Kevin L. Dalal

Diaphragmatic Pacing in Spinal Cord Injury

After cervical spinal cord injuries, many patients are unable to sustain independent ventilation because of a disruption of diaphragm innervation and respiratory functioning. If phrenic nerve function is preserved, the patient may be able to tolerate exogenous pacing of the diaphragm via electrical stimulation. Previously this was accomplished by stimulation directly to the phrenic nerves, but may be accomplished less invasively by percutaneously stimulating the diaphragm itself. The benefits, when compared with mechanical ventilation, include a lower rate of pulmonary complications, improved venous return, more normal breathing and speech, facilitation of eating, cost-effectiveness, and increased patient mobility.

Advances in the rehabilitation management of acute spinal cord injury.

Aggressive assessment and management of the secondary complications in the hours and days following spinal cord injury (SCI) leads to restoration of function in patients through intervention by a team of rehabilitation professionals. The recent certification of SCI physicians, newly validated assessments of impairment and function measures, and international databases agreed upon by SCI experts should lead to documentation of improved rehabilitation care. This chapter highlights recent advances in assessment and treatment based on evidence-based classification of literature reviews and expert opinion in the acute phase of SCI. A number of these reviews are the product of the Consortium for Spinal Cord Medicine, which offers clinical practice guidelines for healthcare professionals. Recognition of and early intervention for problems such as bradycardia, orthostatic hypotension, deep vein thrombosis/pulmonary embolism, and early ventilatory failure will be addressed although other chapters may discuss some issues in greater detail. Early assessment and intervention for neurogenic bladder and bowel function has proven effective in the prevention of renal failure and uncontrolled incontinence. Attention to overuse and disuse with training and advanced technology such as functional electrical stimulation have reduced pain and disability associated with upper extremity deterioration and improved physical fitness. Topics such as chronic pain, spasticity, sexual dysfunction, and pressure sores will be covered in more detail in additional chapters. However, the comprehensive and integrated rehabilitation by specialized SCI teams of physicians, nurses, therapists, social workers, and psychologists immediately following SCI has become the standard of care throughout the world.

Spinal Cord Injury Rehabilitation

This issue includes a range of topics in SCI from acute neuroprotection to chronic complications, focusing on some of the technological advances that have informed specific areas.

Poster 256: Unusual Presentation of Wernicke’s Encephalopathy Secondary to Dysphagia

work. To solve these issues an intrathecal baclofen pump was implanted. Setting: University Hospital Physical Medicine and Rehabilitation Clinic Results: At over 1-year post implantation, the patient continues to benefit from controlled spasms while minimizing the neurocognitive deficits he suffered while on the oral antispasmodic medications. The intrathecal baclofen has enabled our patient to remain a high functioning member of society: improving his quality of life. Discussion: SPS is a rare, difficult to treat, debilitating disorder with estimated prevalence of 1/1,000,000. It commonly presents with fluctuating muscle rigidity that may progress to severely interrupting a person’s daily routine. SPS is believed to have an autoimmune origin as GAD antibodies are demonstrated in more than 70% of cases. Baclofen and benzodiazepines are first line treatment. However, these drugs are well known to cause central nervous system depression making their persistent use a challenge. Understanding the diagnosis and management of SPS is vital to improve care. Conclusions: It is important to consider implanting the intrathecal baclofen pump as we can provide SPS patients with comfort while preserving mental status. Level of Evidence: Level V

Poster 145 Surfer Versus Rock: A Rare Cause of Lower Extremity Weakness and Numbness

Setting: Tertiary Medical Center. Results: Ultrasound guided radial nerve hydrodissection was done from the fascial plane, 1cm distal to the nerve exit of the supinator. Around 4 cc of Dextrose 5% was pushed to open up the fascial surrounding the nerve. Hydrodissection was performed with interval in a two weeks basis. VAS scale dropped from 10 to 7, 7 to 5, and 5 to 2 after 3 times of treatment. There was no marked difference to the change of the hardness of supinator nor the CSD of the nerve when passing supinator muscle. Patient has been followed up for 6 months and no return of the pain was noted. Discussion: Radial nerve hydrodissection using ultrasound guidance can mechanically disrupt the adhesion of nerve by the surrounding fascia, create a potential space and therefore alleviate the symptom. The hardness of the surrounding tissue may not be softened by hydrodissection and may need other intervention or manual therapy to further relieve the pressure on the nerve. Conclusions: Ultrasound guided radial nerve hydrodissection can effectively alleviate radial tunnel syndrome even as chronic as 20 years of history. Level of Evidence: Level V

