Isolated Hyoid Fracture Associated with Blunt Trauma

Trauma-related hyoid fractures are rare entities. These fractures represent only 0.002% of head and neck region fractures. Victims of hanging and strangling constitute the great majority of cases. Fractures associated with trauma are extremely rare. These fractures are difficult to diagnose and can easily be overlooked during physical examination. However, they are also important traumas since airway safety is endangered in these rare cases. We describe a case of a young male presenting with isolated neck injury associated with hitting an electric cable while riding a motorbike. Tenderness was present in the anterior neck region at physical examination, but movement was not restricted and no respiratory difficulty was determined. Isolated hyoid fracture was detected at tomography of the neck performed in the emergency department. Hyoid bone fractures should not be forgotten in patients with pain and tenderness in the anterior neck region following blunt trauma to the neck.©Copyright 2020 by Emergency Physicians Association of Turkey - Available online at www.jemcr.com.

Extracorporeal membrane oxygenation for airway emergencies

Objectives: Extracorporeal membrane oxygenation (ECMO) is well established in cardiorespiratory failure. Here we report the use of ECMO in an airway emergency to provide respiratory support. Method(s): Informed consent was obtained from patient at the time of admission. Result(s): A 48-year-old with COVID-19 requiring venovenous ECMO (VVECMO) for 32 days and tracheostomy for 47 days had developed tracheal stenosis three months after tracheostomy removal, and undergone tracheal resection and reconstruction. He presented two weeks later with acute dyspnea, bloody drainage and a bulge in his neck with coughing. A computerized tomography (CT) of the cervical spine and chest showed dehiscence of the tracheal wound and a gap in the trachea. He was managed with High Flow Nasal Canula and supported on VVECMO support using 25 Fr. right femoral drainage cannula and 23 Fr. left IJ return cannula. A covered stent was placed, neck wound was irrigated and debrided. Patient was decannulated after 10 days on ECMO. Future therapeutic considerations include mediastinal tracheostomy, aortic homograft interposition of the disrupted segment of trachea with stent placement and permanent self-expandable stent with internal silicone stent. Conclusion(s): ECMO is increasingly used in complex thoracic surgery as well as in the perioperative period as salvage support. One of the areas where it has shown promising results is traumatic main bronchial rupture, airway tumor leading to severe airway stenosis, and other complex airway problems. The ease of cannulation, the technological advances and growing confidence in the management of ECMO patients are the main reasons for the expansion of ECMO use beyond conventional indications. The case described above is an example of the use of ECMO in the perioperative management of impending respiratory failure due to airway obstruction or disconnection. (Figure Presented).

Shoulder Weakness Following Intramuscular COVID- 19 Vaccine

History: Transient and generalized adverse effects are common following COVID-19 vaccination;among other adverse effects, shoulder injuries related to vaccine administration (SIRVA) have been known to occur. In this case, a previously healthy right-hand dominant 62-year-old male presented with left shoulder pain and weakness 3 months after receiving a COVID-19 intramuscular vaccine in the left deltoid. Approximately 2 weeks after the injection, he started experiencing pain and numbness around the injection site along with ipsilateral shoulder weakness. Despite conservative management with Motrin, Medrol Dosepak, gabapentin and physical therapy (PT), the pain and weakness persisted. Physical Exam: Left Shoulder-No calor or erythema;significant atrophy of the anterior and middle deltoid muscle relative to right side;abduction 4/5;external rotation with shoulder adducted 4/5;range of motion for active forward flexion was 150 degrees and passive was 170 degrees;passive range of motion for external rotation was 70 degrees;internal rotation to the level of L5;sensation to light touch was intact. Right Shoulder-Range of motion, strength, and sensation were intact. Cervical Spine-Full ROM;no cervical paraspinal tenderness noted. Negative Spurling's and Lhermitte's tests. Differential Diagnosis: 161. Axillary Nerve Palsy 2/2 Chemical Neurotoxicity 162. Brachial Neuritis 163. Mechanical Axillary Nerve Palsy 2/2 Vaccination 164. Partial-Tear of Left Supraspinatus Tendon 165. Acromioclavicular Osteoarthritis Test Results: Left Shoulder-XR:Mild pseudo-subluxation;MRI w/o contrast: 8x9mmpartial-thickness articular surface tear of the distal supraspinatus tendon (<50%fiber thickness). Minimal subacromial bursitis. Mild acromioclavicular joint osteoarthritis. EMG/NCV: Left and Right Axillary Motor Nerves: prolonged distal onset latency;Left Deltoid: increased insertion activity, moderately increased spontaneous activity, reduced recruitment;Remaining LUE muscles without evidence of electrical instability Final Diagnosis: Axillary Nerve Palsy Secondary To Chemical Neurotoxicity from Intramuscular COVID-19 Vaccine. Discussion(s): We postulate that the neurologic deficits presented in our case may be attributed to chemical neurotoxicity to the axillary nerve following vaccination as the delayed onset of pain and weakness are most consistent with this differential. There are several cases of brachial neuritis following vaccination for the prevention of COVID- 19, however, EMG/NCV results in our patient were not consistent with brachial plexopathy. Additionally, while there have been a handful of reported cases of bursitis following COVID-19 vaccines falling under the SIRVA classification of injuries, this is the first case of reported axillary nerve neurapraxia. Outcome(s): The patient's left shoulder numbness and pain improved with PT and medical management. While mild improvement in strength was noted, weakness and atrophy persisted even on the third follow up visit 6 months after the initial appointment. He was counseled on his injury and was recommended to undergo repeat EMG testing to document recovery after his 6-month follow-up appointment. Follow-Up: The patient did not follow-up for a repeatEMG after his 6-month follow-up appointment. At that time, the patient was clinically stable, tolerating PT, and expecting recovery of his deltoid function.

