Faculty Bibliography

Case Description: 60-year-old female with no past medical history who developed new onset neck pain with numbness and tingling in bilateral hands and feet after an episode of forceful coughing spell. She presented to an outside ED, where a head CT showed no abnormalities. She was discharged with neurology follow-up but was unable to follow-up due to insurance issues. Over the course of the following month, her symptoms worsened. She presented to the ED again with an abnormal gait. On physical exam, she was found to have hyperreflexia and clonus. Brain MRI showed a dysplastic skull base characterized by platybasia and cranial settling/basilar invagination. CT scan of cervical spine revealed cervicomedullary mechanical compression at C1/C2 abnormalities. Rheumatology work-up ruled out rheumatoid arthritis as the source of cord compression. She underwent a suboccipital craniotomy and C1 laminectomy with an Occiput-C5 fusion. Patient was admitted to acute inpatient rehabilitation requiring moderate assistance for transfers and ambulation. She was discharged home modified independent with a cane.
Setting(s): Acute Inpatient Rehabilitation Unit Patient: 60-year-old female with platybasia who developed cervical myelopathy. Assessment/Results: Platybasia is usually asymptomatic but can present with neck pain as was seen with the patient above. The patient reported her symptoms began after an episode of coughing and denied any acute cervical trauma. Given her history, the coughing fit was likely the cause of her cord compression in the setting of her platybasia.
Discussion(s): Platysbasia is a congenital flattening of the skull base and can be associated with other congenital abnormalities. This is the first reported case, to our knowledge, of spontaneous medulla-myelopathy after a coughing spell in a patient with congenital platybasia.
Conclusion(s): Presenting clinical symptoms of neck pain and headache following a coughing fit in asymptomatic platybasia should be recognized as a clinical manifestation of cervical myelopathy

Description: A 20-year-old female with spinal cord contusion underwent T8-T9 laminectomy and T4-T11 fusion with bilateral pedicle screw placement. She was transferred to acute inpatient rehabilitation on post-operative day 10. Initial examination was consistent with T10 ASIA C with 1-2/5 muscle strength in the right lower extremity and 1/5 strength of 2nd toe on left, otherwise 0/5. She had modest gains in the right lower extremity over the next week on repeat examinations; however, the left leg remained grossly 0/5 in strength. Review of post-operative images revealed four pedicle screws in the spinal canal on the left side. Ortho spine surgery was consulted and CT myelogram obtained and showed two screws causing mass effect on the spinal cord. The screws were then removed and replaced.
Setting(s): Acute inpatient rehabilitation hospital.
Result(s): Four weeks after revision of the pedicle screws, she had 4/5 strength with left knee extension and 2/5 hip flexion. She has regained voluntary control of her bowel and bladder. She was able to ambulate 50 feet with contact guard assistance with rolling walker.
Discussion(s): This is the first case to our knowledge of pedicle screws potentially worsening spinal cord injury. It is unclear whether her asymmetric SCI occurred at the time of the accident or if misplacement of left sided pedicle screws allowed for further damage on the left side of the spinal cord or both. It is also unclear if her neurologic improvements are associated with natural course of incomplete SCI or with revision of the misplaced pedicle screws.
Conclusion(s): Careful review of postop imaging study and close monitoring of neurologic status are an important way to recognize when intervention is necessary if there are any abnormal findings, and to ascertain further neurologic recovery following an incomplete SCI, subsequently resulting in functional improvements including bowel and bladder function

Case Description: A 44-year-old immunocompetent man presented to Emergency Department with two days of headaches, dizziness, and right-sided weakness. MRI of the brain showed a pontine mass suggestive of glial tumor. Oral steroids were initiated along with referral to neurosurgery. Symptoms progressed to right-sided paresthesias, temperature hypersensitivity, hypertonia of right hand and foot, and diplopia. He returned to the emergency department and repeat MRI of the brain showed left pontine mass with traits of abscess. Broad-spectrum antibiotics were initiated. Biopsy identified Streptococcus oralis and the patient was treated with appropriate antibiotics. Setting: Acute inpatient rehabilitation. Results or Clinical Course: The patient was admitted to inpatient rehabilitation requiring moderate assist for ambulation, minimal assist for transfers and moderate assist for activities of daily living. Rehabilitative efforts focused on balance and dexterity. Compensatory strategies were used to accommodate for sensory deficits, especially inability to determine temperature. Diplopia, caused by cranial nerve 6 palsy, was corrected by partial occlusive lens. He was discharged modified independent for ADL, independent for household mobility and distant supervision for community ambulation. Discussion: Solitary brainstem abscess is an uncommon intracranial infection with high morbidity and mortality, and rare in immunocompetent individuals. No documented cases of rehabilitation have been described in immunocompetent patients with brainstem abscess. Proper identification and treatment are essential for a favorable outcome. The patient's primary functional impairment was ataxia. He had remarkable results with appropriate antibiotics and extensive inpatient rehabilitation. A root cause of the infection was not found. Conclusions: Brainstem abscess are often misdiagnosed leading to poor outcomes. This case demonstrates an initial misdiagnosis with subsequent proper diagnosis allowing for early treatment w!

Objective: To assess the relationship between etiologyand functional outcome in 7 cases of transverse myelitis after acute inpatient rehabilitation. Design: Retrospective review of 7 cases of transverse myelitis. Setting: Inpatient rehabilitation facility. Participants: One male and 6 female patients, admitted from January 2007 to June 2009, were identified with acute transverse myelitis. Results: Two of the patients were positive for anti-NMO (neuromyelitis optica), one had positive herpes antibody, and the rest were idiopathic. All 7 patients were initially treated with intravenous steroids before admission to our rehabilitation facility. Some of those patients also received IVIG, plasmapheresis, or mitoxantrone. Two patients had multiple recurrences. Their functional outcomes were assessed by using Functional Independence Measure (FIM) score upon admission and at discharge. Discussion: Transverse myelitis is a neurologic condition that affects function of the spinal cord with no history of trauma. Most cases are idiopathic and presumably secondary to autoimmune origin. Multiple diseases can be related to this condition, including NMO, SLE, antiphospholipid antibody syndrome, mixed connective tissue disease, CNS sarcoidosis, and infectious disease (herpes zoster). We reviewed the rehabilitation outcome of patients with acute transverse myelitis by comparing their FIM scores upon admission and at discharge. Conclusions: There is limited literature available that has reported functional outcomes among this population. The patients reviewed on this study had different spinal cord levels of a lesion, and their changes with the FIM score appear to be independent from etiology. There was a significant improvement on the functional status of all the patients after participating on acute inpatient rehabilitation, as per preliminary analysis of the FIM scores on admission and discharge. Successful management of patients with acute transverse myelitis is associated with understanding of its pathophysiology and prevention of secondary complication as well as utilization of all rehabilitation disciplines