Diagnostic Pitfalls: Case Report Of Scurvy In A Man With Spinal Cord Injury

Abstract

Background: A 49-year-old man with spinal cord injury (SCI) developed a progressive purpuric rash and painful swelling of the lower extremities, in addition to chronic purpura over the ischial tuberosities.

Design: Case report

Findings: Following an extensive workup for presumed vasculitis, a skin biopsy showed evidence of scurvy. Risk facto rs for scurvy included limited means of transportation, living alone, and alcohol abuse.

Conclusions: Scurvy can be confused with disorders common among SCI patients, such as vasculitis, venous thrombosis, occult trauma, and pressure injury. Scurvy should be considered in the differential diagnosis of skin lesions, especially in individuals who abuse alcohol and live alone.     

Infarction of the Cervical Spinal Cord Following Multilevel Transforaminal Epidural Steroid Injection: Case Report and Review of the Literature

Abstract

Background/Objective: Transforaminal epidural steroid injection is a widely utilized nonsurgical strategy for the management of cervical radicular and axial pain. The technique has been shown to be efficacious in relieving the patients' symptoms. Although effective, there are a range of possible complications associated with this procedure. We report the case of a patient with an acute infarction of the cervical spinal cord after a multilevel transforaminal epidural steroid injection.

Methods: We performed a retrospective chart review of a single case.

Results: The patient suffered an acute brainstem and cervical spinal cord infarction despite the use of many techniques to minimize the occurrence of vascular injury during the procedure. The patient regained some function after medical and physical therapy.

Conclusions: This complication, to our knowledge, has only been reported in the literature on 2 other occasions and serves as a reminder of the potentially devastating consequences of performing procedures in proximity to the nervous system.     

Aging After Spinal Cord Injury: A 30-Year Longitudinal Study

Abstract

Background/Objective: This longitudinal study investigated changes in life satisfaction, general health, activities, and adjustment over 3 decades among individuals with spinal cord injury (SCI).

Participants: The cohort of participants was identified from outpatient records of a large Midwestern United States university hospital. In 1973, 256 individuals completed an initial survey. There were 5 subsequent follow-up surveys, with the most recent being in 2002. Seventy-eight participants completed materials on all 6 occasions.

Methods: The Life Situation Questionnaire was used to identify changes over the 30-year period in 6 areas of life satisfaction, self-rated adjustment (current and predicted), employment status, activities, and medical treatments.

Analyses: These analyses used data from 3 points in time, separated by approximately 15-year intervals. One-way analysis of variance with repeated measures was used to identify changes in outcomes between 1973, 1988, and 2002 for all continuous variables.

Results: We found a mixed pattern of changes over the 30 years, with increases noted during the first 15- year period in sitting tolerance, educational and employment outcomes, satisfaction with employment, and adjustment. Although these changes tended to remain stable during the last 15 years, subtle declines were suggested in some areas, with clear declines noted in terms of diminished sitting tolerance, an increase in the number of physician visits, and decreased satisfaction with social life and sex life.

Conclusions: The results suggest that many positive changes occur within the first 2 decades after SCI, followed by a period of stability in some life areas, but decline with aging in some participation and health-related aspects of life.     

Idiopathic Spinal Cord Herniation: Case Report and Literature Review

Summary  We report one case of spontaneous thoracic spinal cord herniation presenting with a progressive spastic paraparesis for 4 years in a 55 years old man. From preoperative MRI, showing a ventrally displaced atrophic spinal cord at T2–T3 level, a dorsal intradural arachnoid cyst was suspected. At operation, after a 3 level laminectomy, no arachnoid cyst was found and spinal cord herniation into a meningeal diverticulum was confirmed. The herniated myelon was replaced intradurally and the lumen of the diverticulum was filled with Teflon? settled with fibrin glue to prevent recurrence. Postoperatively some neurological recovery was achieved.  The literature was reviewed, regarding clinical and epidemiological features, proposed pathophysiological mechanisms, treatment options and outcome. Only 32 surgically proved cases of thoracic spinal cord herniation with no past history of spine trauma, injury or surgery were found.     

Fulminant Clostridium Difficile Colitis In A Patient With Spinal Cord Injury: Case Report

Abstract

Background:ln certain patients with Clostridium difficile colitis (CDC), a life-threatening systemictoxicity may develop despite appropriate and timely medical therapy.

Design:Literature search and case report.

