Bilateral Lower Extremity Research Articles

Development of the scoliosis research society spinal deformity surgery safety checklist.

Spine deformity surgery is a complex multi-step procedure that has a relatively high complication rate. The use of surgical safety checklists has been shown to reduce perioperative adverse events, but existing lists are varied and non-specific for spinal deformity surgery. Thus, the purpose of this study was to develop a comprehensive surgical checklist for complex spinal corrective surgery. An electronic survey consisting of 187 surgical checklist items that had been developed and used by a group of SRS members over a 5-year period was distributed to the Scoliosis Research Society Safety and Value Committee membership. The survey sections included: (1) pre-operative area, (2) initial operating room visit, (3) before turning, (4) positioning, (5) prepare and drape, (6) pre-incision timeout, (7) intraoperative, (8) finishing implant placement and confirming imaging, (9) final rods and locking, (10) prior to closure, (11) closure, (12) turn to supine, and (13) checkout/debriefing. Respondents graded each item on a five-point Likert scale based on their perceived importance and feasibility for inclusion in the checklist. Features graded as "moderately important" or "very important" to include by at least 70% of respondents were considered to meet the cutoff for inclusion-based standard Delphi practices. Study data were collated using REDCap. A total of 25 surgeons completed the survey in its entirety. The overall checklist "package" was shortened to 9 individual checklist modules, with 2 to 16 items per checklist. In terms of individual checklist items, 40% of items (74 of 187) met the cutoff for inclusion; 17 of these items were graded as "very important," which included verifying the presence of implantable devices, reviewing the surgical plan and positioning with the surgical staff, securing the endotracheal tube, bite block confirmation, prone and lateral positioning, neuromonitoring baseline readings, double-checking that the implant screw caps were locked prior to closure, and confirming that the patient was moving bilateral lower extremities before leaving the operating room when possible. This study has led to the development of a specific spinal deformity surgical checklist of 74 (many specific to spine surgery) items that were considered important for inclusion; 17 were considered "very important".

6812 A Rare Case of Polyglandular Autoimmune Syndrome Type 3B Presenting with Unsteady Gait Due to Subacute Combined Degeneration of the Spinal Cord Associated with Pernicious Anemia

Abstract Disclosure: F. Mohammadrezaei: None. F. Sajid: None. C.A. Resta: None. J.G. Karam: None. A Rare Case of Polyglandular Autoimmune Syndrome Type 3B Presenting with Unsteady Gait due to Subacute Combined Degeneration of the Spinal Cord associated with Pernicious Anemia Background: The coexistence of Hashimoto's thyroiditis and pernicious anemia is well established and is recognized as Polyglandular Autoimmune Syndrome (PAS) Type 3B [1]. We describe a rare case of a patient presenting with subacute combined degeneration of the spinal cord leading to the diagnosis of PAS Type 3B. Case Presentation: A 37-year-old man with no known medical history presented to the Emergency Department after a fall in the subway station. On history, he complained of progressive bilateral lower extremity weakness of 10 months duration, necessitating assistance with ambulation, and significant weight gain, described as an increase in his pants size from 40 to 56. His physical examination was relevant for weight of 145kg, BMI of 46.5, normal motor strength and sensation of the upper extremities, decreased strength at 4 out of 5 of bilateral hip flexion and extension, and decreased vibration sensation of bilateral lower extremities. He could not fully stand or walk due to imbalance and weakness. Blood testing revealed a hemoglobin level of 11.4 gm/dl (14-18), MCV of 108.8 FL (80-94), a significantly low vitamin B12 at 89 pg/ml, and normal folate level. His TSH level was 9.26 MCIU/ML (0.39-4.08), with a free T4 of 0.74 ng/dl (0.8-1.8) and significantly elevated Thyroid Peroxidase Antibody titer at 4320 IU/ml (< 34.9). Intrinsic factor antibody and parietal cell antibody tests both came back elevated at 13.4 AU/mL (0.0-1.1) and 1.8 (<1.2), respectively. A head CT scan showed no acute pathology, but MRI spine with contrast revealed abnormal T2 hyperintensity, primarily affecting the lateral columns throughout the cervical and thoracic cord, likely indicative of subacute combined degeneration. The patient was diagnosed with autoimmune Hashimoto's thyroiditis, pernicious anemia, and subacute combined degeneration of the spinal cord due to vitamin B12 deficiency. He was treated with daily vitamin B12 1000mcg muscular injections, levothyroxine 75mcg orally daily (after ruling out adrenal insufficiency), and physical therapy. Conclusion: This case highlights the complexity of polyglandular autoimmune syndromes and the importance of recognizing atypical presentations early in the history of disease. Comprehensive evaluation and timely intervention are essential to mitigate the progression of these conditions and improve patients' quality of life. Reference: (1) Betterle C, Furmaniak J, Sabbadin C, Scaroni C, Presotto F. Type 3 autoimmune polyglandular syndrome (APS-3) or type 3 multiple autoimmune syndrome (MAS-3): an expanding galaxy. J Endocrinol Invest. 2023 Apr;46(4):643-665. Presentation: 6/1/2024

