CASE PRESENTATIONS

Complications of Urethral Stenting in a Series of Spinal Cord Injured Patients
Fredrickson Mark, MD.1; Santa Maria Daniel.2; MD.
1 Audie Murphy (ALMD) VA Hospital, San Antonio, TX; 2 University of Texas Health Science Center in San Antonio, San Antonio, TX.

Objective: To detail unique complications of urethral stenting in the treatment of detrusor external sphincter dyssynergia (DESD).

Design: A retrospective case series of seven patients cared for in the ALMD VA spinal cord injury (SCI) unit.

Participants/methods: A retrospective electronic medical record review was performed on seven patients with spinal cord injuries and DESD who received urethral stent placement.

Results: As in previous studies, detrusor internal sphincter dyssynergia (DISD) with bladder neck obstruction, bladder stones with urethral obstruction, urethral stricture, stent migration, DESD distal to stent placement, and penile skin breakdown under the condom catheter were noted. However, one patient developed intraoperative hematuria of such a severity that stent placement had to be aborted, and three patients developed significant post procedure autonomic dysreflexia.

Conclusions: While stenting is a less invasive procedure than surgical sphincterotomy, significant complications may result. Proper patient selection may reduce the risk for some of these complications. Suprapubic catheterization and botulinum toxin (Botox) sphincterotomy are potential alternative methods treating DESD. However, these procedures carry their own unique risks and drawbacks.

Support: This project was not funded.

Objective: Illustrate the benefits of an immune-enhancing peptide-based formula (IEPBF) for individuals with SCI and pressure ulcers receiving tube feeding.

Design: Case studies and experiential-based findings.

Participants/Methods: Case reviews of 5 adults with SCI and pressure ulcers receiving standard whole protein-based tube feeding (SWPBF) that were switched to an IEPBF on admission to an acute rehabilitation hospital. Tube feeding tolerance measured by: albumin, bowel function, liver function tests, pre-albumin, serum glucose, weight, and wound assessment.

Discussion/Results: For individuals with SCI and pressure ulcers, SWPBF are often poorly tolerated due to loss of gut integrity associated with protein malnutrition. Diarrhea can hinder nutrient uptake, accelerate nutrient losses, excoriate and macerate skin, contaminate existing wounds, and increase nursing care needs. A standard feeding with fiber is often recommended to correct tube feeding related diarrhea. Fiber feedings in malnourished patients do not correct malabsorption diarrhea, but merely increase the likelihood of bowel impaction. IEPBF are more readily absorbed and contain nutrients to restore gut integrity. With recovery of gut function, other markers of tolerance such as visceral protein stores and wound healing also improve. These case studies illustrate the problems associated with SWPBF in malnourished SCI patients and improved tolerance/outcomes with transition to IEPBF.

Conclusion: Individuals with SCI and pressure ulcers demonstrated improved tube feeding tolerance with transition from a SWPBF to an IEPBF. Institutions which provide health care to individuals at high risk for pressure ulcers need to invest in appropriate enteral formulas in order to improve long-term clinical and financial outcomes.

Objective: To report an unusual cause of spinal cord injury (SCI).

Design: Case report.

Participants/methods: Case report and review of the literature.

Results: A patient presented with acute onset of lower extremity plegia and upper extremity paresis (ASIA-B), shortly after a multilevel transforaminal epidural steroid injection for the management of cervical axial and radicular pain. Imaging studies demonstrated brainstem and cervical spinal cord changes consistent with acute infarction. The patient was managed by the administration of corticosteroids and hemodynamic support and has made significant recovery in neurologic function on short-term follow-up (ASIA-D).

Conclusion: Despite the use of techniques thought to minimize vascular injury, this case highlights the potentially devastating consequence of performing procedures in proximity to the nervous system. Remarkably, the patient has made significant recovery of neurologic function.

Objective: To report a case of spinal cord infarction secondary to cocaine use.

Design: Case report

Participant/methods: A 27 year-old woman, without past medical history, recreationally inhaled cocaine. Several hours later, she noted chest tightness, then back and neck pain, and later bilateral upper extremity weakness.