Findings: A 39-year-old man with Tl0 paraplegia presented with a distended, quiet abdomen followingrecent treatment withantibiotics for pneumonia. Diarrhea was not present. Complete blood counts demonstrated a marked leukocytosis. A CT scan of theabdomen demonstrated a state of diffuse pancolanie inflammation with peritoneal fluid . The patientwas taken to the operating roomand underwent total abdominal colectomy with oversewing of the rectal stump and end ileostomy for treatment of the fulminant CDC.

Conclusion:Patients with spinal cord injury (SC I) often receive antibiotics for infections of the aerodigestive tree and urinary tractand for problems with skin integrity. A heightened awareness of the development of fulminant CDC remains essential in the care ofpatients with SCI. Any unexplained abdominal illness after recent antibiotic administration should alert the physician to CDC and itspotential as a fulminant, potentially fatal illness.     

A Rare but Serious Complication of Percutaneous Coronary Intervention: Spinal Cord Embolism

Abstract

Background/Objective: Many atherothrombotic complications are associated with coronary angiography. Spinal cord embolism with high morbidity and mortality is one of these complications.

Methods: Case report.

Results: A 65-year-old woman was admitted to the hospital with acute myocardial infarction. Immediately after coronary angiography, she complained of paresthesia and paraparesis of her legs. Magnetic resonance imaging (MRI) detected hyperintensity at the level of the conus medullaris. Antiaggregant therapy and a physiotherapy program continued. After 2 months, clinical and MRI findings had improved.

Conclusions: Invasive procedures such as coronary angiography can lead to serious atherothrombotic complications.     

Systemic Naloxone Infusion May Trigger Spasticity in Patients With Spinal Cord Injury: Case Series

Abstract

Background/Objective: Three patients with spinal cord injury (SCI) and 3 able-bodied (AB) patients were infused with naloxone during a study to examine their neuroendocrine function. An unanticipated side effect occurred during the naloxone infusion. All 3 patients with SCI, but none of the AB patients, experienced profoundly increased spasticity during the naloxone infusion. Our report describes this side effect, which has potential implications for the clinical treatment or scientific evaluation of individuals with SCI.

Methods: All patients were in good general health and medication free for 11 days or longer before the study. Each patient was placed on a 30-hour protocol to analyze pulsatile release of gonadotropins. Physiologic saline was intravenously infused on day 1 to serve as a control period for naloxone infusion on day 2.

Results: AB patients experienced no muscle spasm activity or any other side effects at any time during the study. In contrast, all 3 patients with SCI experienced a profoundly increased frequency and duration of spasticity in muscles innervated by the nerve roots caudal to their level of injury. In all 3 patients with SCI, spasticity increased only during the period of naloxone infusion. Within 1 hour of stopping naloxone, spasticity returned to baseline levels.

Conclusions: Naloxone infusion produced a differential effect on the muscle activity of men with SCI compared to AB men with intact spinal circuits. Consistent with previous studies, the results of this study indicate a relationship between opioid neuromodulation and spasticity after SCI.     

Gastric Dysmotility After Abdominal Surgery in Persons With Cervical Spinal Cord Injury: A Case Series

Abstract

Background: Spinal cord injury (SCI) has been found to affect the physiology of the gastrointestinal tract. Changes in gastric motility occur in tetraplegia because of dissociation of antral and duodenal motility. Among individuals with high-level tetraplegia, antral quiescence has been hypothesized as a manifestation of autonomic dysreflexia after surgery. This case series shows the issues with gastric hypomotility after gastrointestinal surgery in tetraplegic patients with tetraplegia, including management strategies.

Objective: To report 3 patients with complete high cervical SCI who developed gastroparesis after abdominal surgery and discuss the effect of autonomic dysfunction on gastric motility.

Methods: Retrospective chart review of 3 cases.

Results: Gastroparesis occurred after abdominal surgery in 3 patients with C4 American Spinal Injury Association (ASIA) A tetraplegia and seemed to be a sign of autonomic hyperreflexia caused by postoperative pain. Management was challenging because it consisted of balancing of appropriate pain medication and dealing with absorption issues and dysmotility. Often gastric motility agents were not effective in improving gastric emptying. However, increased use of pain medication improved gastric emptying, which supports the hypothesis that this issue represents gastric dysfunction from autonomic hyperreflexia.

