S186 S290
GENERAL REHABILITATION POSTER HALL: CASE REPORTS
Poster 168:
Allergic Reaction to an Intrathecal Baclofen Pump
Leading to Pump Extrusion: A Case Report
Christina G. Zaccarini, MD (SUNY Upstate Med Univ/Syracuse,
Liverpool, NY, United States), Gizelda T. Casella, MD PhD,
Claudine A. Ward, MD, Stephen R. Lebduska, MD
Disclosures:
Christina Zaccarini: I Have No Relevant Financial
Relationships To Disclose
Case/Program Description:
A 68-year-old man with C3 AIS D spinal
cord injury secondary to a cervical epidural abscess with intractable
spasticity underwent intrathecal baclofen pump (ITBP) placement
1.5 years after injury. He had several hypersensitivity conditions
including asthma and eczema, but no allergy to oral baclofen. Four
months after ITBP placement, the patient developed erythema and
pain over the pump site. Cellulitis was suspected and treated
initially with Vancomycin and Zosyn followed by Augmentin. After
completion of the antibiotic course, the patient again developed
erythema over the pump. Ultrasound was negative for fluid collec-
tion and CT revealed subcutaneous edema overlying the pump.
Antibiotics were resumed. The patient never developed fever or
peripheral neutrophilia, but did have a consistently high eosinophil
count. Skin biopsy revealed chronic dermatitis with numerous peri-
vascular eosinophils and plasma cells, consistent with a hypersen-
sitivity reaction.
Setting:
Spinal Cord Injury Rehabilitation Facility.
Results:
After treatment with triamcinolone cream, erythema and
pain improved. One month later the pump became exposed however,
requiring removal.
Discussion:
There is one report of ITBP extrusion attributed to a
“foreign body reaction”, not infection. Allergic reactions to ITBPs have
not been documented but reaction to other implanted devices, such as
pacemakers, is well recognized. This patient underwent multiple
antibiotic courses prior to diagnosis of allergic reaction. Despite
treatment with topical corticosteroids, the pump became exposed.
Conclusions:
This patient’s history of asthma and eczema should have
raised suspicion for allergic reaction in the absence of infectious signs.
Allergy testing can be considered in patients with history of hyper-
sensitivity conditions prior to ITBP placement. Allergic reaction to ITBP
is rare, however important to recognize to avoid unnecessary use of
antibiotics and expedite appropriate treatment, which may have
prevented pump extrusion. Multispecialty evaluation and coordination
of care including Physiatry, Dermatology, and Neurosurgery was
needed in this case.
Level of Evidence:
Level V
Poster 169:
Catastrophic Instrumentation-Associated Hematoma
After Therapeutic Anticoagulation Resulting in Spinal
Cord Injury: A Case Report
Brian Fricke, MD (WA Hosp Cntr/Georgetown Univ), Howard A. Gilmer,
DO
Disclosures:
Brian Fricke: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
A 63-year-old woman with multiple
medical comorbidities including remote history of renal transplant was
admitted to acute inpatient rehabilitation after undergoing L3-L5
lumbar laminectomy and fusion due to progressive spinal stenosis with
initial clinical presentation of worsening back pain and lower ex-
tremity claudication. Her initial rehabilitation course was complicated
by development of bilateral pulmonary emboli for which she was
started on warfarin with bridging therapeutic enoxaparin. A week
after being started on therapeutic anticoagulation, she developed
excruciating back pain with new numbness of bilateral lower ex-
tremities in L4-S1 dermatomal distribution. Emergent MRI of lumbar
spine showed 7.2 5.1 3.4 cm hematoma obliterating the thecal
sac.
Setting:
Acute inpatient rehabilitation hospital.
Results:
Patient was immediately taken to the OR for hematoma
evacuation. Operative note commented that incision site, subcu-
taneous tissue, and fascia were all well healed at time of hematoma
evacuation, almost 4 weeks after her initial surgery. Notably, her INR
the evening prior to hematoma evacuation was 1.9, the highest it had
been since starting anticoagulation. Full anticoagulation was stopped
and an IVC filter was placed as an alternative. She continues to have
lower motor neuron bladder and bowel dysfunction and is undergoing
education and training to perform intermittent catheterizations and
her bowel program.
Discussion:
Based on literature review, there has only been one other
report of postoperative epidural hematoma after full anticoagulation
but that case was described within the first 48 hours of spinal surgery.
This case serves as a cautionary tale, especially in those patients with
complex medical problems, to closely monitor patients starting ther-
apeutic anticoagulation as late as 4 weeks after spinal surgery with
instrumentation.
Conclusions:
The risks/benefits of therapeutic anticoagulation in
patients after spinal surgery should be carefully considered. If opting
to start anticoagulation, the patient should remain under close
monitoring up to 4 weeks after spinal surgery.
Level of Evidence:
Level V
Poster 170:
Preservation of American Sign Language Ability in
Patient With Primary Central Nervous System (CNS)
Angiitis and Intra-Parenchymal Hemorrhage (IPH)
Causing Verbal Apraxia and Aphasia: A Case Report
William S. Raoofi, MD (SUNY Upstate Med Univ/Syracuse),
Travis Coats, MD, MPH, Diya Goorah, MD, Carlos Marrero Prats, MD,
Shernaz K. Hurlong, DO, Margaret A. Turk, MD
Disclosures:
William Raoofi: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
The patient is a 32-year-old woman who
initially presented to the ED with tonic-clonic seizures 4 days post
partum. CT of the head revealed IPH in the right basal ganglia with
hemorrhagic extension to the lateral, third, and fourth ventricles
associated with hydrocephalus. Subsequent brain MRI revealed acute
right pontine infarct, left frontal hemorrhage, and diffuse cerebral
edema. Her ICU course was complicated by dysautonomia, pneumonia,
and asystole with successful resuscitation. Rheumatological di-
agnostics returned negative for vasculitis. She was started on empiric
cyclophosamide and prednisone for suspect primary CNS angiitis prior
to inpatient rehabilitation.
Setting:
Acute inpatient rehabilitation hospital.
Results:
Upon admission to our inpatient rehabilitation facility (IRF),
the patient was Ranchos Los Amigos Scale level V and unable to
communicate. She was maximum to total assist with all therapy.
Initially she had poor attention, left sided neglect and severe oral
apraxia. In working with staff the patient spontaneously started using
the American Sign Language (ASL) alphabet for communication. Using
her informal instruction in ASL, the patient was able to spell out words
using ASL to relay her basic needs. This proved useful for the patient
and the rehabilitation team when the patient was unable to commu-
nicate verbally or with written language. Elements of her aphasia were
present in her ASL communication as she occasionally used inappro-
priate signs.
S186
Abstracts / PM R 9 (2017) S131-S290