Lance R. Stone

Reflex sympathetic dystrophy in brain-injured patients

&NA; One‐hundred consecutive patients were prospectively evaluated on admission to our Brain Injury Unit for signs and symptoms of reflex sympathetic dystrophy (RSD) in the upper extremity. Patients averaged 4 months postinjury and had an average age of 29 years. Thirteen patients had clinical signs and symptoms of RSD and were then evaluated with standard radiographs and 3‐phase radionuclide scintigraphy. Twelve of 13 patients had 3‐phase bone scans (TPBS) consistent with RSD (12% overall incidence). RSD was present exclusively in the spastic upper extremity. There were 9 patients with hemiparesis and 3 with quadraparesis. There was a significantly higher (P < 0.01) incidence of associated upper extremity injury in the group with RSD (75%). All patients had a mean Rancho Cognitive Level of V and initial Glasgow Coma Scores less than 8. Patients who developed RSD had lower Glasgow Coma Scores than the non‐RSD patients. Brain‐injured patients often display agitation, hyperalgesia, disuse or neglect of the RSD‐involved extremity. In addition, these patients are often cognitively unable to vocalize complaints of pain. Undiagnosed RSD in these patients can result in a significant delay in rehabilitation and possible loss of the use of an otherwise functional upper extremity.

Percutaneous phenol block of the musculocutaneous nerve to control elbow flexor spasticity

Twenty-three extremities in 17 brain-injured adults were prospectively studied to evaluate the effectiveness of percutaneous phenol blocks of the musculocutaneous nerve in controlling spasticity of the biceps and brachialis muscles. Twenty-one (93%) of the extremities improved after the initial injection. The mean resting position decreased from 120 degrees of flexion to 69 degrees. Elbow range of motion increased an average of 53 degrees. There were no complications. Two patients did not respond to the initial injection and required repeat nerve blocks. Concomitant phenol motor point block of the brachioradialis muscle further improved elbow motion. The mean duration of the block was 5 months. Follow-up averaged 21 months. This study indicates that percutaneous phenol injection of the musculocutaneous nerve provides reliable, temporary relief of spasticity in patients with potential for further neurologic improvement.

Dynamic electromyography to assess elbow spasticity

Control of elbow motion was evaluated in 45 extremities of adults with spasticity resulting from traumatic brain injury with use of dynamic electromyography. Simultaneous recording of elbow motion was obtained using a double parallelogram goniometer. Thirty-four male and 9 female patients were studied. Mean elbow flexion was 85 degrees and mean extension was 20 degrees. The average time of elbow flexion was 1.8 seconds. Extension time was prolonged to a mean of 4.0 seconds. Dynamic electromyography revealed a consistent pattern of muscle activity. Severe spasticity was noted in the brachioradialis muscle. Moderate spasticity was present in the biceps and only mild spasticity was seen in the brachialis muscle. Normal phasic muscle activity was the rule in the triceps. All patients had active elbow flexion, but the flexor spasticity limited smooth extension. Elbow flexor spasticity, especially of the brachioradialis and biceps muscles, commonly interferes with hand placement. Lengthening of the biceps and brachialis tendons combined with release of the brachioradialis enhances elbow motion and improves hand placement.

Peripheral nerve injuries in the adult with traumatic brain injury.

Fifty adult patients who sustained a traumatic brain injury (TBI) were screened for the presence of a peripheral nerve injury (PNI). All suspected patients had diagnostic electromyography performed in order to confirm the clinical findings. The incidence of PNI with TBI was 34%. A variety of nerve injuries were seen, the most frequent of which were ulnar nerve entrapment at the elbow (10%) and brachial plexus injuries (10%). No patient initiated a complaint that led to the diagnosis. In addition, all the neuropathies were missed prior to admission. The neuropathies commonly were found in the neurologically impaired extremity and associated with spasticity. The results of this study suggest that patients sustaining a TBI have a significant and higher incidence of PNI as a complication than previously reported.