Guillian-Barre Syndrome Post Covid-19 Vaccination

Case Report: This is a 50-year-old man that presented to the ED complaining of generalized weakness and acute loss of ability to ambulate which has been progressing for a month. Patient began having left arm and leg weakness, which started in his fingertips of his left upper extremity and soon moved proximally to upper left arm. Symptoms then progressed to right upper and lower arms. Symptoms further continued to progress making the patient bedridden. On presentation, CT head showed a C1/C2 subluxation possibly chronic without significant focal soft tissue swelling. CT cervical spine showed C1-C2 subluxation, possibly chronic. MRI of brain was unremarkable pre and postcontrast without focal findings or abnormal enhancement and showed redemonstration of the C1-C2 subluxation as described on CT scan. MRI of cervical spine showed at the level of C1 there is spinal canal stenosis. However, there is no direct pressure upon the cord/medulla. Upon evaluation, patient had significant motor weakness and required maximal assistance for movement. Patient was moreover noted to have flaccidity of muscles associated with weakness with no bulbar weakness. Patient had no difficulty in breathing or with speech. A lumbar tap was performed which showed elevated protein, WBC, and glucose. Upon further investigation, patient stated that he received his (3rd dose) of the Moderna Vaccine for Covid-19 about a month before the onset of symptoms and felt fine. Two weeks later, he began experiencing subjective fevers, diarrhea, abdominal pain, and fatigue that lasted for a week and then self-resolved. Approximately another two weeks later is when patient began noticing his neurological symptoms. Possible Guillain-Barre Syndrome post Campylobacter Jejuni (C. Jejuni) infection vs. post Covid-19 vaccine induced GBS was suspected at this point and patient was started on Intravenous Immunoglobulin (IVIG). Stool cultures were collected for C.Jejuni which came back negative. Gastrointestinal Pathogen Panel PCR Feces also came back negative. Patient was discharged to a rehab center and planned to receive another round of IVIG for 5 days. Conclusion(s): Guillain Barre Syndrome (GBS) is a rare immune-mediated neurological disorder affecting peripheral nerves and nerve roots, that presents as acute sensorimotor neuropathy starting with distal paresthesia that progresses to weakness of legs and arms, noteably, flaccid paralysis. GBS has several triggers namely infections such as C. jejuni, cytomegalovirus, M. pneumoniae, Epstien-Barr virus and Zika virus. There has also been several case reports and studies that have shown increased incidence of GBS vaccines such as influenza vaccine. Furthermore, there has been several studies that have linked GBS to COVID-19 vaccine. With COVID-19 cases continuing to persist, and increasing advocacy for vaccination against the disease, GBS should be considered as very rare but possible side effect of the vaccine.

An Adult Patient With Acute Ischemic Stroke and Carotid Stenosis Presenting to a Chiropractor: A Case Report.

A 59-year-old male, with a recent history of acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia, presented to a chiropractor with a one-week history of numbness in the right upper and lower extremity that was triggered by neck movement, and lightheadedness/dizziness. On examination, the chiropractor noted limited, painful cervical spine range of motion, right upper extremity weakness, patellar hyperreflexia, positive Hoffman's and Trömner's signs bilaterally, nystagmus, a sluggish right pupillary light reflex, and carotid bruit. Cervical radiographs were suggestive of Klippel-Feil syndrome. The chiropractor suspected a vascular cause such as a transient ischemic attack and referred the patient to the emergency department, which the patient visited the following day. The patient was admitted, and MRI revealed multiple tiny acute to subacute cortical infarcts of the left frontal and parietal lobes while sonography demonstrated left internal carotid artery stenosis. The patient was treated with anticoagulant and antiplatelet medications and carotid endarterectomy with a positive outcome. Given the overlap between symptoms of stroke and those of the cervical spine, chiropractors should be prepared to recognize potential stroke patients and refer them for emergent medical management.

VESTIBULAR DYSFUNCTIONS IN CHRONIC BRAIN ISCHEMIA IN THE POST COVID PERIOD.

