Faculty Bibliography

Background: Paroxysmal tonic spasms, also known as tonic seizures or paroxysmal dystonia, can be an atypical presenting or complicating feature of multiple sclerosis (MS). They entail sudden, stereotyped episodes of abnormal posture. They are often brief, occurring many times a day, either spontaneously or provoked by movement, touch, or other maneuvers. We describe five such patients, all of whom had a demyelinating lesion in the contralateral corticospinal tract in the posterior limb of the internal capsule. Objective: To present a case series of five patients with MS who experienced tonic spasms and their localisation. Methods: Chart review and literature search. Results: Five cases of tonic spasms in MS with correlating corticospinal tract lesions: Case 1: A 29-year-old female presented with cramping in her right arm and leg with abnormal posturing of the hand and foot with clenching and overlapping of digits. Case 2: A 30-year-old female with frequent episodes of right arm and leg dystonic movements with fanning of the fingers and toes. Case 3: A 39-year-old male with left facial twitching and spams of the left hand elicited by yawning. Case 4: A 29-year-old female with MS with involuntary clenching of the left hand. Case 5: A 34-year-old female with tingling of the right arm and leg followed by involuntary flexion of the right wrist and fingers. In all cases, a brain MRI showed a demyelinating lesion in the contralateral corticospinal tract in the posterior limb of the internal capsule, as well as other lesions consistent with MS. Conclusions: Tonic spasms in MS can be localised to the contralateral posterior limb of the internal capsule. While non-epileptic in origin, they often respond to anti-epileptic drugs. Prompt recognition of this phenomenon can expedite work up and facilitate treatment

Objective: To investigate indications for and outcomes of total hip and knee arthroplasty in patients with multiple sclerosis (MS). Background: MS patients may need joint replacement due to MS-related factors, such as falls or avascular necrosis, or for unrelated indications (eg primary/secondary osteoarthritis). Literature on outcomes of total joint replacement in MS patients is limited to case reports that highlight surgical complications or unusual presentations. There are no systematic reviews of indications for and short- and long-term outcomes of hip and knee arthroplasty in MS patients. Design/Methods: Retrospective chart review of NYU MS Center patients who underwent hip or knee arthroplasty after MS onset. Results: 13 MS patients followed at NYU MS Care Center underwent hip (N=8) or knee (N=5) replacement at NYU. Average age at surgery was 56+/-11 years (range 35-69 years) and MS duration was 16+/-9 years; 10/13 were female. 3 patients had prior joint trauma and 1 had avascular necrosis of the hip presumably from steroid use; the remainder suffered from osteoarthritis. Ambulatory status before surgery was: 4-walking unassisted, 7 - cane, 2 - bilateral assistance. Ambulatory status after surgery at last follow up was: 8 walking unassisted, 3 using a cane, and 2 using a walker. Perioperative complications included acute blood loss in 4, pneumonia in 2, DVT in 1, and urinary retention in 1. Reoperation was required in 1 patient for recurrent hip dislocation. Conclusions: Orthopaedic literature focuses on perioperative complications after total joint arthroplasty in MS patients, but our data on unselected patients show that the surgery appears to benefit most of them, though (mostly) non-neurologic complications were seen in approximately half of the cases. These data can help optimize selection and surgical management of MS patients who are considering knee or hip replacement. We intend to present additional data on our patients that will include patient-reported outcomes