Complete spinal cord injury from postoperative seroma following scoliosis surgery: A case report with favorable ambulatory outcomes after comprehensive rehabilitation.

CONTEXT: Postoperative seroma is a known complication following spine deformity surgery. However, complete spinal cord injury (SCI) due to postoperative seroma is rare. Rehabilitation strategies and outcomes of SCI associated with postoperative seroma have been inadequately described. FINDINGS: A 15-year-old female experienced inadvertent durotomy during pinal deformity correction surgery for idiopathic adolescent scoliosis. Despite immediate decompressive laminectomy, she developed complete loss of motor and sensory function with neurological level of injury at T10 immediately following the surgery. Urgent magnetic resonance imaging revealed cord compression due to seroma. Decompressive surgery was performed 48 h later and timely intensive rehabilitation was provided for 3 months, which included the use of robotic-assisted gait training (RAGT) to maximize neurological recovery. She demonstrated impressive improvement from grade A to D on the American Spinal Injury Association Impairment Scale and regained functional ambulation over the 3-month period. We describe a comprehensive rehabilitation program to manage SCI associated with postoperative seroma, entailing the use of a robotic gait device for locomotor training. The progression of the patient's neurological status and functional outcomes was documented accordingly. CONCLUSION/CLINICAL RELEVANCE: Complete SCI due to seroma, a surgical complication of corrective scoliosis surgery, is rare. However, prompt postoperative examination should be performed routinely in anticipation of neurological deterioration. Early rehabilitation comprising of gait re-training and the use of RAGT might enhance the lower-limb motor strength and functional recovery.

Ultrasound-guided Genicular Nerve Blockade With Pharmacological Agents for Chronic Knee Osteoarthritis: A Systematic Review.

BACKGROUND: Ultrasound-guided (ULSD-g) genicular nerve blocks (GNB) using pharmacological agents for pain control in chronic knee osteoarthritis (OA) are gaining in popularity. There lacks a systematic review to evaluate the ULSD techniques and pharmacological agents used during the intervention, and to assess the knee's function postintervention. OBJECTIVES: Our study aimed to determine the clinical characteristics of patients with chronic knee OA selected for ULSD-g GNB, describe the various ULSD-g techniques and pharmacological agents used to target the genicular nerves, and evaluate the primary outcomes of pain and function. STUDY DESIGN: Systematic review. METHODS: We looked at patients with chronic knee OA with symptoms or disease features of at least 3 months and the use of ULSD guidance for GNB using either local anesthetic agents and/or corticosteroids or alcohol. Two major electronic databases (Medline/PubMed and EMBASE) were searched from their inception through August 2021, without language restriction.After removing duplicates, 2 reviewers independently reviewed the abstracts of 340 records. Nine of the 10 full texts that were reviewed were selected for inclusion. A third reviewer was involved in resolving disagreements.Two reviewers extracted relevant information pertaining to study types, patient characteristics, intervention details, outcome measures, and adverse effects. This was followed by independent verification for accuracy. RESULTS: Data synthesis: Nine studies were included with a total of 280 patients who had symptoms or disease features of at least 3 months. The National Institute of Health's Study Quality Assessment Tools were used for quality appraisal, of which 8 studies were at least of fair quality. All studies involved targeted at least the superior medial, superior lateral, and inferior medial genicular nerves. ULSD techniques relied on bony, soft tissue, or periarterial landmarks; either local anesthetic agents and/or corticosteroids or alcohol were used in the injections. Follow-up intervals for pain and functional assessments were heterogeneous, ranging from one week to 6 months postprocedure. Sustained improvements in both pain and knee function were observed for up to 6 months regardless of the choice of pharmacological agents. Minimal adverse effects were reported. LIMITATIONS: Meta-analysis was not performed due to heterogeneity of study designs, ULSD techniques, pharmacological agents used, and dosages administered. Only one study targeted additional genicular nerves; conclusions regarding the therapeutic blockade of these nerves could not be made. CONCLUSIONS: There is fair evidence to at least target the superior medial genicular nerve, inferior medial genicular nerve, and Inferior medial genicular nerve using local anesthetics, corticosteroids, or alcohol to reduce pain and to improve knee function in patients with chronic knee OA under ULSD guidance. The procedure is safe but more research is needed to determine the optimal interventional approach.

Use of botulinum neurotoxin in the treatment of piriformis syndrome: A systematic review.