OBJECTIVE: The aim: The aim of the study is the clinical-pathogenetic reasoning of vestibular dysfunctions (VD) development against the background of chronic brain ischemia in the presence of degenerative changes in the cervical spine (CS) in the post COVID period. PATIENTS AND METHODS: Materials and methods: 82 patients, in the conditions of the clinical base of the Odessa National Medical University in 2019-2021 were examined. Group I with VD against the background of chronic brain ischemia (CBI) at the compensated phase; Group II with VD against the background of CBI at the subcom¬pensated phase (33 men; 49 women), aged from 18 to 55 years. The control group (CG) consisted of 20 patients of the corresponding gender and age. The condition of the state of the autonomic nervous system, vestibular functions, cervical spine, cerebral arteries and emotional condition were examined. RESULTS: Results: Vestibulo-ataxic disorders were higher compared to CG and increased along with the degree of brain damage. An important aspect of the development of VD is autonomic dysfunction against the background of pathological autonomic characteristics with predominant parasympathetic orientation of autonomic tone, especially in the case of insufficiency of autonomic recativity (AR) and pathological autonomic support of activity. Such changes significantly increased in the presence of subcompensation of CBI. The correlation between psychoemotional disorders and changes in autonomic characteristics with VD against the background of CBI with initial regularities depending on the degree of brain damage was defined. The progression of CBI is facilitated by coronavirus infection and manifested in autonomic and psychoemotional dysfunctions. A characteristic hemodynamic feature in groups with compensated and subcompensated CBI is the presence of reduced perfusion in basilar (BA) and vertebral (VA) arteries. Changes in cerebral vascular reactivity with a decrease in cerebrovascular reactivity indicators were characteristic of the subcompensated phase of CBI. Hyperactivity to rotational functional loads in both clinical groups has a high correlation with the presence of stair descent and, to a lesser extent, isolated instability in CS. CONCLUSION: Conclusions: 1. The occurrence of VD is facilitated by the presence of autonomic dysfunction and degenerative-dystrophic changes in the CS, especially in case of subcompensation of CBI. 2. Psychoemotional changes were a characteristic feature of patients with VD against the background of CBI and had certain regularities depending on the phase of CBI. 3. Suffered coronavirus infection contributes to the progression of VD and further decompensation of CBI due to direct damage to the autonomic and vascular systems of the brain. 4. Changes in cerebral hemodynamics in the form of reduced perfusion in BA and VA, a decrease in cerebrovascular reactivity, and an increase in reactivity to rotational functional load were determined in patients with VD against the background of subcompensated CBI.

Telehealth consultation before inter-hospital transfer after falls in a subacute hospital (the PREVENT-2 study).

OBJECTIVE: Inter-hospital transfers are increasingly common due to the regionalisation of healthcare, but are associated with patient discomfort, high costs and adverse events. The aim of the present study was to evaluate the effectiveness of a trauma outreach service for preventing inter-hospital transfers to a major trauma centre. METHODS: This was an observational pre- and post-intervention study over a 12-month period from 1 October 2020 to 30 September 2021. Eligible patients sustained a fall at Caulfield Hospital, a subacute care hospital specialising in community services, rehabilitation, geriatric medicine and aged mental health. The intervention was delivery of site-specific education at Caulfield Hospital and a trauma outreach service by specialist trauma clinicians at The Alfred Hospital who provided remote assessment, assisted with clinical management decisions and advised on appropriateness of transfer. RESULTS: The present study included 160 patients in the pre-intervention phase and 203 after the intervention. The primary outcome of transfer occurred in 19 (11.9%) patients in the pre-intervention phase and 4 (2.0%) in the post-intervention phase (P < 0.001). In the subgroup of patients without pelvis or long bone fractures, pre-intervention transfer occurred for 17 (10.9%) patients and post-intervention transfer occurred for 4 (2.0%) patients (P < 0.001). CT imaging was performed for 54 (33.8%) patients in the pre-intervention and 45 (22.2%) patients in the post-intervention group (P = 0.014). CONCLUSIONS: Telehealth consultation with a trauma specialist was associated with significant reduction of inter-hospital transfers, and significant reduction of CT imaging. This supports continuation of the service with scope for expansion and evaluation of patient-centred outcomes.

Awake Intubation Techniques, and Why It Is Still an Important Skill to Master

Purpose of Review: Awake intubation has been a staple of difficult airway management since the first American Society of Anesthesiologists difficult airway guidelines were developed in the 1980s. In current anesthetic practice, use of second generation supraglottic airways and video laryngoscopy are ubiquitous. The goal of this review is to examine the impact that these airway advances have had on the use of awake intubation and the need to maintain this skill. Recent Findings: Despite advancements, evidence suggests that the rate of awake intubation has changed little over the last two decades. Recent literature has focused on the use of alternatives to the flexible intubation scope, including awake intubation with video laryngoscopy, combined video laryngoscopy-flexible intubation, and combined supraglottic airway-flexible intubation. Summary: Awake intubation remains an essential technique in airway management. Future research should focus on determining the specific patient populations that would benefit from the variety of awake intubation techniques now described.Copyright © 2022, The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.