Conclusions: In persons with complete cervical SCI who have undergone abdominal surgery, postoperative gastroparesis can be a manifestation of pain. This may occur as the excessive sympathetic response from autonomic hyperreflexia inhibits distal antral activity. Thus, treatment of postoperative gastroparesis should focus on improved pain control to decrease excessive splanchnic sympathetic output and circulating norepinephrine.     

Locomotor Training and Muscle Function After Incomplete Spinal Cord Injury: Case Series

Abstract

Background/Objective: To determine whether 9 weeks of locomotor training (LT) results in changes in muscle strength and alterations in muscle size and activation after chronic incomplete spinal cord injury (SCI). Study Design: Longitudinal prospective case series.

Methods: Five individuals with chronic incomplete SCI completed 9 weeks of LT. Peak isometric torque, torque developed within the initial 200 milliseconds of contraction (Torque₂₀₀), average rate of torque development (ARTD), and voluntary activation deficits were determined using isokinetic dynamometry for the knee-extensor (KE) and plantar-flexor (PF) muscle groups before and after LT. Maximum muscle crosssectional area (CSA) was measured prior to and after LT.

Results: Locomotor training resulted in improved peak torque production in all participants, with the largest increases in the more-involved PF (43.9% ± 20.0%), followed by the more-involved KE (21.1% ± 12.3%). Even larger improvements were realized in Torque200 and ARTD (indices of explosive torque), after LT. In particular, the largest improvements were realized in the Torque200 measures of the PF muscle group. Improvements in torque production were associated with enhanced voluntary activation in both the KE and ankle PF muscles and an increase in the maximal CSA of the ankle PF muscles.

Conclusion: Nine weeks of LT resulted in positive alterations in the KE and PF muscle groups that included an increase in muscle size, improved voluntary activation, and an improved ability to generate both peak and explosive torque about the knee and ankle joints.     

精索多形性脂肪肉瘤1例报告并文献复习

目的：分析并总结精索脂肪肉瘤患者的临床表现及其诊断及治疗方法。方法：回顾性分析我院收治的1例精索脂肪肉瘤患者的临床资料：左侧阴囊内有-9．0cm×9．4cm×6．7cm肿块,B超检查示左侧阴囊内存在一非均质实性包块;MRI显示左侧阴囊内有实质性肿瘤,未见肿大淋巴结。血清肿瘤标志物13-HCG、CEA、PSA和AFP检查均无异常。手术切除肿瘤的同时行左侧阴囊部分切除术。结果：术后病理检查提示为多形性混合型脂肪肉瘤。患者术后恢复顺利。结论：精索脂肪肉瘤是一种罕见的泌尿生殖系肿瘤,诊断主要依据病理检查结果确定;治疗以根治性睾丸切除术为主要方式,辅助放疗、化疗疗效不确切;预后与肿瘤组织病理类型密切相关,局部复发很常见,需长期随访。     

Prevention and Treatment Of Heterotopic Ossification After Spinal Cord Injury

Abstract

Background/Objectives: Heterotopic ossification (HO) is a frequent, irreversible complication afterspinal cord injury (SCI). The objective of this article is to explain the etiology of HO; present new advances in prevention, diagnosis, and management of this complication; and provide a suggested algorithm for clinical management.

Etiology: Although still hypothetical, trauma and overexpression of bone morphogenic protein(s) in traumatized soft tissue appear to play important roles as initiating factors of HO.

Prevention: Preventive use of nonsteroidal antiinflammatory agents (NSAIDs) reduces the incidence of HO by a magnitude of 2 to 3.

Management: Early determination of serum creatine phosphokinase may have a diagnostic value in predicting the onset and severity of HO, and an NSAID may be added to etidronate therapy in the initial inflammatory phase of HO formation until C-reactive protein Ieveis return to normal range. Surgery is indicated in a subset of patients, and a regimenthat includes radiation therapy may prevent postoperative recurrence.

Conclusion: Significant progress has been made in the early prevention and management of HO. Further studies are needed to elucidate the etiology.     

Pain Management With lnterventional Spine Therapy in Patients With Spinal Cord Injury: A Case Series

Abstract

Background/Objective: Chronic pain is common in patients with spinal cord injury (SCI). Any newstrategy that is effective in treating this problem would be welcomed by this patient population.

Methods: A case series is presented of SCI with neuropathic pain. In these 3 cases, interventional spinetherapy is used as a diagnostic and/or therapeutic tool in the management of pain.