8233 Cushing Disease Presenting As Severe Persistent Hypokalemia

Abstract Disclosure: G. Palaguachi: None. A. Randhawa: None. M. Sattar: None. G. Mahajan: None. J. Karam: None. Introduction: The clinical presentation of Cushing Disease represents a wide spectrum of clinical and laboratory findings, including electrolyte derangements such as hypokalemia. In this case report, we describe a patient in whom the admission for severe persistent hypokalemia prompted the diagnosis of Cushing Disease. Clinical Case: A 35-year-old woman with history of type 2 diabetes, hypertension, and hyperlipidemia, presented to the Emergency Department with worsening bilateral lower extremities swelling, impairing her ability to walk, found to have severe hypokalemia with K level of 2.8 (3.4-4.8 mmol/L), in additional to right pubic rami fracture, left breast abscess, oral thrush, and severe hyperglycemia with HbA1C of 15.4%. Additional history was relevant for hirsutism, scalp hair thinning, weight gain, and amenorrhea of few months duration. Physical examination was significant for round face, thin scalp hair, oral thrush, facial hirsutism, central obesity, wide abdominal striae, onychomycosis, thin skin with multiple ecchymoses, bilateral lower extremity edema, and thin extremities. Her hypokalemia was resistant to therapy and K level remained in 3.2-3.5 mmol/L range on the third week of admission despite oral and intravenous potassium replacements and spironolactone high dose therapy at 100mg twice a day. Additional laboratory testing showed Cortisol 25.0 (6.70 - 27.60 ug/dL) and normal Aldosterone and renin levels. Given absence of otherwise clear etiology of hypokalemia, and presence of multiple features of Cushing’s syndrome, further inpatient evaluation included 24-hour Urine Free Cortisol level that came back at 2754 (3.5 - 45.0 mcg/24hour), 1 mg Dexamethasone Suppression Test Cortisol of 24.9 (6.70 - 27.60 ug/dL), ACTH of 151.0 (7.2 - 63.3 pg/mL), and 8 mg Dexamethasone Suppression Test Cortisol of 14.2 (6.70 - 27.60 ug/dL). MRI Pituitary showed a pituitary adenoma (0.7 x 0.3 cm) with cavernous sinus involvement. A diagnosis of Cushing disease was made and the patient underwent transsphenoidal surgery on the fourth week of hospital stay with diffuse ACTH staining of the tumor. Postoperatively, cortisol levels were not suppressed suggesting persistent disease, but hypokalemia resolved while on Spironolactone. Conclusion: This patient had several classical features of hypercortisolemia with associated hyperglycemia, recurrent infections, and bone fractures, however the finding that connected the dots and prompted establishing her diagnosis was her severe refractory hypokalemia. Although not a defining feature of Cushing Disease, and usually more pronounced with ectopic ACTH secretion, severe and/or persistent hypokalemia can be part of the presenting symptoms. This case demonstrates the importance of including Cushing Disease as part of the differential diagnosis of persistent hypokalemia in correlation with other clinical signs and diagnostics. Presentation: 6/2/2024

8269 Euglycemic Diabetic Ketoacidosis Secondary to Rapid Weight Loss in a Patient on Dapagliflozin

Abstract Disclosure: A. Sridhar: None. A. Iqbal: None. A. Prabha Kumar: None. F. Haider: None. M. Babic: None. Background: Euglycemic DKA (eDKA) is a potentially life-threatening complication in patients taking SGLT 2 inhibitors (SGLT2i). Common precipitating factors include strenuous exercise, carbohydrate restriction, starvation, and alcohol use. Clinical case: The patient is a 71-year-old female with past medical history of Type 2 diabetes mellitus (DM), gastro-esophageal reflux disease, hypertension, hyperlipidemia, coronary artery disease and chronic pain syndrome. She presented with complaints of nausea, vomiting, reduced appetite and generalized weakness for the past 4 days. She also reported an intentional weight loss of 35 pounds in the last 6 weeks achieved with daily exercise and a carbohydrate restricted diet. She had been taking Dapagliflozin-Metformin 5-1000 mg twice daily and pioglitazone 30 mg once daily for 2 years and Ozempic subcutaneous injection 1 mg weekly for 6 months. Physical examination in the ED showed normal vital signs, dry mucous membranes, and trace bilateral lower extremity edema. Blood work was significant for venous blood gas pH 7.24, bicarbonate 9 mmol/L, anion gap 30 mmol/L, blood glucose 94 mg/dL, HbA1c 5.8 % and WBC 13.2 K/uL. Urinalysis was positive for glucose and ketones. The patient was admitted for management of eDKA and was started on intravenous 10% dextrose infusion and insulin infusion. Endocrinology was consulted and they recommended following DKA protocol and stopping Dapagliflozin at discharge. She was maintained on insulin infusion for 48 hours after which her anion gap normalized, and she was transitioned to subcutaneous insulin with Lantus 8 units and sliding scale insulin. During this time the patient’s symptoms resolved, and she was able to tolerate oral diet. She eventually resumed her home medications with oral Metformin 1000 mg twice daily and pioglitazone 30 mg once daily. Dapagliflozin and Ozempic were discontinued at discharge. Strenuous exercise and carbohydrate restriction which caused rapid weight loss, were likely the triggers for eDKA in our patient. A diabetes educator was involved at discharge and the patient was counseled to avoid possible triggers and identify warning signs and symptoms in the future. The patient was discharged with a follow up appointment with her Endocrinologist. Conclusion: High index of clinical suspicion is important to promptly diagnose eDKA in patients taking SGLT2i. Patient education on avoiding precipitating factors and early recognition of signs and symptoms is necessary to reduce mortality. Presentation: 6/3/2024