Isolated tracheobronchial mucormycosis: Report of a case and systematic review of literature

Background: Isolated tracheobronchial mucormycosis (ITBM) is an uncommonly reported entity. Herein, we report a case of ITBM following coronavirus disease 2019 (COVID-19) and perform a systematic review of the literature. Case description and systematic review: A 45-year-old gentleman with poorly controlled diabetes mellitus presented with cough, streaky haemoptysis, and hoarseness of voice 2 weeks after mild COVID-19 illness. Computed tomography and flexible bronchoscopy suggested the presence of a tracheal mass, which was spontaneously expectorated. Histopathological examination of the mass confirmed invasive ITBM. The patient had complete clinical and radiological resolution with glycaemic control, posaconazole, and inhaled amphotericin B (8 weeks). Our systematic review of the literature identified 25 additional cases of isolated airway invasive mucormycosis. The median age of the 26 subjects (58.3% men) was 46 years. Diabetes mellitus (79.2%) was the most common risk factor. Uncommon conditions such as anastomosis site mucormycosis (in two lung transplant recipients), post-viral illness (post-COVID-19 [n = 3], and influenza [n = 1]), and post-intubation mucormycosis (n = 1) were noted in a few. Three patients died before treatment initiation. Systemic antifungals were used in most patients (commonly amphotericin B). Inhalation (5/26;19.2%) or bronchoscopic instillation (1/26;3.8%) of amphotericin B and surgery (6/26;23.1%) were performed in some patients. The case-fatality rate was 50%, primarily attributed to massive haemoptysis. Conclusion: Isolated tracheobronchial mucormycosis is a rare disease. Bronchoscopy helps in early diagnosis. Management with antifungals and control of risk factors is required since surgery may not be feasible. © 2022 Wiley-VCH GmbH.

The Effect of the Coronavirus Disease 2019 (COVID-19) Pandemic on Elective Cervical Spine Surgery Utilization and Complications in the United States: A Nationwide Temporal Trends Analysis.

OBJECTIVES: As a result of the coronavirus disease 2019 (COVID-19) pandemic, elective surgeries nationwide were suspended. The objective was to compare temporal trends in patient demographics, case volumes, and postoperative complications of patients undergoing elective cervical spine surgery from pre-COVID-19 (2019-2020 Q1) to post-COVID-19 (2020 Q2-Q4). METHODS: The 2019 to 2020 American College of Surgeon's National Surgery Quality Improvement Program database was queried for common elective cervical spine surgeries. Patients pre-COVID-19 (2019-2020 Q1) were compared with those undergoing surgery during post-COVID-19 (2020 Q2-Q4) protocols. Procedural use, patient demographics, and complications were compared. Linear regression was used to evaluate case volume changes over time. P values less than 0.05 were significant. RESULTS: In total, 31,013 patients underwent elective cervical spine surgery in 2019 (N = 16,316) and 2020 (N = 14,697); an overall 10% decline. Compared with the calendar year 2019 through 2020 Q1 mean, elective surgery volume decreased by 21.6% in 2020 Q2 and never returned to prepandemic baseline. The percentage decline in case volume from 2019 to 2020 Q1 to 2020 Q2 was greatest for anterior cervical discectomy and fusion (23.3%), followed by cervical decompression (23.4%), posterior cervical fusion (15.0%), and cervical disc arthroplasty and vertebral corpectomy (13.7%). Patients undergoing surgery in 2020 Q2-Q4 had overall greater comorbidity burden (American Society of Anesthesiologists grade 3 and 4) (P < 0.001). From 2019-2020 Q1 versus 2020 Q2-Q4, there was a significant increase in total complication (5.5% vs. 6.8%, P < 0.001), reoperation (1.9% vs. 2.2%, P = 0.048), and mortality (0.25% vs. 0.37%, P = 0.049) rates. CONCLUSIONS: Elective surgery declined drastically during the second quarter of 2020. Patients undergoing surgery during the pandemic had an overall greater comorbidity burden, resulting in increased total complication and mortality rates over the study period.

Acute flaccid myelitis diagnosed after IVIG: a diagnostic dilemma

Case Report: A 4-year-old African American male presented to an outside emergency department (ED) following sudden inability to move left upper extremity. Past medical history was unremarkable and routine vaccinations were up to date. Radiograph of affected extremity ruled out fractures and patient was discharged to follow up with primary care physician. Two days later mother brought him to our ED due to persistent left upper extremity paralysis, poor appetite, and subjective fever. On exam his left arm was warm and tender to dull and sharp touch;he had definite loss of active movement, hypotonia and absence of deep tendon reflexes. The patient had winging of left scapula and could not shrug left shoulder. MRI of cervical and thoracic spine showed enlargement of spinal cord from C2-C6 level with gray matter hyperintensity, slightly asymmetric to the left. Laboratory studies showed leukocytosis (14 000/mcL) and CSF studies showed pleocytosis of 89 WBC/mcL (93.3% mononuclear cells and 6.7% polymorphonuclear cells), 0 RBCs, normal glucose and protein, and a negative CSF meningoencephalitis multiplex PCR panel. Due to high suspicion of demyelinating or autoimmune condition he was treated with high dose steroids and IVIG. Subsequently neuromyelitis optica was ruled out as aquaporin-4 receptor antibodies (AB) and myelin oligodendrocyte glycoprotein AB were normal. CSF myelin basic protein and oligoclonal bands were absent ruling out demyelinating disorders. CSF arboviruses IgM and West Nile IgM were negative. He showed minimal improvement in left upper extremity movement but repeat spinal cord MRI one week later showed improved cord thickness with less hyperintensity. Respiratory multiplex PCR was negative including enteroviruses. Repeat CSF studies after IVIG showed increased IgG index and IgG synthesis suggestive of recent spinal cord infection, consistent with acute flaccid myelitis (AFM). Pre-IVIG blood PCR was invalid for enteroviruses due to PCR inhibitors found in the sample. Blood post-IVIG was negative for mycoplasma IgM, West Nile IgM, and arboviruses IgM. Enterovirus panel titers (post-IVIG) were positive for coxsackie A (1:32), coxsackie B type 4 (1:80) and 5 (1:320), echovirus type 11 (1:160) and 30 (1:80) as well as positive for poliovirus type 1 and 3. These titers could not distinguish acute infection from patient's immunity or false-positives as a result of IVIG. He was discharged with outpatient follow-up visits with neurology, infectious disease, occupational and physical therapy, showing only mild improvement after discharge. Discussion(s):With the anticipated resurgence of AFM after the peak of COVID-19 pandemic, our case illustrates the need to consider this diagnostic possibility in patients with flaccid paralysis. It is important to remember CSF IgG synthesis is not affected by IVIG. In addition when treatment plans include IVIG, appropriate samples should be collected before IVIG to facilitate accurate work-up for infectious diseases. Copyright © 2023 Southern Society for Clinical Investigation.

