Rehabilitation? A Case Series of Three Patients With Advanced Heart Failure on Continuous Inotropic Support.

The number of individuals with heart failure and the treatment modalities available to manage heart failure are increasing. Continuous inotropic support is a treatment modality used in cases of severe heart failure. Although most patients initiated on continuous inotropic support are discharged home, those with greater functional compromise, comorbid conditions that cause disability, or other significant medical complexity may be referred to acute inpatient rehabilitation. The feasibility and benefits of acute inpatient rehabilitation in this population, however, has yet to be investigated. We report the functional progress and medical complications of 3 patients on continuous inotropic support who participated in acute inpatient rehabilitation. The patients demonstrated varying levels of success, highlighting a need for evidence‐based, preadmission screening criteria for this population.

MRSA T-spine Osteomyelitis Presenting as Abdominal Pain in a 66-Year-Old Woman with a Remote History of a TMA: A Case Report

pelvic floor muscles showed average resting state of 13.1uV (elevated) and maximum voluntary pelvic floor contraction of 16.4 uV (indicating low work to rest ratio). Setting: Women’s Health Clinic. Results or Clinical Course: After the initial pelvic floor evaluation, patient was noted to have painful pelvic floor muscle myalgia. Pelvic floor rehabilitation program will be initiated, that consist of pelvic floor muscles relaxation and strengthening, vaginal dilators, trial of electrical stimulation, and diazepam vaginal suppository. Discussion: This is a case of a patient with chronic pelvic pain with bowel movements and dyspareunia with no clear diagnosis. About 60% of the women with pelvic pain do not have a diagnosis. As pelvic pain poses a diagnostic dilemma, it is important that focused pelvic musculoskeletal history and exam will be included in the evaluation. Conclusions: Patients with chronic pelvic pain can represent a diagnostic challenge for physicians due to the wide range of conditions that can produce this problem. Physiatrist should be the part of the interdisciplinary team involved in the evaluation and treatment of patients with pelvic pain.