Results: In the cases presented, interventional spine therapy proved useful in identifying the patient's paingenerator. In most cases, the intervention was effective in reducing pain for a long enough period to serve asan effective pain management strategy. Other associated problems, such as spasticity, were similarlyreduced.

Conclusion: lnterventional spine therapy should be considered as a tool in the armamentarium of any SCIphysician managing their patient's chronic pain.     

Ileal Perforation in a Patient with High Spinal Cord Injury: Report of a Case

Assessing abdominal complications in patients who have previously suffered high spinal cord injury is very difficult because the resultant loss of sensory, motor, and reflux function of the abdominal wall can mask the typical signs of acute abdomen such as tenderness, muscle rigidity, and peritoneal rebound pain. We recently diagnosed a small intestinal perforation in a 77-year-old man with a C6–7 spinal cord injury sustained 14 years earlier. The patient was correctly diagnosed as having an acute abdominal condition, despite palsy of abdominal wall sensation. An emergency laparotomy was done and a 40-cm length of affected ileum, about 180cm distal to the Treitz ligament, including a 1-cm perforation, was resected, followed by an end-to-end anastomosis. We report this case to raise awareness of the need for appropriate diagnosis and early surgical treatment of abdominal complications in spinal-cord-injured patients.     

Nutrient Intake and Body Habitus After Spinal Cord Injury: An Analysis by Sex and Level of Injury

Background/Objectives: To examine nutrient intake and body mass index (BMI) in the spinal cord injury (SCI) population according to level of injury and sex.

Design: Cross-sectional study conducted at 2 SCI treatment centers.

Participants/Methods: Seventy-three community-dwelling individuals with C5-T12 ASIA Impairment Scale (AIS) A or B SCI. Subjects were divided into 4 groups: male tetraplegia (N = 24), male paraplegia (N = 37), female tetraplegia (N = 1), and female paraplegia (N = 11). Mean age was 38 years; 84% were male; 34% were white, 41 % were African American, and 25% were Hispanic. Participants completed a 4-day food log examining habitual diet. Dietary composition was analyzed using Food Processor II v 7.6 software.

Results: Excluding the 1 woman with tetraplegia, total calorie intake for the other 3 groups was below observed values for the general population. The female paraplegia group tended to have a lower total calorie intake than the other groups, although macronutrient intake was within the recommended range. The male tetraplegia group, male paraplegia group, and the 1 woman with tetraplegia all had higher than recommended fat intake. Intake of several vitamins, minerals, and macronutrients did not meet recommended levels or were excessively low, whereas sodium and alcohol intake were elevated. Using adjusted BMI tables, 74.0% of individuals with SCI were overweight or obese.

Conclusions: Women with paraplegia tended to maintain healthier diets, reflected by lower caloric and fat intakes, fewer key nutrients falling outside recommended guidelines, and less overweight or obesity. Individuals with tetraplegia tended to take in more calories and had higher BMIs, and using adjusted BMI, the majority of the population was overweight or obese. The majority of people with SCI would benefit from nutritional counseling to prevent emerging secondary conditions as the population with SCI ages.     

Nutrient Intake and Body Habitus After Spinal Cord Injury: An Analysis by Sex and Level of Injury

Background/Objectives:     

Neuroarthropathy of the Wrist in Paraplegia: A Case Report

Abstract

Background/Objective: Neuroarthropathy, also known as Charcot joint, is most commonly seen in the spine and other weight-bearing joints in individuals with spinal cord injury (SCI). It is rarely seen in the joints of the upper extremities because the pathophysiology of the neuroarthropathy is thought to be significant repetitive trauma such as with weight bearing in an insensate joint.

Methods: Case report of neuroarthropathy in the wrist of a 46-year-old man with a 30-year history of T4 paraplegia caused by ependymoma.

Results: The patient recently developed a nonpainful swelling in the left wrist, which had decreased sensation since the time of his initial SCI. Radiological evaluation showed marked degenerative changes consistent with neuroarthropathy. A magnetic resonance image of the spine showed spinal cord atrophy at the cervicothoracic junction.

Conclusions: This case shows an unusual presentation of a neuroarthropathy in a wrist in an individual with functional paraplegia. Because the treatment options for neuroarthropathy in the upper extremity in individuals with SCI are limited, early diagnosis is crucial to implement conservative management before significant destruction of the joint occurs.     