P54. Emergency department visits for pediatric spine fractures: trends through COVID-19

BACKGROUND CONTEXT: Pediatric spine fractures are an important medical and surgical emergency. PURPOSE: The aim of this study was to assess trends in emergency department visits for pediatric spine fractures. STUDY DESIGN/SETTING: Descriptive Epidemiological Study. PATIENT SAMPLE: A total of 1,930 (national estimate: 49,186) pediatric patients who presented to the emergency room with a spine fracture from 2001 to 2020. OUTCOME MEASURES: Causes of spine fractures, discharge disposition and demographic variables. METHOD(S): The National Electronic Injury Surveillance System (NEISS) database is a probability sample of hospitals in the United States. This sample was stratified and weighted based on ED size, which was used to generate national estimates (NE). The NEISS database from 2001 to 2020 was queried for less than 18 years old who sustained a cervical, thoracic or lumbar spine fracture. The entire cohort was divided by before and after March 11, 2020, which is when the WHO declared the COVID-19 pandemic. RESULT(S): There were 1,930 (NE: 49,186) pediatric patients who presented to the emergency room with a spine fracture from 2001 to 2020. There were 135 (NE:2,807) ED patients in 2020 compared to 110 (NE: 2,161) in 2019 representing a 30% increase compared to the year before. The rate of males with spine fractures decreased (50.88% DC vs. 62.77% BC;p < 0.001). The rate of spine fractures at home increased (30% DC vs. 22% BC;p < 0.001) while rate of spine fractures in a place of recreation decreased (25% DC vs. 34% BC;p < 0.001). Lumbar spine fractures decreased (15% vs. 24%) while cervical and thoracic spine fractures increased (p < 0.001). The amount of ED spine fractures leading to admission decreased (14.69% DC vs 25% BC) while the amount released increased (61% vs. 55%) (p < 0.001). The most decreased three causes of pediatric spine fractures were football (6.84% DC vs. 11.18% BC), stairs (1.72% DC vs. 5.89% BC), and sleds (0.22% DC vs. 4.34% BC) (p < 0.001). The most increased three causes of pediatric spine fractures in the ED were swings (8.57% DC vs. 1.31% BC), horseback riding (10.85% DC vs. 4.35% BC), and ATV vehicles (7.92% DC vs. 1.91% BC) (all p < 0.001). CONCLUSION(S): There was a spike in pediatric spine fractures during the COVID-19 pandemic compared to the year before. Fractures in males, and those related to recreational activities in public places as well as fractures due to football decreased. Fractures at home and in isolated recreational activities such as swings, horseback riding and ATVs increased. FDA DEVICE/DRUG STATUS: This does not discuss or include any applicable devices or drugs. Copyright © 2022

Spontaneous Cervical Epidural Hematoma Following COVID-19 Illness Presenting to a Chiropractor: A Case Report.

Cervical epidural hematoma (CEH) is a rare and potentially fatal condition in which blood accumulates in the epidural space of the cervical spine. A 64-year-old man presented to a chiropractor with a two-week history of sudden-onset neck pain, shoulder pain, occipital headache, and numbness in the shoulders and upper extremities. He had recovered from a mild course of coronavirus disease 2019 (COVID-19) illness one month prior. The patient's primary care provider had previously prescribed a nonsteroidal anti-inflammatory drug for his neck pain. However, his symptoms worsened, and he visited the emergency department where he had unremarkable cervical spine radiographs and was discharged with a diagnosis of neck strain. The chiropractor ordered cervical spine magnetic resonance imaging (MRI), revealing a ventral CEH extending from C2 to C5. The chiropractor referred the patient to a nearby hospital for urgent management. The patient was admitted and observed, progressively improved, and did not require surgery. After 10 weeks in the hospital the patient was asymptomatic, a follow-up MRI revealed resolution of the CEH, and the patient was discharged. While the current case highlights a temporal relationship between COVID-19 and CEH, further research is needed to determine if COVID-19 is a risk factor for this condition. Clinicians who encounter patients with spinal disorders must be able to recognize the clinical features of CEH and refer these patients for emergency care and/or neurosurgical evaluation.

