Marc K. Ross

Poster 153: The Evaluation of Inpatient Rehabilitation Facility Patient Falls with Imaging Studies: A Quality Improvement Project

Disclosures: Mi Ran Shin: I Have No Relevant Financial Relationships To Disclose Objective: To describe, in a pilot group of children with milder traumatic brain injury (TBI), scores on the Children’s Affective Lability Scale (CALS) at 2 and 12 months post-injury and their relationship to parent-report of executive functioning and child’s quality of life. Design: Longitudinal observational study. Setting: Pediatric rehabilitation hospital. Participants: Seventeen children aged 10-17 years at injury with mildcomplicated TBI (mTBI) (n1⁄47), moderate (n1⁄49) or severe (n1⁄41) TBI; 14 returned for re-evaluation 12 months post-injury. Interventions: Not applicable. Main Outcome Measures: Children’s Affective Lability Scale (CALS) (2 and 12 months), Behavior Rating Inventory of Executive Function (BRIEF) (2 and 12 months) : Behavioral Regulation Index (BRI), Metacognition Index (MI), Global Executive Composite (GEC) and Pediatric Quality of Life inventory (PedsQL): Emotional health (12 months only). Results: 2 months post-injury, 2 of 17 children (both with mTBI) had CALS scores above the mean for outpatient psychiatric patients. No child had elevated scores 12 months post-injury. Mean CALS scores for the TBI cohort was within the normal range and decreased over time (at 2 month, mean 9.59, SD1⁄49.71; at 12 months mean 3, SD 3.62; p<.05). CALS score was strongly correlated with BRI at both time points (2months r1⁄40.914, p<.01;12 months r1⁄40.675, p<.01), with more affective lability associated with worse behavioral regulation). CALS scores were negatively correlated with emotional quality of life from the PedsQL (r1⁄4-0.893, p<.01), with more affective lability associated with worse emotional quality of life at 12 months. Conclusions: The CALS identified clinically elevated affective lability in a subset of children with milder TBI as well as improvements in affective lability over the first-year post-injury. As affective lability after TBI is associated with, difficulties with behavior regulation and emotional quality of life, the CALS may represent a useful brief screen for identifying youth who would benefit from additional resources for care. Level of Evidence: Level II

Poster 376: Post Meningioma Resection Complicated by Intracranial Hemorrhage in a Neurosyphilis Patient: A Case Report

Disclosures: Araj Sidki: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 40-year-old man with no past medical history was admitted to an acute care hospital after a near pool drowning, post phencyclidine ingestion. Patient was intubated for airway safety, extubated, medically stabilized and transferred to acute inpatient rehabilitation. On admission, he responded well to external stimuli and spoke single words. On physical exam, he was confused and had difficulty following commands. Although he was able to move all extremities, he demonstrated weakness throughout. He fell as he attempted to walk without assistance, and was placed on restraints for safety. He was noted to have a painful neck mass, which increased in size, limiting cervical range of motion. X-ray, CT and MRI showed heterotopic ossification (HO) of the cervical spine, but no protrusion into the spinal canal. His only complaint was neck pain, but he didn’t experience any neurologic deficits. He underwent inpatient physical, occupational and speech therapy and his strength, speech, and comprehension greatly improved. The patient also experienced a decrease in size and pain of the neck mass. Setting: Community Rehabilitation Hospital. Results: Ongoing physical and occupational therapy, range of motion exercises and mobilization techniques provided relief and diminished the neck mass size. Discussion: HO is the formation of mature lamellar bone in soft tissue. It may develop in patients with traumatic brain injury (TBI), spinal cord injury, or those with severe neurologic disorders. Patients demonstrate swelling, warmth, progressive loss of range of motion, and elevated alkaline phosphatase. Triple phase bone scan is the definitive diagnostic test for early HO diagnosis. Pharmaceutical treatment includes bisphosphonates. As TBI patients usually develop HO in hip joints, this patient’s cervical spine HO describes an atypical location. Conclusions: Surgery, radiation, and conservative treatments provided by physical therapy or occupational therapy have been shown to lower the incidence of HO in patients with severe TBI. Level of Evidence: Level V

Post Meningioma Resection Complicated by Intracranial Hemorrhage in a Neurosyphilis Patient: A Case Report

A 48-year-old African American female with a medical history of hypertension, GERD, asthma, neurosyphilis and status post meningioma resection presented to the emergency department with complaint of headaches and lethargy for two days. The patient had a remarkable past surgical history of 30 days’ post-operative sphenoid meningioma resection with bilateral craniotomy and on-going treatment with penicillin for active syphilis infection with positive RPR and FTA antibodies. Head CT performed secondary to altered mental status demonstrated right frontal intracranial hemorrhage and the patient underwent emergent craniotomy with hematoma evacuation, without noted complication during surgery. CT angiography of the neck and brain was negative for intracerebral aneurysm and arteriovenous malformation. Coagulopathy studies were negative.

Poster 21 Leptomeningeal Carcinomatosis Presenting as Tetraparesis: A Very Rare Case of Small Cell Prostate Carcinoma

replacement of the tube. BBS is commonly diagnosed only after a patient complains of abdominal pain, however as in our patient with no intact sensation in the lower abdomen, it should be part of the differential in SCI patients with difficulty flushing the PEG. Conclusions: It is important to consider BBS in patients with ongoing PEG obstruction as failure to do so could result in further complications such as peritonitis and death. Preventing traction on the PEG will reduce the chances of developing BBS. Allowing for 1.5-2cm between the external bumper and the skin, gently rotating and manipulating the PEG in and out daily, and measuring the length of the external tube can help to recognize migration of the tube. Level of Evidence: Level V

Poster 146 Autoimmune Induced Necrotizing Myopathy

elements which essentially protected his spinal cord by serving to decompress the spinal canal. Conclusions: To partially restore anatomic alignment and limit further extensive open intervention, closed reduction via manual traction can be performed if there are fractures of the posterior elements which yield the protective effect of an enlarged spinal canal. This case supports previous literature that manual traction can be safely performed in patients with posterior element fractures prior to open surgical intervention. Level of Evidence: Level V

Poster 340 Analysis of Neurosurgical Patients Acutely Discharged (AD) vs Non-Acutely Discharged (NAD) from an Inpatient Rehabilitation Facility (IRF).

abductor pollicis brevis, and 1st dorsal interosseous. Electromyogram (EMG) of adductor digiti mini (ADM) and pronator teres were within normal limits. NCS was repeated two months later: median motor and sensory showed prolonged latencies and decreased amplitude. Motor responses were obtained at the first dorsal interosseous and ADM by stimulating both the median and ulnar nerves at the wrist. There was evidence of median neuropathy across the wrist as well as a neuropathy affecting the deep terminal ulnar branch distal to the innervation of the hypothenar muscles. Furthermore, this patient demonstrated an anastomosis present in the palm between the median nerve and deep ulnar branch proximal to the hypothenar branch as evidenced by motor response at the ADM when stimulating the median nerve. Discussion: Isolated deep ulnar branch lesions are rare. To our knowledge there is no published literature regarding isolated lesions of the deep ulnar branch and the median nerve along with a palmar median to ulnar anastomosis. Conclusions: Isolated lesions of the deep ulnar branch and rare anastomosis should be considered as potential etiology in complicated cases of hand weakness and numbness. Level of Evidence: Level V

Poster 407 Pain Assessment Survey (PAS) for Assessing Physical Pain in Post-Cerebrovascular Accident (CVA) Patients

Disclosures: James Wilson: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 54-year-old man presented to the outpatient clinic for management of cervical dystonia. The primary manifestation of this syndrome was right laterocollis. His baseline Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) was 62. 1000 units of abobotulinumtoxinA were administered intramuscularly to the right upper trapezius, sternocleidomastoid and scalene muscles using electrical stimulation for localization purposes. His TWSTRS score dropped to the mid-30s but the duration of effects was only 3-4 weeks. Afterwards, his TWSTRS score returned to the low-60s. This pattern was maintained for a series of 3 injections. Setting: Academic Rehabilitation Hospital Clinic. Results: In an effort to prolong the botulinum toxin effect, the patient was pretreated with zinc supplement. The patient was prescribed two tablets of zinc citrate (25mg) combined with phytase (500mg) for 5 consecutive days prior to injection. With this treatment strategy, the patient’s TWSTRS score again dropped to the mid-30’s but the duration of effect was prolonged for up 20 weeks. The patient reported no adverse events relative to this treatment approach. Discussion: Botulinum toxin injections are considered standard of care for cervical dystonia. One limitation of this technique is a short duration of effect. Oral zinc supplementation has been reported to prolong the duration of botulinum toxin effect for cosmetic purposes but has not yet been studied in other conditions such as spasticity or dystonia. The purpose of this report is to describe an enhanced duration of botulinum toxin effects for cervical dystonia with oral zinc supplementation. Conclusions: This is the first reported case of prolongation of botulinum toxin effect with cervical dystonia using oral zinc supplementation. Further investigation is warranted to explore whether this finding can be reproduced in other patients. Level of Evidence: Level V

Poster 309 Implementing the Siebens Domain Management Model During Inpatient Rehabilitation to Increase Functional Independence and Discharge Rates to Home from an Inpatient Rehabilitation Facility in Stroke Patients and Minimize Acute Discharges: IRB Approved Study

Disclosures: George Francis: I Have No Relevant Financial Relationships To Disclose Case/Program Description: Sacral neoplasms often present as large masses refractory to chemotherapy and radiation, requiring a sacrectomy. Multiple sacral nerve roots and vessels may be compromised, resulting in immobility, pressure ulcers, orthostasis, and neurogenic bowel and bladder. Our goal is to review the rehabilitative needs and outcomes post-sacrectomy via two inpatient case presentations. A 58-year-old woman with a solitary fibrous tumor underwent an en bloc resection involving a subtotal sacrectomy from S2 to coccyx, an L5-S1 laminectomy, ligation of her bilateral S2-5 nerve roots, neurolysis of bilateral S1 and sciatic nerve roots, and bilateral gluteal flap closures. Post-operatively, activity precautions included no walking initially and no hip flexion for two weeks. She required tilt table treatments and was ambulating at post-op Day 8. The rehabilitation challenges included: training on the management of her neurogenic bowel and bladder, controlling her neuropathic and somatic pain, and mobilizing her despite the hip restrictions. The second case includes a 67-year-old male with a sacral chordoma who underwent a two-stage surgery. Stage one involved preparation for the en bloc resection of the sacral tumor. One day later, stage two involved an L5-S1 laminectomy, ligation of the S2-5 nerve roots, en bloc resection of the sacral, bilateral S1 root and sciatic neurolysis, and bilateral gluteus muscle flaps for closure. His rehabilitation challenges included: severe protein malnutrition, orthostatic hypotension, delayed wound healing, fluid collection, uncontrolled pain, and neurogenic bowel and bladder. Setting: Tertiary cancer center. Results: Highly functional outcomes are seen in these patients, including independent bowel and bladder management and return to pre-operative ambulatory status. Discussion: Rehabilitation interventions for these patients include: medical stabilization, pain management, wound healing, transfers, mobility, and neurogenic bowel and bladder management. Conclusions: These are highly complex surgical patients with extensive rehabilitation needs that require the management by a physiatrist. Level of Evidence: Level V

Thymic carcinoma with metastasis in a 29-year-old male causing radiculopathy

Thymic carcinoma is a rare, aggressive neoplasm with low 5-year survival rates ranging from 28 to 67%. Initial presentation with spinal or bone metastasis in primary thymic carcinoma is extremely rare. Thymic carcinoma, compared with thymoma, has higher recurrence rates and worse survival. We report one patient, a 29-year-old African-American male, with thymic carcinoma with metastasis to the epidural space (with cord compression), multiple bony structures (T10–L1) and left supraclavicular lymph node. Immunohistochemical staining was CD5 and c-Kit positive, consistent with thymic carcinoma. Patient underwent T12–L1 laminectomy with tumor resection to relieve cord compression and leg numbness/weakness. Patient was deemed a good candidate for rehabilitation. Soon after starting a rehabilitation program, he quickly demonstrated gains in gait distance with little to no assistance. Follow-up appointments with oncology were scheduled, and further planning of radiation and chemotherapy treatments were discussed.