Spinal cord stimulation for the symptomatic treatment of rigidity and painful spasm in a case of stiff person syndrome.

BACKGROUND: Stiff person syndrome (SPS) is a rare neuroimmunological disorder characterized by rigidity and painful spasm primarily affecting the truncal and paraspinal musculature due to autoimmune-mediated neuronal hyperexcitability. Spinal cord stimulation (SCS) is an approved therapy for managing painful neuropathic conditions, including diabetic peripheral neuropathy and refractory angina pectoris. We describe the novel use of SCS for the treatment of spasm and rigidity in a 49-year-old man with seropositive stiff person syndrome (SPS). The patient was treated with intravenous immunoglobulin (IVIG) and oral medications over a 13-month period with minimal improvement, prompting consideration of SCS. To our knowledge, this is the first report of the successful use of SCS in SPS with the demonstration of multifaceted clinical improvement. METHODS: Following a successful temporary SCS trial, permanent implantation was performed. Spasm/stiffness (Distribution of Stiffness Index; Heightened Sensitivity Scale; Penn Spasm Frequency Scale, PSFS), disability (Oswestry Disability Index, ODI; Pain Disability Index, PDI), depression (Patient Health Questionnaire-9, PHQ-9), sleep (Pittsburgh Sleep Quality Index, PSQI), fatigue (Fatigue Severity Scale, FSS), pain (Numerical Pain Rating Scale, NPRS), quality of life (EuroQoL 5 Dimension 5 Level, EQ-5D-5L), and medication usage were assessed at baseline, 6-month, and 10-month postimplantation. RESULTS: ODI, PHQ-9, FSS, NPRS, PSQI, and EQ-5D-5L scores showed a notable change from baseline and surpassed the defined minimal clinically important difference (MCID) at 6-month and 10-month follow-up. Oral medication dosages were reduced. CONCLUSIONS: The novel use of SCS therapy in seropositive SPS resulted in functional improvement and attenuation of symptoms. We present possible mechanisms by which SCS may produce clinical response in patients with SPS and aim to demonstrate proof-of-concept for a future comprehensive pilot study evaluating SCS-mediated response in SPS.

Intrathecal Injection of Gadobutrol: A Tale of Caution.

In the field of interventional pain medicine a radiocontrast agent is commonly used in conjunction with fluoroscopy. Limited work has been published regarding the use of gadolium based contrast agents (GBCA) in the intrathecal space. We report a case of an intrathecal gadobutrol injection resulting in neurotoxic manifestations.A 60-year-old female with a history significant for lumbar post-laminectomy syndrome and intrathecal drug delivery implantation was admitted for lumbar fusion and kyphoplasty. Postoperatively, the patient had escalating pain medication requirements. A pump and intrathecal catheter contrast study was completed to assess the integrity and proper placement of the intrathecal catheter. Due to patient.s allergy to iodinated contrast, the physician requested gadolinium contrast dye. Unknown to the staff was that Magnevist had recently been replaced with an alternative GBCA, Gadavist (gadobutrol). 2 cc of Gadavist was injected. The catheter was determined to be intact and in proper position. Less than five minutes after the injection of gadobutrol, the patient reported spastic pain of the lower extremities. There is a lack of evidence as it relates to the use of GBCA specifically gadobutrol in the intrathecal space. The use of gadobutrol in the intrathecal space should be used with caution.

Rate of return to acute care hospital based on day and time of rehabilitation admission.

OBJECTIVE: To determine if a patient's return to the acute care hospital (RTACH) from an inpatient rehabilitation facility (IRF) because of medical acuity is affected by the day of the week and time of rehabilitation admission. DESIGN: Retrospective chart review. SETTING: Inpatient rehabilitation facility. PARTICIPANTS: All adult patients admitted to the IRF from January 1, 2009, to June 30, 2011. RTACH was defined as an interruption in the patients' rehabilitation course as a result of medical and/or surgical complications requiring a higher level of care. The control group was defined as patients who completed an uninterrupted rehabilitation course. The study included 2282 patients (2026 control patients and 256 case patients). MAIN OUTCOME MEASURES: We compared patient demographics, admission impairment groups, discharge diagnosis, admission and discharge Functional Independent Measure (FIM) scores, length of stay, attached hospital versus outside hospital admissions, and RTACH rates between case patients and control patients. RESULTS: Out of 2282 patients admitted to the IRF over a 30-month period, 256 patients (10.85%) required an RTACH for a higher level of care not available in the IRF. Two statistically significant results were found for RTACH, including rehabilitation admission time and FIM scores (admission motor and cognition scores). Day of the week for inpatient rehabilitation admission was not statistically significant. CONCLUSION: This study found that the later in the day a patient was admitted to the IRF, the higher the rate of RTACH. In addition, a lower Motor FIM score was found to be correlated with a higher rate of RTACH. Admission day of the week was not found to be statistically significant with regard to the rate of RTACH. Further research is needed to determine the underlying contributing factors that would help decrease the rate of RTACH.