Rare Diagnosis of Para-infectious SARS-COV2 Associated Acute Transverse Myelitis Based off Clinical Presentation and CSF Studies with Negative Imaging: A Case Report

Case Diagnosis: Rare Diagnosis of Para-Infectious SARS-COV2 Associated Acute Transverse Myelitis Based Off Clinical Presentation and CSF Studies with Negative Imaging Case Description or Program Description: Patient was admitted for two weeks of ascending paresthesias and weakness of his lower extremities around ten days after recovering from a mild SARS-COV2 associated illness. While in the hospital, his weakness progressed to flaccid paralysis of his lower extremities with a sensory level at T10. Initial workup including magnetic resonance imaging (MRI) of his brain, cervical, thoracic and lumbar spine were negative. Initial electrodiagnostic (EMG) testing was unrevealing. He received a course of intravenous immunoglobulins followed by a five day course of intravenous solumedrol, both of which did not result in any improvement. Multiple weeks into admission, the patient began to exhibit hand intrinsic weakness and paresthesias, so plasmapheresis was attempted without any change in his symptoms. Setting(s): Major Academic and Referral Center with Level 1 Adult Trauma Assessment/Results: After admission to our inpatient rehabilitation unit, repeat MRIs of his cervical and thoracic spine were again unrevealing. Initial cerebrospinal fluid analysis showed lymphocytic pleocytosis, elevated protein and positive oligoclonal bands (2). Repeat EMG obtained after his upper extremity symptoms began did not reveal a cause for his weakness. Inflammatory and neoplastic workups were negative. He also developed upper motor neuron signs on neurological examination late in his admission. Discussion (relevance): There are documented cases of neurologic complications, specifically transverse myelitis, associated with the multi-systemic inflammatory/ immunological response in the post-infectious period of SARS-COV2. What is exceedingly rare, but documented, is a diagnosis based on clinical presentation, elevated CSF protein and lymphocytes alone with the exclusion of other diagnoses. Conclusion(s): The neurologic complications of SARSCOV2 in the post-infectious period include transverse myelitis and in rare cases like this, can present without the typical findings seen on imaging of the spinal cord.

A Complex Clinical Presentation of Cervical Radiculopathy with Concurrent Parsonage Turner Syndrome: A Case Report

Case Diagnosis: A 59-year-old, previously healthy female. Case Description or Program Description: The patient presented with sudden-onset, severe left posterior shoulder pain. After two days, the pain resolved and she noticed numbness and tingling throughout the left upper extremity and weakness in her left hand. Three weeks prior to symptom onset, the patient experienced COVID-like symptoms but had a negative rapid antigen test. Two weeks prior, the patient received a third COVID-19 vaccination. Cervical spine MRI revealed severe foraminal stenosis at C4-5 and C6-7 and significant central canal stenosis at C6-7, measuring 8.3 mm. MRI imaging of the brain and brachial plexus, as well as upper extremity sonography, were noncontributory. EMG findings suggested a left C5-C6 radiculopathy and a left brachial plexopathy involving the lower trunk. A diagnosis of both cervical radiculopathy and Parsonage Turner Syndrome (PTS) was made, with viral infection followed by vaccination as the suspected etiology. Setting(s): Outpatient PMR Clinic Assessment/Results: A methylprednisone dose-pack, pregabalin 150 mg twice daily, and outpatient physical therapy were prescribed. She was referred to neurosurgery for further evaluation. The patient's symptoms have continued to slowly improve with steroids. Discussion (relevance): The patient's presentation includes a variety of overlying pathology. Posterior shoulder pain, upper extremity numbness and tingling, and hand weakness are common symptoms of radiculopathy and PTS. MRI and EMG confirmed C5-C6 cervical radiculopathy. Clinically, concurrent PTS was diagnosed due to the resolution of shoulder pain, occurring after a viral illness and COVID vaccination, and the improvement of strength without therapy. As COVID-19 vaccination efforts increase, PTS must be considered to maintain a comprehensive differential. Conclusion(s): PTS is a rare neurological condition that is underrecognized. Physiatrists play a critical role in identifying PTS through performing a detailed history, physical exam, and diagnostic studies. As COVIDrelated illness and vaccination rates increase, future studies are needed to explore the frequency of PTS in conjunction with other diagnoses.

Asymmetric Guillain-Barre Syndrome as Primary Presentation of Minimally Symptomatic COVID-19 Infection