7148 Fake Fingerstick: Artifactual Hypoglycemia in a Hospitalized patient with Systemic Sclerosis

Abstract Disclosure: S. Shteyman: None. F. Mirza: None. Introduction: Artifactual hypoglycemia is a problem in hospitalized patients. It often leads to unnecessary use of resources and creates anxiety for the patient and medical team. We describe a case of a 60-year-old female with history of systemic sclerosis (Raynaud, telangiectasias, esophageal dysmotility, interstitial lung disease, pulmonary hypertension), rheumatoid arthritis, autoimmune hepatitis and hypothyroidism who initially presented to the hospital emergency department with bilateral lower extremity radiculopathy, and new onset urine incontinence. She underwent spine surgery initially, followed by emergent left upper extremity thrombectomy two days later. Postoperatively, she was noted to have fingerstick glucose of 34 mg/dL. Dextrose and juice were given, and endocrinology service was consulted. The patient was monitored with 2 hourly fingerstick glucose and was noted to have frequent hypoglycemia on fingerstick monitoring. Serum glucose in AM labs was consistently within normal limits. Patient denied both adrenergic and neuroglycopenic symptoms during periods of “hypoglycemia”. She was asked to fast till fingerstick glucose was noted to be at 43 mg/dl, when blood was drawn for serum glucose, insulin, proinsulin, C-peptide, B-hydroxybutyric acid, IGF-2, insulin AB, and sulfonylurea panel, prior to giving her any dextrose. She was asymptomatic at the time. All labs were within normal limits, with serum glucose at 119 mg/dL. At that point, artifactual hypoglycemia was suspected. Serum glucose was checked twice again when fingerstick glucose was noted to be <45mg/dL, and corresponding serum glucose was noted to be normal at both times (>100 mg/dL). Decision of artifactual hypoglycemia was made and fingerstick glucose monitoring was discontinued in this non-diabetic patient, with recommendation to check serum glucose only if symptoms of hypoglycemia occur, as fingerstick glucose values were not reliable. Fasting serum glucose continued to be normal for the remainder of the hospitalization. Discussion: There have been a handful cases of artifactual hypoglycemia reported in patients with CREST, systemic sclerosis, and Raynaud’s disease. It is thought to be due to abnormal small vasculature causing delayed transit of blood through capillaries, and increased uptake of glucose into the interstitial tissue. Some recommend using earlobe sticks as a replacement for fingerstick glucose monitoring in these patients. Future research can explore if continuous glucose monitoring can be used reliably in these patients. Presentation: 6/1/2024

7743 A Case Study of Ectopic Adrenocorticotropic Hormone Secretion from Pancreatic Neuroendocrine Tumor

Abstract Disclosure: K.S. Wei: None. J. Huang: None. Introduction: Pancreatic neuroendocrine tumors (PanNETs) are uncommon cancers that account for less than 2% of pancreatic malignancies. Even rarer are ACTH-producing NETs which may only become symptomatic until after metastasis. This case study examines the distinct presentation and diagnostic complexities associated with ectopic adrenocorticotropic hormone (ACTH) secretion from a PanNET. Clinical Case:A 42 year-old male with hypertension and type 2 diabetes initially presented to the hospital with increased abdominal girth for one month, bilateral lower extremity edema for two weeks, and generalized abdominal pain. He had unremarkable surgical, family, and social histories. Patient was afebrile, normotensive, saturating well on room air, with exam notable for a distended abdomen and 2+ bilateral pitting edema. Admission labs were notable for potassium of 2.4 (ref: 3.5-5.1 mmol/L). MRI abdomen showed hepatomegaly with numerous heterogeneously enhancing masses and an ill-defined pancreatic tail mass with involvement of the spleen. Liver biopsy showed well-differentiated neuroendocrine tumor, grade 2. He was started on octreotide 20mg q4weeks and capecitabine/temozolomide q4weeks. Two months later, the patient was readmitted after presenting with back pain for two days, found to have acute compression fractures of T9-L1 without spinal PET activity. At follow-up visit with endocrinology, he endorsed easy bruising and muscle weakness and had hypertension (161/96 mmHg) with hypokalemia. Random cortisol was 43.7 (ref: 2.5-11.9 mcg/dL). ACTH was 124 (ref: 6-50 pg/mL) despite receiving chemotherapy. 24-hour urine cortisol was 3,049 (ref: 4-50 mcg/24 hrs). He was diagnosed with ectopic Cushing’s disease from ACTH-producing PanNET leading to osteoporosis and fracture of the vertebral bodies. For the ectopic Cushing’s disease, he was started on ketoconazole 200mg BID with plan to start osilodrostat once approved. For the fracture, he is scheduled for Zometa infusion and IR kyphoplasty. Conclusion: This case offers several important clinical insights. In patients with PanNET with Cushingoid exam findings, ACTH-producing PanNET should be high on the differential. Most ACTH NETs are aggressive often with liver metastases, whereby metastatic disease will have already occurred by the time the Cushingoid features develop. The initial severe hypokalemia and hypertension should have prompted investigation for mineralocorticoid excess from hypercortisolism, which may have led to an earlier diagnosis of ectopic ACTH Cushing’s disease, thereby decreasing the possibility of developing vertebral fractures, uncontrolled diabetes and hypertension. Ketoconazole or osilodrostat may be used to treat Cushing’s disease from ACTH NETs. Presentation: 6/1/2024