Objective: To determine the pain, functional and adverse outcomes of patients with piriformis syndrome who received botulinum neurotoxin injection, and to determine the optimal dosing of botulinum neurotoxin and choices of modality used during this intervention. Literature survey: Systematic review of relevant clinical studies published in English language using PubMed/Medline, Embase and CINAHL databases from October 1, 2002 to October 6, 2020. Methodology: A comprehensive search was performed to identify all studies addressing the treatment of piriformis syndrome with botulinum toxin. Two reviewers independently screened the titles, abstracts, and full texts and extracted data based on a set of predefined inclusion and exclusion criteria. 23 full-text articles were identified of which consensus was achieved for seven articles for data extraction and quality assessment. The qualities and risk of potential bias of the seven studies were appraised using the National Heart, Lung and Blood Institute (NIH) Study Quality Assessment tools for case controls, cohort studies and randomized trials. Synthesis: Seven studies (n = 152 patients) were included consisting of three randomized controlled studies (RCTs), two case control studies and two cohort studies. The qualities of these studies were: Two good and one fair for the RCTs, fair for both the case controls and one good and fair for the cohort studies. Most studies reported some reduction in pain using various modalities to guide injection (CT, EMG, US or fluoroscopy). However, the included studies were heterogeneous, making it difficult to quantify pain reduction. There was minimal description of other functional outcomes. Botulinum toxin A doses range from 100 to 300U. Mild adverse effects were reported with no medical intervention needed. Conclusions: There is fair quality of evidence to suggest botulinum toxin is safe to reduce pain in piriformis syndrome. There is insufficient data to quantify pain reduction and to describe other functional outcomes. The optimal dose of botulinum toxin A remains unclear. Modalities to guide botulinum injection into the piriformis muscle remain heterogeneous.

Cervical neuromyelitis optica with thoracic ependymoma.

BACKGROUND: The occurrence of cervical neuromyelitis optica (NMO) in a patient with a thoracic ependymoma is uncommon. Here, we present a patient with a spinal ependymoma who developed the new onset of NMO 2 months later. CASE DESCRIPTION: A 66-year-old male presented with right lower limb weakness. The magnetic resonance (MR) revealed an intramedullary spinal cord tumor at the T2-T4 level. It was surgically excised and proved pathologically to be an ependymoma. 2 months later, the patient presented with an acute partial quadriparesis and a high signal intensity cord lesion at the C2-C3 level attributed to seropositive NMO (i.e. additional diagnostic studies confirmed this diagnosis). CONCLUSION: Patients with intramedullary thoracic ependymomas may also develop NMO resulting in recurrent/ new neurological deficits. Critical studies utilized to diagnose NMO include brain and spine MRs showing unique intramedullary brain/cord lesions, aquaporin-4 positive serology, and classical abnormal visual studies. If the diagnosis of NMO is established, multiple additional medical therapies are warranted.

Dextrose prolotherapy in knee osteoarthritis: A systematic review and meta-analysis.

OBJECTIVE: To summarize the evidence for dextrose prolotherapy in knee osteoarthritis. DATA SOURCES: The authors searched PubMed and Embase from inception to September 2020. All publications in the English language were included without demographic limits. STUDY SELECTION: Randomized clinical trials comparing the effects of any active interventions or placebo versus dextrose prolotherapy in patients with knee osteoarthritis were included. DATA EXTRACTION: Potential articles were screened for eligibility, and data was extracted independently. The risk of bias was assessed using the Cochrane Risk of Bias tool. Meta-analysis was performed on clinical trials with similar parameters. The Strength of Recommendation Taxonomy (SORT) was used for evaluating the strength of recommendations. DATA SYNTHESIS: In total, eleven articles (n = 837 patients) met the search criteria and were included. The risk-of-bias analysis revealed two studies to be of low risk. The overall effectiveness was calculated using a meta-analysis method. Prolotherapy was no different from platelet-rich plasma on the pain subscale at the 6-month time point. Prolotherapy was inferior to platelet-rich plasma at 6 months (MD 0.45, 95% CI 0.06-0.85, p = 0.03) on the stiffness subscale. Prolotherapy was found to be safe with no major adverse effects. CONCLUSION: Prolotherapy in knee osteoarthritis confers potential benefits for pain but the studies are at high risk of bias. Based on two well-designed studies, dextrose prolotherapy may be considered in knee osteoarthritis (strength of recommendation B). This treatment is safe and may be considered in patients with limited alternative options (strength of recommendation C).

