Jackson Cohen

An Anaplastic Astrocytoma Presenting as Worsening Paresis in an Incomplete Paraplegic Patient: A Case Report

therapy. On initial evaluation at three weeks post blast, patient’s Glasgow coma scale (GCS) was 6T. He underwent multiple surgeries, including exploratory laparotomy, skin graft procedures, and soft tissue repair. Patient continued to improve from his traumatic brain injury reaching a GCS 15T by six weeks post blast. On day 61 post-blast, after 53 surgeries or procedures, and day two post decannulation, patient suffered respiratory failure followed by cardiac arrest. The code lasted ten minutes and patient remained unresponsive and was noted to have decerebrate posturing and dilated pupils. A head CT demonstrated diffuse symmetric cerebral edema and hydrocephalus and he underwent an emergent ventriculostomy. EEG demonstrated evidence of anoxic encephalopathy. Brain MRI suggested anoxic brain injury with cortical encephalomalacia. Patient was admitted to an emerging consciousness rehabilitation program at eight months post injury and has undergone neuropsychology batteries and therapies, mutlispecialty therapy programs, and started on modafinil as a neurostimulant with no cognitive improvement. Patient remains in a persistent vegetative state. Conclusions: Patient remains in a persistent vegetative state at 14 months post injury. This is a poignant demonstration of the poor outcomes related to second insults to a still recovering cerebral tissue and the importance of gauging appropriate decannulation timing in this population.

Developing an Ultrasound Course for a Physical Medicine & Rehabilitation Residency Program

Disclosures: B. Curtin, No Disclosures: I Have Nothing To Disclose. Objective: In measuring plantar pressures during gait, earlier methods have used a platform system that does not take into account the interactions feet havewithorthotics and shoewearing.Thepurpose of the study was to provide normal insole plantar pressure parameter data during stance phase using the Pedar pressure insole system. Design: Twenty-nine normal children, age 6 to 16 years, were recruited and walked along the 25mwalkway at self-selected speeds. Patients were divided into 2 separate groups for statistical analysis– juniors (<12 y old) and teenagers (>13 y old). The pressuremapwas divided into 8 regions (masks) determined by anatomic landmarks and a total of 7 pressure parameters were analyzed of each mask. Setting: The patients were evaluated at the musculoskeletal functional assessment center at Children’s Hospital ofWisconsin. Subjects walked along a 25m long walkway. Patients walked at a self-selected speed 3 separate times and then data was collected and analyzed. Participants: Twenty-nine normal male and female individuals were either current patients seen in the orthopedic clinic or patients recruited from local schools. Owing to an incorrect cable connection of the insole sensors, data were lost for 4 patients. The remaining 14 male patients and 11 female patients participated in the study, with a total of 49 individual feet examined. Patient age ranged from 6 to 16 years, with a mean age of 11.08 years. Main Outcome Measures: 7 parameters were analyzed of each mask: plantar contact area (cm2), maximum force (N), peak pressure (N/cm2), contact time for peak pressure occurrence as a function of stance phase(%), maximum mean pressure (N/cm2), pressure-timeintegral (NS/cm2), and force-time integral (NS). Results or Clinical Course: We did not detect significant differences in foot pressures between juniors and teenagers when regarding sex, or left and right feet for 7 parameters measured. Conclusions: This normative data will provide a basis with which to more accurately assess pediatric pathologic foot deformities and to distinguish dynamic foot deformities from anatomic foot deformities.

Radiographic Evidence of Lumbar Zygapophysial Joint Arthritis on MRI at Initial Zygapophysial Joint Injection or Medial Branch Block

Disclosures: A. Miciano, No Disclosures: I Have Nothing To Disclose. Objective: 1) To adapt the PROMIS item banks to spine medicine by administering it in individuals with chronic spine pain (CSP) and comparing the outcomes of different spine intervention groups (non-invasive vs. invasive procedures); and, 2) To correlate the PROMIS scores with clinician-derived tests. Design: Retrospective study Setting: Outpatient rehabilitation clinic Participants: Records of 100 patients were reviewed after being referred for CSP; 17 had previously undergone no invasive interventions (NII), 15 with therapeutic spinal injections (TSI), and 17 with a spinal reconstruction intervention (SRI). Interventions: N/A Main Outcome Measures: All study participants had completed the PROMIS global health item banks: physical function, anxiety, depression, fatigue, sleep disturbance, satisfaction with social roles, and pain impact. Also, clinician-derived tests had been administered: skeletal muscle mass (SM) and skeletal muscle index (SMI) by Bioelectric Impedance Analysis; spinal flexor and extensor strength by the 1-Repetition Maximum Method; and, physical performance tests Dynamic Gait Index (DGI), Berg Balance Scale, and 6-Minute Walk Test. Results or Clinical Course: Age was a significant covariate only for PROMIS-Fatigue, wherein there was a negative correlation between fatigue and age in all three treatments. Gender differences were present for DGI, flexor strength, SM, and PROMIS-Physical Function; in all cases, male scores were significantly higher than females. Intervention differences were significant in PROMISFatigue (both NII and SRI had higher mean scores than did TSI); PROMIS-Sleep disturbance (SRI had a higher mean score than did TSI); PROMIS-Pain impact (SRI had a higher mean score than did TSI). Conclusions: This study had differentiated the global health outcomes in individuals with chronic spine pain and who have undergone varied interventions. It also showed that the PROMIS item banks can provide efficient and precise dimensional estimates of comparative outcomes that can be utilized to monitor patient progress in individuals with CSP. Measurement practice in busy outpatient spine clinics and in research can be advanced by using the PROMIS. Further evaluation in clinical populations on a larger scale is warranted before the PROMIS item banks can be used for spine clinical trials. Poster 474 Radiographic Evidence of Lumbar Zygapophysial Joint Arthritis on MRI at Initial Zygapophysial Joint Injection or Medial Branch Block. Jackson Cohen, MD (University of Miami Miller School of Medicine, Miami, FL, United States); Daniel Rivera, MD; Douglas Johnson-Greene, PHD; Jose Mena, MD; Andrew L. Sherman, MD.

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.