7854 Ablation Aberration: A Case of Thyroid Dermopathy Exacerbation in a Filipino Male Following Radioactive Iodine Ablation and Total Thyroidectomy Improved by Weekly Intradermal Long-Acting Glucocorticoid Injection

Abstract Disclosure: K.T. Lim: None. O.C. Dampil: None. Ablation Aberration: A Case of Thyroid Dermopathy Exacerbation in a Filipino Male Following Radioactive Iodine Ablation and Total Thyroidectomy Improved by Weekly Intradermal Long-Acting Glucocorticoid Injection Introduction: Thyroid dermopathy (TD) represents an unusual extrathyroidal presentation of Graves' disease (GD), impacting about 0.5–4% of patients. RAI treatment for hyperthyroidism is known to progress Graves' ophthalmopathy. RAI-induced TD exacerbation, however, is rare in literature. Here, we present a case of worsening TD and ophthalmopathy in a Filipino patient with GD who underwent definitive therapy for persistent hyperthyroidism. Clinical Case: A 44-year-old man with GD had bilateral lower extremity indurated, mildly erythematous plaques for 4 years. Hyperthyroidism persisted despite methimazole compliance, so he underwent RAI ablation two years earlier, total thyroidectomy a year later, and has been on levothyroxine since. Despite definitive treatment, his extrathyroidal symptoms worsened. A punch biopsy of the skin lesions revealed upper and mid-lower dermis mucin deposition, with occasional spindle-shaped and stellate fibroblasts, and mast cells. These histopathologic findings were consistent with pretibial myxedema. We assessed his thyroid function and found he was euthyroid with normal TSH (3.1 μIU/mL; reference range 0.27-4.20) and an elevated TRAb (35.73 IU/L; reference range <1.75). Physical examination revealed thickened skin, cobblestone-like plaques, and non-pitting edema on the pretibial, ankle, and pedal areas. A 3.5-cm-diameter, circumscribed, orange-peel-textured, indurated plaque covered his left ankle. Fluocinolone acetonide 0.025% w/w ointment was initiated. After 3 weeks, his cutaneous symptoms improved by 35%, albeit his left ankle circumscribed plaque improved marginally. Triamcinolone acetonide 40 mg/mL was injected into this and other nodular lesions at 4mg (0.1 mL) per 1-cm-diameter circular region. Each dose was equally dispersed by multipoint intradermal injections using a 1 mL syringe with a 0.5”x 25G needle. A week after intralesional triamcinolone injection and continuous topical steroid application on the non-nodular lesions, a 70% improvement in cutaneous manifestations was observed (from baseline) with the plaques becoming thinner and softer. After three weekly intradermal steroid injections, the circumscribed plaque had flattened (with residual hyperpigmentation), and the other plaques and nonpitting edema dissipated. Conclusion: Our experience with this patient highlights a paradoxical TD exacerbation following RAI ablation and definitive surgery for persistent hyperthyroidism in GD. It also reveals that weekly administration of multiple subcutaneous injections of a long-acting glucocorticoid alleviates lesions where topical ointment does not. Presentation: 6/1/2024

6666 Asymptomatic Fasting Hypoglycemia After Sleeve Gastrectomy

Abstract Disclosure: K. Mitrollari: None. H.K. Deveaux: None. A. Gundeti: None. A.P. Calimag: None. T. Yasmeen: None. Introduction: Post-bariatric surgery hypoglycemia (PBSH), though previously considered rare, is increasingly recognized, occurring not only after Roux-en-Y gastric bypass (RYGB,) but also following various bariatric procedures. PBSH can manifest as postprandial or fasting hypoglycemia, requiring thorough investigation and prevention due to potential asymptomatic presentations that may lead to severe consequences, including coma and death. Case Report A 45-year-old female with a history of type 2 DM, ESRD on HD, gastric sleeve surgery, bilateral trans-metatarsal amputations, coronary artery disease, and congestive heart failure presented with bilateral lower extremity wounds. On admission her venous blood glucose was 71 mg/dL. Glycohemoglobin was 3.9% and fructosamine was 225 (205-285 umol/L). Her glycohemoglobin levels consistently remained below 6.4% status post sleeve gastrectomy off diabetes medications. Throughout admission, she experienced almost daily episodes of fasting asymptomatic hypoglycemia correlated with venous sample with lowest blood glucose reading 38 mg/dL. Initially, these episodes were attributed to NPO status for procedures or decreased PO intake. Her diet consisted of fast food brought by her family, which she reported was similar to her diet at home. Workup during a hypoglycemic episode (glucose 51 mg/dL,) revealed insulin 4 mUnits/L, proinsulin 7.1 pmol/L (<=7.2 pmol/L), C-peptide 25.7 ng/mL (0.8-3.9 ng/mL), and beta-hydroxybutyrate 0.5 mmol/L (0.0-0.3 mmol/L). Negative insulin antibodies and sulfonylurea panel, normal cortisol, and ACTH levels were noted. The patient was placed on a 10% dextrose infusion to avoid further episodes of hypoglycemia. However, she continued to experience hypoglycemia and was started on oral diazoxide. A CT pancreas with and without contrast was unremarkable, and endoscopic ultrasonography only revealed a 10 mm accessory spleen. The patient was discharged with counseling on glucose monitoring, dietary changes, and follow-up with endocrinology. Conclusion: PBSH should be considered as a differential diagnosis in patients with unexplained hypoglycemia and a history of bariatric surgery. PBSH mimics insulinoma or non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS) with elevated insulin, proinsulin, C-peptide, and low beta-hydroxybutyrate during hypoglycemia, however NIPHS is exclusive to non-bariatric patients. Imaging is crucial to rule out insulinoma, and invasive tests such as endoscopic ultrasound aid diagnosis. PBSH is a diagnosis of exclusion; therefore, workup involves ruling out other causes of hypoglycemia. First-line treatment involves diet modification, with medications like diazoxide or acarbose considered if dietary changes prove insufficient. This case underscores the complexity of hypoglycemia, implicating bariatric surgery as a contributing factor. Presentation: 6/3/2024

Xylazine-induced Skin Necrosis, Emerging Public Health Crisis and the Ethical Considerations in Surgical Reconstruction: A Case Report

Xylazine, a non-opioid veterinary sedative, is increasingly being used to adulterate illicit fentanyl. Injection into the extremities causes progressive necrotic wounds, resulting in a compromised limb and life. Managing xylazine-induced skin necrosis may require extensive surgical intervention, including serial debridements and soft tissue reconstruction. Moreover, managing these complex wounds requires a multi-disciplinary approach, including hospital medicine, infectious disease, psychiatry, addiction medicine, pain/palliative care, ethics, wound care, orthopedic surgery, and plastic surgery. A 38-year-old female with a history of intravenous drug use presented with severe bilateral dorsal forearm wounds, and despite initial non-compliance with surgical debridement, she eventually underwent successful skin grafting after extensive treatment, including antibiotics and negative pressure therapy, but was later lost to follow-up. She relapsed into fentanyl use, leading to severe bilateral lower extremity wounds requiring further debridement and skin grafting, and later returned with new forearm wounds, at which point further reconstruction was deemed inappropriate without addressing her addiction; she refused inpatient rehabilitation and ultimately being lost to follow-up again.

Lower extremity muscle activity during reactive balance differs between adults with chronic traumatic brain injury and controls.

Control of reactive balance is key to achieving safe independent walking and engagement in life activities. After traumatic brain injury (TBI), motor impairments and mobility challenges are persistent sequelae. To date, no studies have explored muscle activity of individuals with chronic TBI during a task that requires reactive control of balance. To investigate lower extremity muscle activity during a reactive balance test performed by adults with chronic severe TBI and matched controls. We hypothesized that abnormal activity of lower extremity muscles would be related with poorer reactive balance performance. Also, we performed an exploratory analysis for those with TBI investigating the impact of unilateral versus bilateral lower extremity involvement in the control of reactive balance. Ten adults with chronic severe TBI who were independent community ambulators and ten matched controls performed the computerized reactive balance test (Propriotest®) while lower extremity muscle activity was recorded. Electromyographic (EMG) activity was contrasted (Mann-Whitney U Test) between groups across each 10 s epoch of the 120 s test. Additionally, test scores were correlated (Spearman) with lower extremity composite EMG activity to distinguish muscle activity patterns related with reactive balance performance. Lastly, reactive balance test scores were correlated with reactive balance test scores and clinical functional measures only for the TBI group. Although the TBI group exhibited greater EMG activity across the entire test compared with the control group, significant differences were not observed. Greater composite EMG activity correlated significantly with poorer reactive balance performance across most of the 10 s windows of the test. Greater muscle activity exhibited during the reactive balance test by individuals with chronic severe TBI compared to those without disabilities, particularly at small unexpected perturbations, highlights the greater physiologic effort required to control reactive balance even after independent ambulation is achieved.

A confounding pediatric spinal cord injury: Anterior, central, or both?

Pediatric spinal cord injury (SCI) most commonly affects the cervical region. Central cord syndrome most often occurs in the lower cervical injury due to hyperextension injury, while anterior cord syndrome is primarily due to vascular infarction after hyperextension injury. An unusual case of a pediatric patient who physically presented with central cord syndrome but radiologically had evidence of anterior spinal artery syndrome is described. A two-year-old male presented after a fall from three feet with flaccid upper extremities and dysesthesias but maintained functional strength in bilateral lower extremities. Although his clinical presentation was that of central cord syndrome, he was found to have an anterior spinal artery infarct spanning from C2-T3 with a ligamentous injury at C3 and an incidental finding of Chiari I malformation on MRI. Given the negative evaluation for a cardiac or hematologic source of embolus and normal angiography, it was theorized that compression of vertebral arteries by previously undiagnosed Chiari I malformation in the setting of trauma could have made the patient more vulnerable to this complication. During inpatient rehabilitation, he regained scapular movement and shoulder flexion. However, he regained distal movement in supination, wrist extension, and finger flexion instead of the more usual proximal-to-distal motor recovery observed in SCI. While he had a relative sparing of strength in his legs, he had impaired proprioception and balance, leading to gait impairment. This case highlights the complexity of pediatric cervical SCI diagnosis and prognostication. While classic SCI subtypes are well described, many pediatric and adult patients will present and recover in unexpected ways. All with SCI should be evaluated thoroughly for common etiologies and transitioned to rehabilitation therapies to assist in recovery.

New-onset hydrocephalus in an adult with cerebral palsy: A case report and review of the literature.

Hydrocephalus is a common comorbidity associated with brain injuries, including cerebral palsy (CP). In CP, hydrocephalus typically presents in infancy or early childhood. This report describes a patient in their mid 20 s with mixed dyskinetic-spastic CP with adult-onset hydrocephalus of unknown cause initially presenting with new-onset bilateral lower extremity spasms. Multiple interventions were trialed, including ischial bursal steroid injections, botulinum toxin injections, trigger point injections, multiple oral medications, and physical and massage therapies without benefit. Given lack of treatment response, imaging of the neuraxis was obtained. Magnetic resonance imaging (MRI) of the brain demonstrated new diffuse moderate ventriculomegaly compared to prior MRI. Ophthalmologic evaluation demonstrated papilledema, and opening pressure on lumbar puncture was elevated to 44 mmHg H2O. The patient underwent ventriculoperitoneal shunt placement with rapid and near-resolution of their spasms and pain. This patient represents a unique case of new-onset hydrocephalus in an adult with CP. To ensure appropriate and timely diagnosis and treatment, individuals with neurologic conditions such as CP should have ongoing surveillance and comprehensive evaluation for any neurologic or functional changes, including changes in baseline tone. Future research is needed to better understand if adults with CP are at higher risk for the development of hydrocephalus in adulthood.

Effects of unilateral and bilateral lower extremity fatigue on static stance and postural adjustments response to the externally initiated perturbation

The study investigated the effects of unilateral and bilateral lower extremity fatigue on both postural stability and postural adjustments. Fourteen young male subjects performed unilateral and bilateral dynamic lower extremity pedaling exercises with 5 sets of 20 times at 50 % maximum voluntary contraction. Center of pressure (COP) signals were recorded before and after the fatigue exercise. Electromyography activities of six trunk and leg muscles were recorded and analyzed during the anticipatory (APAs) and compensatory (CPAs) postural adjustments. The results showed that both fatiguing exercises caused an increase in COP and larger APAs and CPAs in the rectus femoris and tibialis anterior during externally initiated perturbation. However, the observed indicators showed no clear difference between unilateral and bilateral fatigue. These results validated that when enlarged APAs were not sufficient to resist the external perturbation, the central nervous system increased the strength of CPAs to maintain the stability of the body. These findings provided a perspective on the association between APAs and CPAs, which may apply to the athletic training or rehabilitation on postural control.

A case of MERS presenting with acute motor aphasia and tetraparesis and literature review

BackgroundMild encephalopathy wıth reversible splenial lesions (MERS) are a clinical–radiological diagnosis that can be diagnosed with radiological imaging and can be accompanied by impaired consciousness, aphasia, headache, and paralysis. MERS can be divided into two different types based on radiological findings; Involvement of the splenium is seen in type 1, and involvement of the splenium and deep white matter is seen in type 2. MERS Type 2 is very rare in adults. Here, we describe a patient diagnosed with MERS Type 2 and our therapeutic intervention.Case presentationA 22-year-old woman presented with slurred speech, weakness in the extremities and headache that started 14 h ago. The patient had sore throat and fever of 37.6 °C for 2 days, and medical history or family history were unremarkable. Neurological examination revealed that she was conscious, cooperative, with no signs of meningeal irritation. Speech comprehension, naming, and repetition were preserved, motor examination revealed 5/5 left upper extremity strength, 4/5 right upper extremity strength, and 2/5 bilateral lower extremity strength. Diffusion-weighted magnetic resonance imaging (MRI-DWI) revealed bilateral deep white matter and splenium symmetrical diffusion restriction. Blood tests showed high C-reactive protein (CRP) and no leukocytosis. No cells were detected in the cerebrospinal fluid (CSF), protein was 151 mg/dl, glucose was within normal limits. The patient, who developed quadriparesis during follow-up, was started on pulse dose steroids. Neurological examination improved to patient’s baseline at the 12th hour of treatment. In the 72nd hour control MRI-DWI, it was seen that the lesions had regressed. Culture/Polymerase chain reaction (PCR) for bacterial/viral infection agents came back negative. After steroids were given for 5 days, patient was discharged at her baseline.ConclusionsMERS is a rare diagnosis in adults and can be radiologically confused with acute toxic leukoencephalopathy. It can be distinguished clinically by the absence of prior infection, fever, and toxic agent exposure. Although there is no consensus in the literature regarding the treatment, the clinical picture improved rapidly after steroid in our case. Despite being rare, it should be considered in the differential diagnosis of patients with deep white matter lesions in adults.

Risk factors of preoperative deep vein thrombosis in patients with non-traumatic osteonecrosis of the femoral head