Case Diagnosis: Asymmetric acute inflammatory demyelinating polyneuropathy as presenting symptom of COVID-19 infection. Case Description or Program Description: A 54-year-old male with history of alcohol use with fiveday history of left leg weakness with progression to numbness and weakness to the left side of his face. He then developed right sided weakness, more severe than his left side, primarily distally, as well as numbness and tingling into his bilateral hands. Imaging was negative for acute cause of his symptoms. He did test positive for COVID-19 but was asymptomatic except for occasional dry cough one week prior. His symptoms were initially thought to be from peripheral neuropathy secondary to alcohol use, however he then developed new dysarthria and dysphagia. Setting(s): Acute Inpatient Rehabilitation Hospital Assessment/Results: MRI brain, CTA head and neck, CT cervical spine were negative for acute causes of weakness. Negative HIV and paraneoplastic panel. Lumbar puncture showed albuminocytologic dissociation consistent with Guillain-Barre Syndrome (GBS) . Electrodiagnostic testing is scheduled and pending at this time. Discussion (relevance): GBS generally presents as a symmetric, ascending weakness secondary to a potential viral attack on myelin and Schwann cells. GBS can rapidly ascend and cause autonomic and respiratory failure, so early and accurate diagnosis and treatment are essential. This case demonstrates GBS related to COVID-19 with minimal other symptoms. It also demonstrates the importance of thorough investigation of the potential differentials for neuropathy, as this patient's diagnosis was initially thought to be from alcohol use, which can lead to inappropriate treatment with worse outcomes. In this case, there was a lower suspicion for GBS given its unusual presentation and non-definitive association with COVID-19 infection. Conclusion(s): There is growing research of a positive correlation between COVID-19 infection and GBS, which is further supported by this case with unusual presentation of asymmetric GBS. Continued research is needed to determine the risk of GBS with COVID-19 infection.

Parsonage Turner Syndrome After COVID-19 Vaccine Booster: A Case Report and Review of the Literature

Case Diagnosis: A 78-year-old man with Parsonage- Turner Syndrome (PTS). Case Description or Program Description: The patient developed acute left-sided neck and shoulder pain upon awakening five days after receiving a Moderna COVID-19 vaccine booster shot. Clinical examination, electrodiagnostic studies, and magnetic resonance imaging were consistent with a diagnosis of PTS. Setting(s): Tertiary referral center. Assessment/Results: His physical exam revealed severe weakness in left shoulder abduction and external rotation without sensory deficits. An urgent MRI of his cervical spine demonstrated multilevel degenerative changes including severe bilateral C5-6 neural foraminal narrowing, and an MRI of the left shoulder showed mild degenerative changes. He was treated with a sixday course of an oral methylprednisolone dose pack and his pain and weakness significantly improved. He was referred for electrodiagnostic testing 24 days after the onset of his symptoms, and by the time of the study, his pain and weakness had improved by 50%. The test revealed no significant abnormalities in the sensory and motor nerve conduction studies. Needle electromyography showed abnormal spontaneous activity in both the left infraspinatus and left deltoid with decreased recruitment of polyphasic motor unit action potentials in the left deltoid. Notably, the left mid/low cervical paraspinals, and other left C5/C6 innervated muscles including the biceps, and brachioradialis were all normal, making a diagnosis of cervical radiculopathy unlikely. Discussion (relevance): There have been eight published reports of PTS related to COVID-19 vaccinations at the time of this publication, which are also reviewed. Reports have occurred in three separate vaccines with variable onset of symptoms and recovery patterns as detailed in the table provided. Conclusion(s): Our case report and review of the literature highlights the importance of recognizing PTS as a potential cause of severe shoulder/arm pain and weakness after administration of a COVID-19 vaccine.

Ulnar Neuropathy During COVID-19 Infection: A Case Report

Case Diagnosis: Ulnar Mononeuropathy following COVID-19 infection. Case Description or Program Description: A 44-year-old male with history of morbid obesity presented with coronavirus disease 2019 (COVID-19) infection resulting in a prolonged hospitalization of 37 days. While admitted he was largely proned, however never required intubation. While hospitalized, he developed numbness, tingling, and weakness in digits 4-5 of his left hand exacerbated by pressure on the elbow. No symptoms were present in the contralateral arm. Setting(s): Academic Acute Care Hospital Assessment/Results: Magnetic resonance imaging of the brain and cervical spine were unremarkable. Physical examination of digits 4-5 in the left hand revealed reduced sensation to light touch, an inability to fully extend the digits, and 4/5 strength with abduction. Electrodiagnostic testing demonstrated absent left ulnar sensory nerve action potential when recorded from the left 5th digit and reduced motor conduction velocity across the elbow (39m/s) compared to the below-elbow segment (53m/s) when recorded from the left ulnar abductor digiti minimi, consistent with conduction block. He declined needle electromyography due to potential pain. His hemoglobin A1c was 7.3%. Discussion (relevance): Peripheral nerve injuries (PNIs) may occur in up to 14.5% of patients with COVID-19 who undergo prone positioning, and the ulnar nerve is the most frequently affected. We present a case of ulnar mononeuropathy during COVID-19 hospitalization. Etiology is likely multifactorial, with prone positioning, similar risk factors, or direct pathogenicity contributing. Compressive injuries of the ulnar nerve have been associated with improper prone positioning. Additionally, PNI shares risk factors with severe COVID-19, namely obesity and diabetes in this patient. The hyperinflammatory state associated with COVID- 19 also increases the risk of PNI. Lastly, COVID-19 invades cells by binding angiotensinogen converting enzyme-2 receptors, which are present in the nervous system. Conclusion(s): COVID-19 infection may be associated with an increased risk of peripheral nerve injuries through a multifactorial mechanism. Further research is needed to establish the association.

A Case of Anterior Spinal Artery (ASA) Syndrome After Vaccination -Coincidence or Causality?