Carpal tunnel syndrome secondary to wrist and finger flexor spasticity

Ten patients with spastic wrist flexion deformities secondary to traumatic brain injury were evaluated for carpal tunnel syndrome. The angle of wrist flexion deformity averaged 75 degrees (range, 58 to 115 degrees). Nerve conduction studies demonstrated prolonged median motor and/or sensory latencies in all patients. Preoperative wick catheter measurements of carpal tunnel pressures in eight patients averaged 11 mm Hg in the resting position, 21 mm Hg in maximal wrist flexion, and 15 mm Hg in maximal extension. Each patient had carpal tunnel release with simultaneous wrist and finger flexor tendon releases or lengthenings. At surgery nine of the median nerves were constricted at the proximal edge of the transverse carpal ligament. The presence of normal carpal tunnel pressures and impingement of the median nerve at the proximal edge of the transverse carpal ligament indicates that the chronically flexed posture of the wrist resulted in median nerve compression, and this condition may be aggravated by underlying pressure from the spastic finger flexors.

The treatment of spastic planovalgus foot deformity in the neurologically impaired adult.

The surgical correction of 14 feet with spastic planovalgus in the neurologically impaired adult is reviewed. Evaluation of the patterns of lower extremity muscle activity preoperatively by dynamic EMG showed overactivity of the peroneus longus. A new gait pattern which has not been previously reported was observed. This “combination foot” deformity, noted in six patients, consists of equinovarus in swing, and planovalgus in stance during the gait cycle. The remaining eight patients exhibited planovalgus in swing and stance. Transfer of the peroneus longus tendon to either the cuboid or navicular was performed in seven (50%) patients. Release of the peroneus longus was performed in four (29%) patients. Two patients had Z-lengthening of the peroneus longus, and tenodesis of the peroneus longus to posterior tibialis was performed in one patient. The mean postoperative follow-up time was 34.6 months. All feet were plantigrade. Ten (71%) feet were balanced. Four (29%) feet were improved. There were no failures or complications. Thirteen patients were able to ambulate independently after surgery and one patient continued to require only stand-by-assistance secondary to balance problems. No patient decreased in ambulation level. Seven (64%) of the 11 patients who required bracing, preoperatively became brace free. Peroneus longus was found to be the major deforming force in spastic planovalgus. Release, transfer, or tenodesis of the peroneus longus is effective in correcting planovalgus.

Acute subdural haematoma mimicking an epidural haematoma on a CT scan.

This paper reports an acute subdural haematoma mimicking an epidural haematoma as seen on a non-enhanced computerized tomography (CT) scan of the head in a patient who had sustained a traumatic head injury. The patient had undergone a craniotomy 4 years prior to the injury described here.

Acquired limb loss in patients with traumatic brain injury

The outcome associated with long-term prosthetic use was evaluated in 12 patients who had a dual disability of severe traumatic brain injury and an extremity amputation. The incidence and nature of complications after limb loss was also reviewed. The 12 patients sustained 15 extremity amputations. Lower extremity amputations were the most common disability. Fifty percent of the patients had at least one postoperative complication after amputation. All patients (100%) had at least one complication documented on rehabilitation admission. No patient was using a prosthesis at the time of rehabilitation admission. At discharge six patients were able to use a prosthesis. Only one patient was considered independent. Patient follow-up averaged 28.6 months. At long-term follow-up six patients were using a prosthesis. Four were considered independent. One-third of the total group was considered able to use the prosthesis independently in the community. Of the lower extremity amputated population, only 40% became ambulatory. This is considerably less than can be expected to become ambulatory if there was no amputation. All three upper extremity amputees did not use a prosthesis. All efforts should be directed at salvaging a limb threatened by amputation after survival of traumatic brain injury. Early transfer to a facility specializing in traumatic brain injury rehabilitation may decrease complications, reduce total hospitalization and improve overall functional ability

An uncommon cause of fever in a brain injured patient.

The evaluation of the brain injured patient with fever can present challenging diagnostic problems to those responsible for their care. The brain injured patient, because of an altered level of consciousness, may be unable to provide a history of present illness or complain of symptoms that would direct the physician to the source of fever. This paper presents an uncommon cause of fever, which emphasizes the importance of an astute clinician and using laboratory information to identify the source of fever in the brain injured patient.