Guy W. Fried

Spinal cord injury and bladder recovery

Abstract Objective: To investigate whether spinothalamic tract preservation and posterior column sparing are predictors of neurogenic recovery of bladder function after spinal cord injury (SCI). Designs and Participants: In a retrospective review, the initial perianal pinprick sensation (S 4,5 dermatomes) and position sense of the great toes were examined and correlated with bladder function at 1 year after SCI in 19 consecutive spinal cord injured patients (age 18 to 68 years), Frankel A-D, with spinal injury (level C-4-T-12). All patients were admitted to the Regional Spinal Cord Injury Center of Delaware Valley (RSCIDDV) within 72 hours of injury between July 1990 and June 1991 and were available for a 1-year follow-up evaluation. Main Outcome Measures: The correlation of initial perianal pinprick and great toe position sensation with bladder management approximately 1 year after SCI. Results: During the initial 72 hours, 10 of the 19 patients had positive perianal pinprick sensation and 9 did not feel the pin. Eight patients had positive great toe position sense, and 11 had no proprioception. At the 1-year follow-up visit, 7 of the 10 patients with initial preserved perianal pinprick were voiding volitionally, whereas none of the 9 patients who did not have pinprick voided volitionally at 1-year after SCI. Six of the 8 with initial preserved great toe position sense were voiding volitionally at 1 year, but only 1 of the original 11 without initial toe position sense was voiding volitionally. Conclusions: Both perianal pinprick sensation and toe position sense are sensitive in predicting return of bladder function. Although both tests have positive predictive value, their negative predictive values are much more noteworthy. A patient without initial position sense of the great toes will likely not regain volitional voiding, whereas a patient without initial perianal pinprick sensation will definitely not regain volitional voiding.

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.

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.

Spinal Cord Injury and Bladder Recovery

OBJECTIVE To investigate whether spinothalamic tract preservation and posterior column sparing are predictors of neurogenic recovery of bladder function after spinal cord injury (SCI). DESIGNS AND PARTICIPANTS: In a retrospective review, the initial perianal pinprick sensation (S4.5 dermatomes) and position sense of the great toes were examined and correlated with bladder function at 1 year after SCI in 19 consecutive spinal cord injured patients (age 18 to 68 years), Frankel A-D, with spinal injury (level C-4-T-12). All patients were admitted to the Regional Spinal Cord Injury Center of Delaware Valley (RSCIDDV) within 72 hours of injury between July 1990 and June 1991 and were available for a 1-year follow-up evaluation. MAIN OUTCOME MEASURES The correlation of initial perianal pinprick and great toe position sensation with bladder management approximately 1 year after SCI. RESULTS During the initial 72 hours, 10 of the 19 patients had positive perianal pinprick sensation and 9 did not feel the pin. Eight patients had positive great toe position sense, and 11 had no proprioception. At the 1-year follow-up visit, 7 of the 10 patients with initial preserved perianal pinprick were voiding volitionally, whereas none of the 9 patients who did not have pinprick voided volitionally at 1-year after SCI. Six of the 8 with initial preserved great toe position sense were voiding volitionally at 1 year, but only 1 of the original 11 without initial toe position sense was voiding volitionally. CONCLUSIONS Both perianal pinprick sensation and toe position sense are sensitive in predicting return of bladder function. Although both tests have positive predictive value, their negative predictive values are much more noteworthy. A patient without initial position sense of the great toes will likely not regain volitional voiding, whereas a patient without initial perianal pinprick sensation will definitely not regain volitional voiding.

Post-Traumatic Syringomyelia Refractory to Surgical Intervention: A Series of Cases on Recurrent Syringomyelia

Objective: To analyze a series of traumatic spinal cord injury (SCI) patients with diagnosis of syrinx who had recurrence of symptomatic syrinx following surgical intervention. Design: Case series. Setting: Acute inpatient rehabilitation facility. Participants: Patients (NZ 6) with post-traumatic syringomyelia who had recurrent syrinx despite surgical repair. Interventions: Not applicable. Main Outcome Measure(s): Time period between injury and clinical manifestations of syrinx, time to recurrence, and presenting symptoms. Results: Amongst the 6 patients, there is great variability between timeof the initial SCI and development of syrinx. In terms of temporal relationship between diagnosis of syrinx and recurrence of syrinx, there is also some variability (ranged 6 to 936 weeks). The median length of time to recurrence was 104 weeks. In all cases, the presenting symptom was ultimately weakness, and in most cases associated with rising sensory deficits. Notably, all patientsweremale, aged 31-55, had suffered diffuse traumatic SCI, and 4of 6 patients lost the ability to ambulate due to syrinx formation. Conclusions: This series suggests that there may be risk factors for developing post-traumatic syringomyelia; particularly in young men with diffuse type versus penetrating injuries. Further study is warranted to determine whether there are factors that put some patients at increased risk of syrinx recurrence following surgical intervention. Furthermore, by the time the syrinx has caused obvious symptoms, it may be more difficult to treat. Earlier detection and prevention may be important in optimizing outcomes in recurrent post-traumatic syringomyelia.

Poster 334: Brown-Sequard Syndrome After Cervical Laminectomy for Cervical Myelopathy Secondary to Cervical Stenosis: A Case Report

90 and his symptomatology resolved. Setting: Acute inpatient rehabilitation center. Results: The patient’s signs and symptoms were consistent with autonomic dysreflexia (AD). The precipitant cause was likely related to his Foley catheter; due to the deflated balloon, it is possible that the catheter became lodged within his urethra. With reinsertion of a new catheter, his symptoms resolved. Discussion: Although AD is typically seen at or above the T6 level, there have been cases reported at the T10 level as well. This is a rare case where AD was observed below the T10 level and even more unique as patients who have incomplete SCIs usually present with less severe symptomatology. The precipitant of the dysreflexia was related to his urological system which is reported as the most common underlying cause. Conclusions: With appropriate signs and symptoms, AD should always be considered in patients regardless if their injury is below T10 as these patients are at risk of grave complications and even death.

Normalization of Central Cord Syndrome Spinal Cord Injury Urodynamics After Intrathecal Baclofen Therapy: A Case Report

Objective. To report a case of improved urodynamics in a central cord syndrome spinal cord injury after intrathecal baclofen therapy. Methods. A 47‐year‐old man fell resulting in C4–C5 disc herniation with ventral spinal cord compression and cord edema. Results. He underwent an anterior cervical discectomy and fusion. Postoperatively, his examination revealed a C4 ASIA D injury in a central cord syndrome pattern. Cystometrogram (CMG) revealed a hyperactive detrusor with sphincter dyssynergia managed with intermittent self‐catheterization. One and a half years later, he was impaired by severe lower limb spasticity, despite oral medications and botulinum toxin injections. After intrathecal pump therapy, CMG revealed relatively normal detrusor and minimal sphincter tone. He volitionally voids with urgency but improved continence, which was maintained in one‐year follow‐up. Conclusion. Although the main indication for intrathecal baclofen therapy is spasticity, improved urodynamics can be an additional benefit in central cord syndrome spinal cord injury.