Objective: To describe a case of Anterior Spinal Artery (ASA) syndrome after vaccination -coincidence or causality? Background: As efforts to improve SARS-CoV-2 vaccination continue, more questions safety of the vaccination continues to be raised. Ischemic stroke, intracerebral hemorrhage, and cerebrovascular venous sinus thrombosis have been reported in the literature after COVID -19 mRNA vaccination. Although rare cases of acute transverse myelitis have also been reported, literature regarding post-COVID vaccination ASA syndrome is even rarer. Design/Methods: A 32-year-old female with no significant past medical history presented with acute onset of bilateral extremity weakness and numbness that started 2 weeks ago. Result(s): Patient was awake, alert, and oriented. Physical examination showed decreased tone in wrist bilaterally. Motor examination was normal except for 1/5 handgrip, 2/5 wrist, and 3/5 triceps bilaterally. Triceps and brachioradialis reflexes were absent bilaterally. Sensory examination showed absent pinprick sensations C7 and below. Vibration and proprioception sensations were intact. Patient was recently admitted at outside hospital for same complaint. Neurological work was unremarkable except of an enlarged 4th ventricle for which she underwent left frontal ventriculostomy. Lumbar puncture showed normal IgG index and negative serum NMO Ab. She was treated with IVIG for presumed inflammatory disorder with minimal improvement. Patient underwent a repeat neurological workup at our facility due to ongoing symptoms. EKG showed normal sinus rhythm CT head showed prominent 4th ventricle. CT spine were unremarkable. MRI of the brain showed Postprocedural changes associated with recent prior left trans frontal ventriculostomy catheter. MRI of the cervical and thoracic spine showed T2 hyperintense lesion extending from C3/4 to T1 with central predominance rostrally, whole cord involvement at C5, and with anterior predominance caudally with extent to the upper thoracic level of T1;shows patchy enhancement. TTE was unremarkable. Infectious and hypercoagulable workup was also unremarkable. Patient-reported receiving first dose of Moderna mRNA Covid vaccine 2 weeks prior to onset of symptoms. She was discharged to rehab on aspirin and atorvastatin. Conclusion(s): Our patient presented with symptoms and imaging consistent with ASA syndrome 2/2 infarct of an anterior spinal artery C5-T1. Extensive neurological, infectious, rheumatological, and hypercoagulable workup was negative for etiology. The patient had onset of symptoms after receiving her first dose of mRNA COVID-19 vaccine, however, unclear if the presentation is consistent with postvaccination vaccine ASA syndrome or idiopathic.

Anesthetic Considerations for Chiari I Malformation in a BMI 62 Patient

Patients with Chiari I malformations present with tonsillar herniation below the foramen magnum causing abnormal spinal anatomy. Anesthesia challenges in this population include difficult airway management, monitoring intraoperative autonomic dysfunction, avoiding increased intracranial pressure, and accommodating sensitivity to neuromuscular blockade. We present a case with an additional airway management challenge due to morbid obesity with a BMI of 62. A 23 year old female with a history of Covid pneumonia and morbid obesity who presented with syringomyelia and Chiari I malformation. She initially presented with bilateral numbness, tingling, weakness, and pain in her hands. Imaging with MRI at the time showed downward displacement of the cerebellar tonsils with the tips reaching the lower portion of C1 and overall 10-12 mm displacement below the level of the foramen magnum. Syrinx was also visualized from the level of C1-C2 extending down to the level of T5-T6. Repeat MRI a year later showed no significant changes. However, she has worsening symptoms of pain in her right arm preventing her from working. She is agreeable to surgical decompression of the posterior fossa through a suboccipital craniotomy with resection of the posterior arch of C1 with duraplasty. Significant findings on the physical exam include Mallampati III, shorter thyromental distance, and limited range of motion of her cervical spine due to pain in her arms. We chose awake fiberoptic intubation due to difficult airway from morbid obesity and limited cervical spine range of motion and the consideration of hypercapnia induced from brief apnea the patient may not tolerate. She was premedicated with versed, glycopyrrolate, and dexmedetomidine, and given a 5% lidocaine paste lollipop to topicalize oropharynx. She was also started on a low dose remifentanil infusion for sedation during the awake fiberoptic approach. Blood pressure, heart rate, respiratory rate with continuous end-tidal capnography, and pulse oximetry were monitored during the awake fiberoptic intubation. A 7.0 endotracheal tube was lubricated with viscous lidocaine and placed over a fiberoptic scope. Once there was visualization of the vocal cords, additional 2% lidocaine was administered directly at the vocal cords. She was intubated smoothly on the first attempt. She was then immediately induced to general anesthesia with propofol and non-depolarizing muscle relaxant to avoid using succinylcholine due to the possible hypersensitivity caused by denervation. Intraoperatively, a conventional air warmer was used to prevent hypothermia. Invasive arterial blood pressure monitoring was applied. Normotensive blood pressure and normocapnia were maintained throughout the surgery. Muscular blockade was reversed with sugammadex at the end of surgery to ensure adequate ventilation especially with the patient's body habitus. Upon extubation, the patient had acute hypertension which was managed by nicardipine infusion and hydralazine boluses. Patient was taken to a neurosurgical intensive unit and monitored for two days. She was discharged home without any complication. In conclusion, anesthetic considerations for patients with Chiari I malformation include airway management, monitoring for autonomic dysfunction, avoiding increase in ICP, and optimizing postoperative neurological status with balanced anesthetic management.