S236 S290
Setting:
Acute Inpatient Rehabilitation Hospital.
Results:
During inpatient rehabilitation, the patient developed pro-
gressively worsening dysphagia of unclear etiology. This was later
followed by the onset of new myoclonus and he was transferred to an
acute care hospital for further assessment. Video electroencephalog-
raphy was negative for epileptiform activity and a swallow study
demonstrated moderate-to-severe oral dysphagia. This was thought to
be secondary to oropharyngeal myoclonus, and he was diagnosed with
chronic post-hypoxic myoclonus (PHM). He required percutaneous
endoscopic gastrostomy tube placement and was started on valproic
acid for myoclonus management. He subsequently completed inpa-
tient rehabilitation with notable functional gains demonstrated at
discharge.
Discussion:
Chronic post-hypoxic myoclonus, also known as Lance-
Adams syndrome, is a rare complication following HIE. The myoclonus
appears days to weeks after cardiopulmonary resuscitation in patients
who have regained consciousness. It is triggered by movement, sensory
stimulation, or anxiety and has no electroencephalographic correlate.
Myoclonus most commonly affects the arms and legs but can also
affect the palate, larynx, and pharynx. While myoclonus and
dysphagia have previously been described in association with a number
of neurologic diagnoses, to our knowledge, dysphagia has never been
described as a presenting symptom of chronic PHM.
Conclusions:
New onset dysphagia following HIE in the acute inpa-
tient rehabilitation setting should warrant further workup for chronic
PHM. Prompt diagnosis leading to earlier treatment initiation may have
significant implications on functional outcomes in the acute inpatient
rehabilitation setting.
Level of Evidence:
Level V
Poster 328:
Bilateral Vertebral Artery Dissection, Spinal Cord
Infarct and Brainstem Stroke in a Patient with
Posterior Neck Pain Before Cervical Manipulation: A
Case Report
Sima C. Patel, MD (Univ of Minnesota)
Disclosures:
Sima Patel: I Have No Relevant Financial Relationships To
Disclose
Case/Program Description:
A 59-year-old man with a history of hy-
pertension presented to the Emergency Department hours after
chiropractor manipulation for a 3 day history of posterior neck pain.
He had paresthesias, vertigo, and difficulty ambulating. Workup
revealed bilateral vertebral artery dissections at C1 and C2, along with
ischemic infarcts in the upper cervical spinal cord, medulla, and left
cerebellar hemisphere. Exam was notable for significant sensory and
motor ataxia, weakness in all extremities, and sensory loss below the
jaw line. Additionally, the patient was noted to be in hypertensive
emergency. The patient’s blood pressure was controlled and he was
bridged from a heparin drip to warfarin for anticoagulation.
Setting:
Acute Rehabilitation Unit.
Results:
Eight days later, he was discharged to an acute rehabilitation
unit to address his functional deficits. He was found to be C2 ASIA D.
Initially, he was maximum assist of two for transfers and mobility, and
required moderate assistance for feeding, dressing and grooming. By
day 30 of his rehabilitation stay, the patient was independent in
feeding with adaptive equipment, transferring squat to pivot with
assistance of one, and mobilizing with a manual wheelchair.
Discussion:
To our knowledge, this is the first case of bilateral
vertebral artery dissection, stroke, and spinal cord infarct leading
to a C2 ASIA D spinal cord injury with ataxia, presenting as posterior
neck pain before cervical manipulation. A systemic review in 2012
revealed that conclusive evidence for strong association is lacking
between cervical manipulation and cervical arterial dissection. The
increased risks of vertebral artery dissection associated with
chiropractic visits are likely due to the patients’ neck pain from the
dissection.
Conclusions:
Physiatrists must recognize the importance of ruling out
vertebral artery dissection in a patient presenting with an initial
complaint of neck pain. Rehabilitation after injury is crucial to
recovering and optimizing function.
Level of Evidence:
Level V
Poster 329:
An Unusual Presentation of Cervical Myelopathy and
Lumbar Radiculopathy in the Setting of Spinal
Arachnoiditis due to Neurocysticercosis: A Case
Report
Shayan Senthelal, MD (Albert Einstein Col of Med, New York, NY,
United States), Ankush Jain, DO, Justin Raper, MD, Neel Chandel, MD,
Kevin Sperber, MD
Disclosures:
Shayan Senthelal: I Have No Relevant Financial Re-
lationships To Disclose
Case/Program Description:
A 55-year-old Ecuadorian man diagnosed
with neurocysticercosis in 2004. He underwent ventriculo-peritoneal
shunt placement for hydrocephalus and was evaluated for burning pain
and stiffness of the lower back over the past 2 months. Pain radiated
from the midline (S1) proximally to the occiput, both shoulders and
down the lateral aspects of both arms to the elbows. Intermittently,
this sacral pain spread along the posterior of the left leg. Review of
systems revealed that he suffered from dizziness and loss of balance
with a sensation of falling to his right. He admitted to having weak-
ness, numbness and tingling of his left lower extremity from all 5 distal
phalanges proximally up the posterior of the left leg to the popliteal
region when he had pain. Physical exam revealed upper motor neuron
symptoms, specifically hyperreflexia of the biceps, triceps, brachior-
adialis, quadriceps and gastrocnemius tendons. Spasticity (MAS of 1+)
of elbow extension, shoulder, knee and plantarflexion bilaterally were
also appreciated. Hoffman’s sign was positive bilaterally and tandem
gait was performed with difficulty. No sensation deficits were appre-
ciated. MRI of cervical spine revealed chronic inflammatory changes of
arachnoiditis and a stenotic cervical canal, likely preceded by long-
standing neurocysticercosis.
Setting:
Outpatient Rehabilitation Clinic.
Results:
In this case, we present an unusual case of cervical
myelopathy and lumbar radiculopathy caused by spinal arachnoiditis
due to a previous infection from neurocysticercosis. Though relatively
uncommon in the United States, infectious causes of upper motor
neuron syndromes should be considered in patients originally or trav-
elling from epidemic regions.
Discussion:
In this case, we present and investigate the pathophysi-
ology and presentation of an individual with arachnoiditis due to
neurocysticercosis.
Conclusions:
Neurocysticercosis and other parasitic pathogens are a
concern in the immigrant communities of the United States. The
subsequent neurological and musculoskeletal manifestations in which
they present opportune unique etiologies for familiar diagnoses.
Level of Evidence:
Level V
Poster 330:
Physiatric Coordinated Inpatient Rehabilitation
Management and Ambulatory Follow-up of a Patient
with Guillain-Barre Syndrome Secondary to Zika Virus
Infection: A Case Report
Neil Mandalaywala, MD (New York University School of Medicine, New
York, NY, United States), Young IL Seo, MD, Kevin Franzese, DO,
Mark V. Ragucci, DO, Robert Petrucelli, MD
Disclosures:
Neil Mandalaywala: I Have No Relevant Financial Re-
lationships To Disclose
Case/Program Description:
The patient is a 64-year-old woman with
history of HTN who presented to the ER with worsening extremity
S236
Abstracts / PM R 9 (2017) S131-S290