False-Negative Triple-Phase Bone Scans in Spinal Cord Injury to Detect Clinically Suspect Heterotopic Ossification: A Case Series

Abstract

Background/Objective: Heterotopic ossification (HO) is a complication seen in patients after spinal cord injury (SCI). Triple-phase nuclear bone scanning is the most sensitive test for the detection of HO. This retrospective study assesses whether patients with clinically suspected HO but negative triple-phase nuclear bone scans develop delayed positive nuclear bone scans.

Methods: Case series: A cohort of patients with SCI and clinically suspected HO who underwent triple phase nuclear bone scans over a period of 2 years was identified from retrospective chart review of an acute inpatient SCI rehabilitation service. A subgroup of 7 patients with initially negative but subsequently positive triple-phase nuclear bone scans was identified, and the following data were collected: date, mechanism, admission level, and admission completeness of injury as well as date, number, and results of bone scans. Laboratory studies were also collected during the time of imaging.

Results: Over a 2-year period, 343 patients were admitted to the SCI rehabilitation service; 60 patients were suspected of having HO and underwent a total of 85 triple-phase nuclear bone scans. Seven patients were identified with initially negative but subsequently positive bone scans.

Conclusions: In patients with clinically suspicious HO but negative bone scans, follow-up scans are indicated to identify initial false-negative studies.     

Idiopathic Spinal Cord Herniation: Case Report and Review of the Literature

Background: Idiopathic spinal cord herniation (ISCH) is a rare cause of progressive myelopathy frequently present in Brown-Séquard syndrome. Preoperative diagnosis can be made with magnetic resonance imaging (MRI). Many surgical techniques have been applied by various authors and are usually reversible by surgical treatment.

Methods: Case report and review of the literature.

Findings: A 45-year-old woman with Brown-Sequard syndrome underwent thoracic MRI, which revealed transdural spinal cord herniation at T8 vertebral body level. During surgery the spinal cord was reduced and the ventral dural defect was restorated primarily and reinforced with a thin layer of subdermal fat. The dural defect was then closed with interrupted stitches.

Results: Although neurologic status improved postoperatively, postsurgical MRI demonstrated swelling and abnormal T2-signal intensity in the reduced spinal cord. Review of the English language literature revealed 100 ISCH cases.

Conclusions: ISCH is a rare clinical entity that should be considered in differential diagnosis of Brown-Séquard syndrome, especially among women in their fifth decade of life. Outcome for patients who initially had Brown-Séquard syndrome was significantly better than for patients who presented with spastic paralysis. Although progression of neurologic deficits can be very slow, reduction of the spinal cord and repair of the defect are crucial in stopping or reversing the deterioration.     

Development Of A Hybrid Gait Orthosis: A Case Report

Abstract

Objective: The purpose of this case study was to improve stability, posture, and speed of gait in an individual with paraplegia through the application of a hybrid system including trunk-hip-knee-ankle-foot orthosis (THKAFO) with lockable joints and multichannel functional electrical stimulation (FES) with implanted electrodes.

Methods: Two hybrid orthoses were implemented and evaluated on a person with complete absence of motor function and sensation below the T-9 level spinal cord injury. The first hybrid was a modified isocentric reciprocal gait orthosis (IRGO) with the knees controlled by FES, the ankles fixed at neutral, and the hips coupled with a reciprocator. The second hybrid had a THKAFO instrumented with lockable joints using wrap-spring clutches at the hips and knees (THKAFO-LJ) that provided free extension and allowed for flexion only when disengaged by solenoids. A microprocessor-controlled stimulator provided muscle stimulation and activation signals for the solenoids. These two hybrid systems were compared with an FES-only system.

Results: The IRGO hybrid system with the hip reciprocator engaged provided a stable gait with erect posture with minimal anterior trunk lean using only quad canes for support. However, the walking speed was slow, due to limited step length imposed by the reciprocator. The walking speed with the THKAFO-LJ hybrid system was significantly faster than that with the IRGO hybrid with the reciprocator engaged, and was comparable with the FES-only gait; however, it resulted in excessive anterior trunk lean. A walker with 2 wheels was required to maintain balance.

Conclusion: The results point to the need for a hybrid system that allows for unencumbered hip and knee joint motion for stepping without excessive anterior trunk lean. Such a hybrid system could provide a reasonable speed in gait powered by muscle stimulation, without the usual joint motion constraints imposed by the bracing, while providing stability that is normally seen only with bracing. Further advantages would include reduction in required stimulation during standing and support phases of gait.     

Idiopathic Spinal Cord Herniation: Case Report and Review of the Literature

Background: