Maria R. Reyes

Examining health-care utilization in the first year following spinal cord injury

Abstract Objective To identify factors associated with health-care utilization during the first year after inpatient rehabilitation (IR) in individuals with traumatic spinal cord injury (SCI). Design Prospective cohort. Methods One hundred and sixty-eight patients were prospectively enrolled and followed over 1 year after discharge from an SCI Model System IR program. Telephone follow-up occurred at 3, 6, 9, and 12 months. Participants were grouped into four impairment levels (C1–4 American Spinal Injury Association (ASIA) Impairment Scale (AIS) A–C, C5–C8 AIS A–C, paraplegia AIS A–C, and all AIS D). Three domains of health-care utilization were examined: hospital care, outpatient provider visits, and home services. Results Health-care utilization in the first year following IR was high with 45% of subjects reporting re-hospitalization. Twenty percent of patients were initially discharged to a skilled nursing facility (SNF), and an additional 10% required SNF care during this first year. Overall, those with C1–4 AIS A–C used the most services. Participants discharged home used less health care compared to those discharged elsewhere. SCI due to falls (vs. vehicular crashes) was associated with fewer in-home service visits. Age, sex, race, and education were unrelated to higher use. Conclusion Those with greater neurological impairment or not discharged home after IR had higher health-care utilization, while age was not associated with utilization. Targeted efforts to reduce genitourinary and respiratory complications may reduce the need for hospital care in the first year after IR.

Benefits of an exercise wellness program after spinal cord injury

Objective: To describe the initial benefits of a structured group exercise program on exercise frequency and intensity, perceived health, pain, mood, and television watching habits. Design: Pre-test/post-test. Participants/methods: Eighty-nine persons with SCI participated voluntarily in a no-cost, twice weekly physical therapy group exercise class over 3 months. Forty-five persons completed pre- and post-participation interviews on exercise frequency and intensity, perceived health, pain, mood, sleep, and television watching habits. Results: Mean participant age of the respondents was 43.82 years. 49% had AIS C or D injuries, 24% had AIS A,B paraplegia, 9% had AIS A,B C1-C4 and 18% had AIS A,B C5–C8. 75.6% of participants were male and 84.4% had a traumatic etiology as the cause of their SCI. There was a significant improvement in days of strenuous and moderate exercise as well as health state. There was an average decrease in pain scores, depression scores, number of hours spent watching television, and days/week of mild exercise. Conclusion: Participation in structured, small group exercise as a component of a wellness program after SCI shows promise for improving regular exercise participation and health state, but benefits may also occur across other areas of health and function including mood, pain, and hours spent watching television. Further follow-up is needed to determine whether improvements can be maintained after program completion and across all neurological levels.

Dorsal column myelopathy following intrathecal chemotherapy for acute lymphoblastic leukemia

Abstract Objective/context To describe a distinctive clinical and radiographic pattern of myelopathy following intrathecal chemotherapy. Myelopathy is a rare complication of intrathecal chemotherapy used in the treatment of acute lymphoblastic leukemia (ALL). We present a 42-year-old female with T-cell ALL who developed a myelopathy primarily involving the dorsal columns. Method Case report and literature review. Findings Within 24 hours of an injection of intrathecal methotrexate, cytarabine, and hydrocortisone, the patient developed ascending lower limb numbness and balance difficulties progressing to the inability to ambulate. Clinical examination showed profound loss of lower limb proprioception and light touch sensation below T5, mild proximal limb weakness, but preserved pinprick and temperature sensation with intact bowel and bladder function. Initial thoracic and lumbar spine magnetic resonance imaging (MRI) at 1 week revealed no abnormalities. However, repeat imaging at 6 weeks showed abnormal signal in the posterior cord with sparing of the anterior and lateral columns, diffusely involving the lower cervical cord through the conus medullaris. Dermatomal somatosensory-evoked potential (DSEP) conduction abnormalities were consistent with thoracic myelopathy. An empiric trial of high-dose intravenous corticosteroids during inpatient rehabilitation more than 6 weeks later produced no significant clinical improvement. Conclusion/clinical relevance Preferential and persistent dorsal column myelopathy is a distinctive clinical and radiographic presentation of a rare complication of intrathecal chemotherapy. The MRI abnormalities were initially absent, but evolved to consist of multi-level spinal cord T2 and STIR hyperintensity with regional gadolinium enhancement. DSEPs more accurately reflected the clinical level of spinal cord dysfunction.

Early selective surgical resection of traumatic heterotopic ossification after extensive crush injuries: a case report.

Heterotopic ossification (HO) is pathologic ectopic bone formation that typically affects periarticular regions and is most commonly associated with neurologic injuries such as traumatic brain or spinal cord injuries, burn injuries, trauma, joint arthroplasty, amputation, and other orthopedic surgical procedures. The prevailing recommendation for management of HO consists of nonsurgical treatment with gentle range of motion (ROM) exercises, nonsteroidal anti-inflammatory drugs, and bisphosphonates [1,2]. Consideration for surgical resection of HO is reserved for heterotopic bone that is severely functionally limiting or is associated with significant morbidity [1-3]. Concern for the possibility of recurrent ectopic bone formation triggered by resection of immature heterotopic bone has led to the conventional practice of delaying surgical excision of HO until demonstration of full bone maturation or reduction in neurologic stimulus for recurrence [2,3]. However, progressive malignant evolution of HO that is extensive or critically located can result in early, substantial ROM loss or other functional limitations that adversely affect the acquisition of basic rehabilitation skills. Its eventual maturation despite conventional treatment can result in permanent disability. Although the timing of surgical resection of HO from various etiologies remains controversial, the evidence regarding the efficacy and safety of early and subtotal surgical intervention for traumatic HO is even more limited [2,4]. This case presentation demonstrates the use of early and selective resection of disabling post-traumatic HO.

Autonomic Dysreflexia as a Potential Adverse Effect of Duloxetine and Amitriptyline Combination Therapy: A Case Report

Pharmacologic triggers of autonomic dysreflexia (AD) have rarely been described. This report describes the case of a 31‐year‐old woman with T3 American Spinal Injury Association Impairment Scale A spinal cord injury who developed recurrent AD while receiving duloxetine and amitriptyline combination therapy for neuropathic pain. After excluding other AD generators, duloxetine was discontinued and the AD episodes resolved. Although secondary hypertension is a known side effect of amitriptyline and duloxetine, neither drug has been previously associated with AD. One potential mechanism for inhibition of duloxetine metabolism is discussed. Unexplained AD in at‐risk patients receiving duloxetine and amitriptyline should prompt consideration of an adverse reaction to combination therapy.