Botulinum Toxin Injection and Electromyography in Patients Receiving Anticoagulants: A Systematic Review.

OBJECTIVE: To identify the different practice patterns of botulinum toxin injection (BTX) and electromyography (EMG) in patients receiving anticoagulation and to evaluate the incidence, reporting, and management of bleeding complications and compartment syndrome from BTX and EMG. LITERATURE SURVEY: Systematic review of relevant clinical studies in PubMed/Medline and Embase databases using key terms from inception to 31 May 2020. All publications in the English language were included without demographic limits. METHODOLOGY: A comprehensive search was performed to identify all studies addressing BTX and EMG in patients receiving anticoagulants. Two reviewers independently screened the titles, abstracts, and full texts and extracted data based on a set of predefined inclusion and exclusion criteria. All studies that met the inclusion criteria were assigned their respective levels of evidence using the Joanne Briggs Institute (JBI) Level of Evidence for Effectiveness. SYNTHESIS: Eighteen studies were included in this review of which there were nine studies each on BTX and EMG. The results indicated heterogeneity in the practice patterns of BTX and EMG in patients taking anticoagulants. These included the decision for continuation of anticoagulant, international normalized ratio (INR) results acceptable to practitioners, the modality for procedure guidance, and surveillance of bleeding complications. In addition, there were variations in the description of targeted muscles and description of needle sizes. The overall incidence of bleeding complications and compartment syndrome rates were low. CONCLUSIONS: Despite the varied practice in anticoagulated patients undergoing BTX or EMG, practitioners should allow periprocedural continuation of anticoagulants, targeting an INR of 2 to 3 while using the smallest needle (25 gauge or smaller) of appropriate length. Some of the evidence on procedural guidance and complication surveillance were weak and more research in these areas is required.

Adult human metapneumovirus encephalitis: A case report highlighting challenges in clinical management and functional outcome

We report a rare case of adult human metapneumovirus(HMPV) in a healthy 32-year-old man. There was dramaticdeterioration in his condition developing pneumonia withType-I respiratory failure and encephalitis. He neededmechanical ventilation in the intensive care setting and wastreated with intravenous ribavirin. Post-extubation heremained severely physically and cognitively impaireddespite rehabilitation. Treatment of HMPV pneumonia is atpresent, still without specific antiviral therapy. ManagingHMPV-encephalitis remained supportive and challenging.More definite treatment strategies are needed.

A pilot project of early integrated traumatic brain injury rehabilitation in singapore.

Objective. Document acute neurosurgical and rehabilitation parameters of patients of all traumatic brain injury (TBI) severities and determine whether early screening along with very early integrated TBI rehabilitation changes functional outcomes. Methods. Prospective study involving all patients with TBI admitted to a neurosurgical department of a tertiary hospital. They were assessed within 72 hours of admission by the rehabilitation team and received twice weekly rehabilitation reviews. Patients with further rehabilitation needs were then transferred to the attached acute inpatient TBI rehabilitation unit (TREATS) and their functional outcomes were compared against a historical group of patients. Demographic variables, acute neurosurgical characteristics, medical complications, and rehabilitation outcomes were recorded. Results. There were 298 patients screened with an average age of 61.8 ± 19.1 years. The most common etiology was falls (77.5%). Most patients were discharged home directly (67.4%) and 22.8% of patients were in TREATS. The TREATS group functionally improved (P < 0.001). Regression analysis showed by the intervention of TREATS, that there was a statistically significant FIM functional gain of 18.445 points (95% CI -30.388 to -0.6502, P = 0.03). Conclusion. Our study demonstrated important epidemiological data on an unselected cohort of patients with TBI in Singapore and functional improvement in patients who further received inpatient rehabilitation.

Advances in rehabilitation medicine.

Rehabilitation medicine is the medical specialty that integrates rehabilitation as its core therapeutic modality in disability management. More than a billion people worldwide are disabled, and the World Health Organization has developed the International Classification of Functioning, Disability and Health as a framework through which disability is addressed. Herein, we explore paradigm shifts in neurorehabilitation, with a focus on restoration, and provide overviews on developments in neuropharmacology, rehabilitation robotics, virtual reality, constraint-induced therapy and brain stimulation. We also discuss important issues in rehabilitation systems of care, including integrated care pathways, very early rehabilitation, early supported discharge and telerehabilitation. Finally, we highlight major new fields of rehabilitation such as spasticity management, frailty and geriatric rehabilitation, intensive care and cancer rehabilitation.