Poster 396 Gabapentin-Induced Myoclonus in Spinal Cord Injury

Disclosures: Alexander Tucker: I Have No Relevant Financial Relationships To Disclose Case/Program Description: Proximal upper extremity weakness is a poorly understood complication of cervical spine surgery. The cause of this complication is unknown, although most patients recover completely over weeks to months with conservative treatment. We present two cases of postoperative, transient C5 palsy after laminectomy and fusion. Electrodiagnostic (EDX) studies performed after surgery revealed active denervation of the deltoid and biceps muscles on the symptomatic side, however the rhomboid muscles appeared unaffected. Setting: Tertiary care hospital. Results: By 6 months postoperatively, both patients had clinically improved strength in all previously affected muscle groups. We suggest that the current models of postoperative C5 palsy pathogenesis may be inadequate to explain our findings and propose an alternative theory of watershed ischemia distal to the origin of the dorsal scapular nerve as a contributing factor to the etiology of this surgical complication. Discussion: The cases described above illustrate postoperative C5 palsy, a notorious and under-recognized complication of cervical decompressive surgery, that was diagnosed clinically and correlated with EDX evidence. This description is the first to present the results of preoperative and postoperative electrophysiological studies; confirming deltoid and biceps weakness with rhomboid sparing. Conclusions: Serial EDX studies, as were performed on the patients presented here, may be used to assist with diagnosis, confirmation of involved root levels, prognostication, to follow recovery or to offer clues into the pathophysiology of the condition. Level of Evidence: Level V

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.

A Pilot Study of the Impact of Music on Self-Report Ratings of Pain, Anxiety, Stress, Relaxation, Mood, and Exertion During Physical or Occupational Therapy Sessions

lymphedema after right breast mastectomy followed by chemotherapy and radiation. Approximately 11 years later, she suffered a left brain infarct resulting in right upper extremity spastic hemiparesis and worsening of arm edema. Patient was never treated for lymphedema until presentation to our clinic. We sent her for complete decongestive therapy and ordered compression sleeve. At the same time, we tried to manage her spasticity with physical therapy, bracing, and multiple pharmacological agents, but failed. Given the risk of Botulinum A toxin injection potentially causing infection or worsening lymphedema, this treatment was considered a last resort. However, after discussing the risks and benefits, the patient opted to try the injections for her spasticity. Cephalexin 500 mg twice daily was started 2 days prior to the injections. Patient received a total of 200 Units of Botulinum A toxin (50 units to biceps, triceps and pectoralis major each, and 25 units to the pronator teres and flexor digitorum superficialis each). Setting: Outpatient Rehabilitation Clinic. Results or Clinical Course: At 4 weeks follow up, patient had no signs of infection or worsening lymphedema. Also, Modified Ashworth scores, right hand opening and grip improved. Injections will be repeated in 2 months. Discussion: According to our literature review there are no publications on the treatment of upper extremity spastic hemiparesis in the presence of lymphedema with Botulinum A toxin injections. Conclusions: We have demonstrated improvement of spasticity and hand function after Botulinum A toxin injection without worsening upper limb lymphedema.

Poster 494 Impact of Race on Functional Outcome Following Spinal Cord Injury

data collection during dives they previously arranged. Interventions: Core temperature is collected by ingesting a small, FDA-approved “pill” thermometer called the CorTemp® probe prior to diving. Main Outcome Measures: Core temperature analysis is collected after dives with a receiver and data will be statistically analyzed at a later date. Results: Preliminary data has shown a C7 ASIA A tetraplegic had a core body temperature decrement of approximately 3.04 degrees Celsius during a 60-minute dive in training pool with an average temperature of 27.7 degrees Celsius. An able-bodied diver with similar body habitus had a core body temperature decrement of only 0.8 degrees Celsius in the same conditions for the same duration. Conclusions: Divers with SCI are more susceptible to hypothermia while participating in diving than their able-bodied counterparts. Special considerations must be taken to ensure maintenance of safe core body temperature in divers with SCI. Further studies may identify the efficacy of measures to conserve body heat in divers with SCI. It is our hope that the study results will help lead to established guidelines for safe adaptive diving.

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.