PurposeThis study aims to identify independent risk factors for preoperative lower extremity deep venous thrombosis (DVT) in patients with non-traumatic osteonecrosis of the femoral head (NONFH), and to develop a prediction nomogram.MethodsRetrospective analysis of prospectively collected data on patients presenting with non-traumatic osteonecrosis of the femoral head between October 2014 and April 2019 was conducted. Duplex ultrasonography (DUS) was routinely used to screen for preoperative DVT of bilateral lower extremities. Data on demographics, chronic comorbidities, preoperative characteristics, and laboratory biomarkers were collected. Univariate analyses and multivariate logistic regression analyses were used to identify the independent risk factors associated with DVT which were combined and transformed into a nomogram model.ResultAmong 2824 eligible patients included, 35 (1.24%) had preoperative DVT, including 15 cases of proximal thrombosis, and 20 cases of distal thrombosis. Six independent risk factors were identified to be associated with DVT, including Sodium ≤ 137 mmol/L (OR = 2.116, 95% confidence interval [CI]: 1.036–4.322; P = 0.040), AGE ≥ 49 years (OR = 7.598, 95%CI: 1.763–32.735; P = 0.008), D-Dimer > 0.18 mg/L (OR = 2.351, 95%CI: 1.070–5.163; P = 0.033), AT III ≤ 91.5% (OR = 2.796, 95%CI: 1.387–5.634; P = 0.006), PLT ≥ 220.4*10⁹ /L (OR = 7.408, 95%CI: 3.434–15.981; P = 0.001) and ALB < 39 g/L (OR = 3.607, 95%CI: 1.084–12.696; P = 0.042). For the nomogram model, AUC was 0.845 (95%CI: 0.785–0.906), and C-index was 0.847 with the corrected value of 0.829 after 1000 bootstrapping validations. Moreover, the calibration curve and DCA exhibited the tool’s good prediction consistency and clinical practicability.ConclusionThese epidemiologic data and the nomogram may be conducive to the individualized assessment, risk stratification, and development of targeted prevention programs for preoperative DVT in patients with NONFH.

The hybrid operation based on microsurgery assisted by intraoperative spinal angiography in patients with spinal dural arteriovenous fistula: a series of 45 cases from multicenter research

BackgroundTo assess the clinical effects of hybrid surgery, which includes spinal angiography-assisted microsurgery, in the treatment of spinal dural arteriovenous fistulas (SDAVF).MethodsWe retrospectively reviewed 45 patients who underwent hybrid Spinal dural arteriovenous fistula (SDAVF) resection between September 2019 and June 2022. The hybrid surgery involved intraoperative digital subtraction angiography (DSA) of the spinal vessels to determine the source of the blood-supplying artery, location of the fistula and draining vein, indocyanine green fluorescence (ICG)-assisted microsurgical resection of the fistula, and postoperative DSA to verify therapeutic efficacy. The Hamilton Anxiety Scale (HAMA), Hamilton Depression Scale (HAMD), Visual Analog Scale (VAS), Barthel score, modified Rankin Scale (mRS) and modified Aminoff-Logue score (key indicator) were used to assess the clinical effects of SDAVF resection.ResultsA series of 45 patients with SDAVF were successfully treated with hybrid surgery without fistula recurrence. There were no intraoperative complications related to spinal angiography, and none of the patients died. Postoperatively, two patients experienced clinical deterioration of spinal cord function, which manifested as bilateral lower extremity paralysis and bladder sphincter dysfunction. Postoperatively, improvement in mALS scores was observed in 16 cases (35.6%) within 1–2 days, 12 cases (26.7%) at 1 week, and 7 cases (15.6%) at 6 months. No SDAVF recurrence was detected in the spinal MRA examination 6 months after surgery. When compared with preoperative mALS scores, 35 cases (77.8%) showed significant improvement in symptoms, 8 cases (17.8%), remained unchanged, and 2 cases (4.4%) deteriorated. Compared with the preoperative scores, the postoperative mALS score was significantly decreased [postoperative vs. preoperative: 2(1,3) vs. 3(2,4)], HAMD score [(12.2 ± 5.5) vs. (19.6 ± 6.3)], HAMA score [(15.6 ± 5.5) vs. (20.5 ± 6.5)], and VAS score [3(2,5) vs. 5(4,8)]. Conversely, Barthel scoresshowed significant increase [(74.6 ± 8.7) vs. (67.8 ± 9.2)] (P < 0.05). However, the mRS scores were lower than preoperatively [1(1,2) vs. 2(1,2.5)], but the difference was not statistically significant (P > 0.05). There was a significant increase in “good” neurological outcomes at follow-up compared with preoperative function (62.2% vs. 33.3%) (P = 0.023).ConclusionHybrid surgery is a safe and effective treatment for patients with SAVF, which is beneficial for improving anxiety, depression, spinal cord, and neurological function, and relieving pain. However, the treatment of patients with SDAVF is a complex, long-term process requiring further multidisciplinary interventions, including clinical care, psychosocial interventions, and neurorehabilitation.

The Possible Role of Lymphaticovenous and Lymph Node to Vein Anastomosis for Improvement of Milroy Disease Related Congenital Chylothorax and Lower Extremity Lymphedema.

Primary lymphedema is characterized by lymphatic dysplasia in which one variant is Milroy's disease. The association with congenital chylothorax is even rarer with poor outcome. This is the first report to utilize peripheral lymphovenous anastomosis (LVA) and lymph node to vein anastomosis (LNVA) for the management of such condition. Retrospective chart review of patients with Milroy's disease with complication of chylothorax between 2019 till 2023 was performed. Clinical assessment and radiological investigations were reviewed. Six patients with mean age of 12±3.9 years and disease duration of 10.5±2.8 years were reviewed. Three had ISL stage 3 while others had stage 2 late disease. All had bilateral lower extremity lymphedema and chylothorax with history of chest tube drainage. After LVA and LNVA, significant reduction in extremity volume was noted (p=0.028) along with near complete resolution of chylothorax was noted during the long-term follow-up (32 ±17.9 months). Milroy's disease complicated with chylothorax remains to be challenging. This is the first report utilizing peripheral bypass (LVA and LNVA) which resulted in improvement of both lower extremity lymphedema and chylothorax. The utility of this approach represents a promising modality in the management of this devastating condition.

Diagnosis and treatment of secondary nephrotic syndrome with rash as the first symptom: a case report

BackgroundMembranous nephropathy (MN) is a common type of nephrotic syndrome (NS) in adults, accounting for about 20–30% of cases. Although secondary to specific factors, the coexistence of MN and mantle cell lymphoma (MCL) has been scarcely reported in clinical literature.Case presentationA 59-year-old Chinese male was admitted to the hospital with a generalized pruritic rash with bilateral lower extremity edema, which did not improve significantly after symptomatic treatment. He had undergone renal biopsy, and the diagnosis was thought to be secondary MN (SMN), therefore, we did a lymph node biopsy on the patient and found that MN was complicated with MCL. Soon after, the patient was admitted to the hematology department for a BR chemotherapy regimen (composed of bendamustine 90 mg/m2 BSA (body surface area), rituximab 375 mg/m2 BSA and dexamethasone 5 mg), and during the post-treatment follow-up, both his symptoms and renal function improved.ConclusionsThe mechanism underlying the combination of SMN and MCL remains elusive and exceedingly rare, consequently often overlooked in clinical practice. This case serves to offer valuable clinical insights for diagnosis and treatment, while emphasizing the pivotal role of renal pathology in clinical assessment.

Patient-Centered Outcomes of a Lymphedema Pump in Patients with Symptomatic Lower Extremity Edema

Phlebolymphedema is a challenging condition to manage, with limited options for effective treatment. For patients, this may be debilitating and lead to infection, loss of independence and affect quality of life. This study aims to evaluate patient-reported outcomes of an advanced pneumatic compression device (APCD) in the treatment of lower extremity phlebolymphedema. Patients with diagnosis of lower extremity phlebolymphedema at an acute care facility within the New York City Health and Hospitals Cooperation treated with the Flexitouch (FLX) (Tactile Systems Technology, Inc, Minneapolis, Minnesota) APCD from December 2021 to March 2023 were evaluated. Patient-perceived subjective outcomes were assessed via a short questionnaire, with subsequent analysis using chi-squared test. Primary end points were subjective improvements in 1) swelling, 2) pain, and 3) ease of use of device as surrogates for patient satisfaction. Secondary end point was subjective patient-reported compliance, obtained by investigating 1) if patients were trained to use device, and 2) if patients were using the device. A total of 52 participants were included in this study, consisting of 30.8% male and 69.2% female patients with a mean age of 71.7years. While selection criteria did not exclude unilateral disease or alternative etiologies, we note that the entire study population had been diagnosed with bilateral lower extremity lymphedema in the setting of chronic venous insufficiency. Other patient characteristics including race, comorbidities and smoking status were documented in Table1. Table2 demonstrates the results of chi-squared analysis. This study noted significant patient-perceived improvement in swelling and pain (91.4% with P<0.00001; 85.7% with P=0.00002 respectively) and patient-reported ease of use of the FLX device (85.7% with P=0.00002). Additional secondary findings included a majority of patients reporting being trained on how to use FLX and also maintaining compliance with the device (69.2% with P=0.005; 67.3% with P=0.012 respectively). FLX APCD use has been found to demonstrate desirable patient-reported outcomes as a general trend. The participants in this study noted statistically significant subjective improvement in swelling and pain, ease of use of device and adherence to training and compliance with device. FLX appears to be positively received by patients, and the authors recommend its consideration for management of bilateral lower extremity phlebolymphedema.

Prevalence and risk factors of deep venous thrombosis of hospitalizations in plateau: a cross-section analysis

BackgroundDeep venous thrombosis (DVT) is a serious public health issue that threatens human health and economic development. Presently, differences in the prevalence of DVT among individuals from different nationalities, residents of high-altitude areas, and those consuming any special diet are unknown. Therefore, we aimed to elucidate the prevalence of and the associated risk factors for DVT in hospitalized patients in the plateau areas.MethodsThe subjects were hospitalized patients in three grade III-a hospitals in the Qinghai Province, China, during January–October 2020. The demographic, clinical, and laboratory data were collected at admission, and ultrasonography of the bilateral lower extremities was performed. The hospital stay-duration was recorded at the time of discharge.ResultsA total of 3432 patients were enrolled, of which 159 (4.60%) were diagnosed with DVT. The age of > 50 years (OR = 2.434, 95% CI: 1.521–3.894252, P < 0.001), residence altitude of ≥ 3000 m (OR = 2.346, 95% CI: 1.239–4.440, P = 0.009), D-dimer level of ≥ 0.5 mg/L (OR = 2.211, 95% CI: 1.547–3.161, P < 0.001), presence of comorbidities (OR = 1.904, 95% CI: 1.386–2.705, P < 0.001), a history of varicose veins (OR = 1.990, 95% CI: 0.959–4.128, P = 0.045), and current medications (OR = 2.484, 95% CI: 1.778–3.471, P < 0.001) were identified as risk factors for DVT in these plateau areas.ConclusionThe prevalence of DVT in the hospitalized patients of the studied plateau areas was 4.60%. We recommend considering individualized risk stratification (age > 50 years, residence altitude ≥ 3000 m, a history of varicose veins, D-dimer level ≥ 0.5 mg/L, current medications, and comorbidities) for patients at the time of admission.