Results: Physical examination revealed flaccid paresis of the upper extremities. Spasticity, but no detectable weakness, developed in the lower extremities. Cocaine was detected in the urine. MRI showed hyperintensity in the anterior cervico-thoracic spinal cord; the brain was normal. Electrodiagnostic studies of the upper extremities were consistent with anterior horn cell death. No infectious, inflammatory, embolic or thrombotic etiology was found.

Conclusion: Cocaine abuse is well known to be associated with cerebrovascular events and stroke, perhaps secondary to vasospasm, hypertension, and cardiac problems. Spinal cord effects are less commonly reported. The subject above appears to have sustained an infarct in the distribution of the anterior spinal artery, with clinical, imaging, and electrodiagnostic findings of upper extremity lower motor neuron injury, accompanied by spasticity of the lower extremities. Gray matter has increased susceptibility to ischemia compared to white matter, producing flaccid weakness in the cervical region with isolated arm weakness. While uncommon, cocaine abuse can cause spinal cord as well as cerebral infarction.

Support: There was no outside funding.

Objective: Occipitocervical fusion is the treatment of choice for unreduced odontoid fractures. Although neurological sequelae from odontoid fractures in children are uncommon due to the large spinal canal at the atlas, open reduction of such an injury has never been attempted.

Design: We report a case of six weeks old displaced fracture of odontoid with anterior atlantoaxial dislocation who was treated with open reduction and internal fixation with anterior plating after the failed attempted closed reduction.

Methods: The child was put on crutchfield traction of 6 lbs for five days with no improvement. Closed reduction under anaesthesia also failed. The fracture ends were exposed through anterior cervical retropharyngeal approach under radiographic control. All fibrous tissue from the fracture surfaces was excised including a small periosteal flap. Continued longitudinal traction to the neck and posteriorely directed manual pressure over the odontoid and the anterior arch of the atlas while an assistant extended the neck holding the patient’s chin reduced the atlantoaxial dislocation. The residual anterior angulation of the fracture did not allow putting screw across the fracture. The fracture surfaces was packed with cancellous chips from the iliac crest. A mini fragment ‘T’ buttress plate was put anteriorely across the fracture and fixed with one 2.7 mm screw through the odontoid and two similar screws through the body of the axis. The patient was neurologically intact and immobilized on a posterior plaster shell for about 2 months.

Results: The fracture united in approximately 3 months time with no segmental instability on flexion extension radiographs. Patient had regained full range of all neck movements except terminal 100 of lateral rotations and was involved in all bizarre childhood activities including that of the neck at 6 months postoperatively.

Conclusions- Occipitocervical fusion is a safe procedure but causes considerable limitation of neck movements and thus may not be a desirable option particularly in children who have yet to play a long and active inning. Open reduction of the displaced odontoid process provides a stable and the mobile spine with normal anatomical configuration and appears a viable alternative in selected patients.

Objective: We report an unusual case of spontaneous spinal subdural haematoma without underlying pathology.

Design: Case Report

Participants/methods: A 44-year-old male

Results/ case report: Our patient presented with sudden severe low back pain following a minimal effort, with rapid onset of complete paraplegia. MRI revealed an anterior
subdural haematoma from T2-T6 level with cord compression. An urgent laminectomy
was performed. MRI scan, surgery, and a further CT angiogram did not reveal any
underlying pathology to account for the subdural haematoma.The patient demonstrated
substantial clinical improvement after 6 weeks of bed rest and intense rehabilitation
programme with good motor power in both lower limbs (3-4/5), normal sensation,
and bowel control.

Conclusion/ Discussion: Spinal subdural haematoma (SSDH) is uncommon and can be caused by abnormalities of coagulation, blood dyscrasias, or due to trauma, underlying neoplasm, and AVM. SSDH is rare in the absence of these underlying conditions and only a few cases of spontaneous subdural haematomas were previously reported. It occurs most commonly in the thoracic spine and presents with sudden back pain radiating to the arms, legs or trunk, varying degrees of motor, sensory, and autonomic disturbances. On MRI, SSDH is seen as a space occupying lesion, usually ventrally, contained within the dura matter and can demonstrate variable T1 & T2 signal depending on the age of the haematoma. The prognosis is variable. Majority of cases in the literature had surgical decompression, though cases which were managed conservatively have been reported to be successful as well. The indications of surgery need to be clarified.

Support: Institute of Orthopaedics, RJ&AH Orthopaedic Hospital.

Subject: Patient with T6 incomplete SCI due to epidural abscess

Case Description: A 63 year-old, white man had severe low back pain, lower extremities weakness and dysuria. MRI revealed epidural abscess and was drained via T9-L2 laminectomy. Complications included acute renal failure requiring hemodialysis, re-exploration of his laminectomy site and development of swelling and stiffness of all limbs, rendering him totally dependent. Skin biopsy suggested scleroderma. NCS concluded carpal tunnel syndrome, while EMG suggested inflammatory myositis. Predisone for three weeks afforded some improvement. He received extensive in-patient rehabilitation and discharged home with improved ADLs, moderate assistance with transfers using overhead trapeze and manual wheelchair mobility for 150’. A month later, he had worsening weakness and rigidity. Repeat deep skin biopsy revealed Nephrogenic Fibrosing Dermopathy (NFD). Treatment included high-dose prednisone, plasmapheresis and in-patient rehabilitation. Arms responded to ROM, but legs remained rigid. Since diagnosed with NFD and his initial hospitalization two years ago, he had undergone six cycles of plasmapheresis. With progression of his NFD, he currently uses a power wheelchair for mobility and is dependent with ADLs and transfers.

Discussion: NFD is an acquired, idiopathic disorder in patients with renal disorder resembling scleroderma. Skin is affected with fibrotic nodule and plaques that can morbidly restrict ROM. If not for NFD, this patient could have been modified independent at T6 level. Earlier recognition would have allowed for treatment to lessen progression of the condition, leading to independent function.

Conclusion: NFD causes severe stiffness that creates an additional disability regardless of underlying condition. PM&R has a role in providing care to NFD patients. The combination of incomplete SCI and NFD has not been previously reported. Ideally this condition should be recognizable and treated as early as possible with coordinated care involving PM&R and other consult services.

Disclosure: None

Study Design: Single-subject, multiple baseline, multiple probe design.

Objective: To determine if an exercise program for spinal cord injured persons will increase motor and sensory function, and improve quality of life.

Setting: Commonwealth of Massachusetts Public Health Facility

Participants/Methods: Individuals who sustained spinal cord injuries at least one year prior to the study. A six-month guided exercise program with ASIA, Manual Muscle Test, and Catz-Itzkovich SCI scores obtained at 0, 3, and 6 months.

Results: Four single-subjects in the study.
#1 – No significant ASIA changes. MMT/L - six 2-point increases, two 1-point increases; R - one 3-point increase, three 2-point increases, three 1-point increases. Improvement in 12 areas of CI-SCI.
#2 – No significant ASIA motor, sensory/touch 10-point increase, sensory pinprick 4-point increase. MMT/L - five 2-point increases, three 1-point increase; R - three 2-point increases, five 1-point increases. Improvement in 13 areas of CI-SCI.
#3 – No significant ASIA motor or sensory/touch. Sensory pinprick 40-point increase. MMT/L - one 3-point increase, five 2-point increases, six 1-point increases; R - one 3-point increase, two 2-point increases, seven 1-point increases. Improvement in 7 areas of CI-SCI.
#4 – ASIA motor 8-point increase, sensory touch 32-point increase, sensory pinprick 42-point increase. MMT/L - five 2-point increases, four 1-point increases; R - three 2-point increases, one 1-point increase. Improvement in 15 areas of CI-SCI.

Conclusions: A structured exercise program that continues beyond a traditional rehabilitation period may lead to motor and sensory gains, increased muscle strength, and improved quality of life in persons with spinal cord injuries.

Support: Pilot phase funded in part by grants from the Christopher Reeve Paralysis Foundation and the Travis Roy Foundation. Study phase funded in part by grants from the Travis Roy Foundation and the Gustav and Louisa Pfeiffer Foundation.

Objective: To demonstrate that tracheostomies can be associated with major complications in patients with high spinal cord injury, that they may be responsible for weaning / decannulation failures and that they should be resorted to only after due consideration of alternatives.

Design: Single case design, Case report

Participants / Methods: All traumatic tetraplegic patients who required a tracheostomy in the period 2003 – 2005 were identified. All those who developed major complications related to the tracheostomy were further identified and their medical notes analysed.

Results: 104 traumatic tetraplegic patients were treated during the period. Of this 4 patients developed tracheostomy related complications which included subglottic tracheal stenosis, tracheal stricture and granulation tissue and obstruction around the distal end of the tracheotomy tube. 3 patients encountered breathing difficulty when the tracheal tube was capped while the fourth patient who had associated acquired brain injury developed post decannulation dyspnoea, had a cardiac arrest and required resuscitation. In all the patients a percutaneous tracheostomy technique was used. 2 of the 4 patients had associated swallowing difficulties. In three patients a spiral CT reconstruction of the trachea was done which clearly showed the tracheal abnormality. Two patients required tracheal reconstruction after failure of stenting, one patient was treated by excision of the granulation tissue and the fourth patient responded to tracheal dilatation.

Conclusion: Tracheostomies have the potential to cause complications which can increase morbidity and potentially mortality. Treatment of these complications is often difficult and may require multiple procedures. Weaning and decannulation difficulties may be indicative of underlying tracheal problems and a high index of suspicion is required for timely detection. CT reconstruction is a useful and non invasive way of assessing the airway in such situations. The relationship between percutaneous tracheostomy techniques and the development of tracheal problems requires further evaluation.

Traumatic Unstable Fracture Subluxation of the Cervical Spine in a Patient With Ankylosing Spondylitis (AS) and Root Signs Treated Conservatively - A Case Report
Changgeng Hu, M.D.1; Wagih S El-Masry, FRCS.2
1Changgeng Hu MD, PhD, Zhengzhou Orthopaedic Hospital, Zhengzhou, Henan, China
2WS El Masri (y) FRCS Ed, The Midlands Centre for Spinal Injuries (MCSI), Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, UK

Objective: To illustrate that conservative management is successful in the treatment of markedly unstable transverse 3 column fractures of the cervical spine with Ankylosing Spondylitis

Design: Retrospective study of medical records and materials of imaging.

Participants/ methods: A 48-year-old female sustained a hyperextension injury after a fall backward on a level 10.12.1994.

She felt severe tingling and pins and needles in the thumb and index finger bilaterally followed by hyperaesthesia. She was otherwise neurologically unimpaired. She was admitted to the MCSI within 24 hours post injury. X-ray showed fracture of the 6th cervical vertebra with subluxation at C5/6 level. Skull traction and later a Philadelphia collar was applied. She was discharged on 24/03/1995

Results: The patient was neurologically intact on discharge . On last followed up on 23/11/2005 she had no complaints. Her neck was stable clinically and radiologically. She regained a horizontal gaze, which had not been possible prior to the injury.

Conclusion: Cervical spine fractures in AS are usually unstable and potentially dangerous with high complication rate. Although very unstable, they heal well1. Operative management is widely used but deterioration of neurology may occur. The surgical mortality is high (26.3%)2. The good results in this patient may have been achieved by a more complex surgical procedure, but the risk of complications could have been high3. This case illustrates that expert conservative treatment can achieve good results with a low risk of complications.

1. Hosssain M, McLean A, Fraser MH Outcome of halo immobilisation of 104 cases of cervical spine injury. Scott Med J. 2004 Aug; 49(3):90-2
2.Cornefjord M, Alemany M, Olerud C. Posterior fixation of subaxial cervical spine fractures in patients with ankylosing spondylitis. Eur Spine J. 2005 May; 14(4):401-8.
3. Metz-Stavenhagen P, Krebs S, Meier O. Cervical fractures in ankylosing spondylitis. Orthopade. 2001 Dec;30(12):925-31.

Objective: Study the effect of intrathecal baclofen on neurogenic bladder

Design: Case study.

Participans/methods: Ten subjects affected by severe spasticity and detrusor hyperattivity due to spinal cord lesions: encephalomyelitis (2), multiple sclerosis (5), SCI (3). After testing the response to an intrathecal injection of baclofen to spasticity (a decrease of at least 2 degrees of Ashworth scale), a continuous intrathecal infusion pump (Medtronic system) was implanted to the patients. To evaluate the effect on bladder function, a videourodynamic examination was performed before and after the implantation.

Results: All the implanted subjects showed a marked reduction of spasticity, muscle spasms, pain. The bladder function improved in 7 subjects: the detrusor pressure decreased from 45 ± 14 to 8 ± 2 cm H20 (p<0,001) and the bladder volume increased from 257 ± 81 to 417 ± 85 ml (p<0,05). Two of the three not responsive cases were affected by vesico-uretheral reflux.

Conclusion: In many subjects affected by severe spasticity and neurogenic bladder due to spinal cord diseases, the intrathecal baclofen administration not only reduces spasticity, but can also improve bladder function. The reason of the negative results observed in 3 out of 10 patients should be investigated in a larger population, but it seems that an abnormal anatomical situation, as the vesico-uretheral reflux, prevents the increasing bladder compliance effect of baclofen.

Use of Tegaserod in the Treatment of Gastroparesis in the Patient with Spinal Cord Injury and or Multiple Sclerosis
Mark D. Fredrickson, M.D.1,2., Susan J. Rogers, Pharm.D. BCPS,1,2 Gregory Morton, P.A.1
1Audie L. Murphy Veterans Hospital, San Antonio, TX; 2University of Texas Health Science Center at San Antonio, San Antonio, TX

Objective: Report utility of tegaserod in hard to manage patients with gastroparesis

Design: Case series

Participants/methods: Individuals with spinal cord injury or multiple sclerosis with long history of symptoms of gastroparesis (bloating, gas) and /or constipation not responsive to current methods of therapy. Structured interview used to determine utility of tegaserod.

Results: Five spinal cord injury patients and one multiple sclerosis patient are being treated with low dose tegaserod 2mg twice a day with slow increase in dosage when indicated. Patients have been followed for up to forty-five weeks. All patients showed some improvement in targeted symptoms with one patient developing an apparent tachyphylaxis to the 2 mg dose. Two patients opted for no increase in the dose of the drug due to significant relief of their gas and bloating. Three patients have been increased to 4mg twice a day at their request. One patient has been increased to 6mg twice a day with significant improvement in symptoms. No adverse effects have been noted so far with the use of the drug.

Conclusions: Clinical efficacy has been reported in at least five out of six patients. No adverse effects have been noted. Tachyphylaxis may limit the drug’s utility, however the incidence of tachyphylaxis cannot be determined at this time. Tegaserod may prove to be a useful pharmacological agent in the treatment of symptoms of gastroparesis secondary to spinal cord injury or multiple sclerosis.

Measurement Methods of Spinal Cord Blood Perfusion and Introduction of Near Infrared Spectroscopy as a Suitable Assessment Tool
Cheong H. Lee, MBBS. MRCSEd1,2; Adrian T.H. Casey, FRCS SN2; David T. Delpy, FRS.3; Michael D. Craggs, PhD CBiol MIBiol MIPEM1
1Spinal Research Centre, Royal National Orthopaedic Hospital, Stanmore, UK; 2Spinal Surgery Unit, Royal National orthopaedic Hospital, Stanmore, UK; 3Department of Medical Physics & Bioengineering, University College London, London, UK

Objective: To assess the sensitivity of Near Infrared Spectroscopy for measurement of central nervous tissue and its potential for measurement of Spinal Cord Blood Perfusion.

Design: Prospective Pilot Study

Participants/methods: A Hamamatsu NIRO 500 spectrophotometers (NIRS) was connected via special optodes to the scalp of 2-3 healthy volunteers. This will measure the accumulation of Indocyanine Green (ICG) dye for cerebral central nervous tissue perfusion. A Pulsion LiMON ICG pulse oximeter recorded the general arterial input ICG concentration. Using the ‘central volume principle’ with ‘impulse residue function’, absolute perfusion in the cerebral cortex of central nervous system could be derived. Measurements were taken at rest and with CO2-induced vasodilatation.

Results: 3 subjects were invited into the study. Mean cerebral blood perfusion was 20.37ml/100g tissue/min (+/- 2.9 SD). CO2-induced vasodilatation increased perfusion to 35.03ml/100g tissue/min (+/- 4.34 SD). These values are consistent with established literature.

Conclusion: There is a lack of literature information regarding measurement methods and values of spinal cord blood perfusion. Near Infrared Spectroscopy shows promise in being sensitive enough to detect central nervous tissue perfusion and its changes. NIRS could theoretically be employed in measurement of spinal cord blood perfusion. This study will continue with progress on NIRS and intra-operative spinal cord blood perfusion.

Support: This project is funded by Royal National Orthopaedic Hospital NHS Trust and FH Muirhead Charitable Trust

Result: Patient underwent cervical vertebrectomy, decompression, and fusion with cages with allograft bone chips and Atlantis cervical plate, magnification technique.

Conclusion: This is a rare case of SCI complication in a paraplegic secondary to persistent bacteremia from endocarditis.

Objective: To present four cases of progressive neurological damage resulting from SCI following lumbar epidural steroid injection (LESI), and propose factors that may have contributed to these complications.

Design: Retrospective case review of four patients.

Participants/methods: Four individuals, 2 female, and 2 male, ages 26-73, underwent LESI between March and July of 2005 using a blind loss of resistance technique and with no pre procedure MRI in 2 of the 4 cases.

Results: Ensuing neurologic deficits occurred within 1 hour to 2 days post injection secondary to hematoma in two cases, and without radiographic evidence of damage in the other two cases. Acute complications included parasthesias with paralysis, Brown Sequard Syndrome, Cauda Equina Syndrome, and Conus Medullaris syndrome. These patients continue to experience varying levels of spasticity with neurogenic bowel and bladder. Lack of fluoroscopic guidance, combined with failure of the clinician to recognize the patient’s post injection symptoms as sequelae of spinal cord injury, appear to be contributing factors leading to paraplegia in our subjects.

Conclusions: We present 4 cases that add to a growing body of literature on potential risks of an increasingly common procedure. We propose that improper screening, failure to identify acute neurologic changes post injection, delayed neuro-imaging, and use of a “blind” approach without fluoroscopy may be factors leading to the neurologic decline of these four patients. Establishing relationships with specialists in SCI prior to performing LESI could enable the practitioner to reduce likelihood of devastating neurological complications, and institute appropriate treatment expeditiously.

Objective: Description of unusual methodology in resolution of refractory urinary tract infections.

Design: Descriptive Case Series

Participants/Methods: A 46-year old male with T12 ASIA B spinal cord injury (SCI) secondary to a fall in 1973. After approximately 18 years he began to notice recurrent urinary tract infections (UTIs) progressively resistant to treatment with multiple antibiotics. No evidence of stone formation was detected. After 12 years, he developed epididymo-orchitis and with suppressive therapy also contended with bouts of Clostridium difficile. A second case involves a 51-year old male C7 ASIA B SCI after motor vehicle accident in 1984. He managed the urinary tract with the use of an external device and three sphincterotomies, with episode of failed Volume stent. After 15 years, he was noted to develop repeated UTIs and noted the onset of testicular pain. Subsequently he developed overt epididymitis and bilateral hydrocoele which were not eradicated by antibiotics.

Results: In both cases, a vasectomy was performed in an effort to prevent reflux of urine and accompanying bacteria into the vas deferens as a source of recurrent infection. The frequency of UTIs in both patients has been drastically reduced since this procedure. Testicular pain has also been relieved.

Conclusions: Vasectomy has potential for use as a successful treatment for recurrent UTIs resistant to multiple antibiotic therapies.

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