Bilateral Lower Extremity Paralysis Research Articles

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.

Management of Bone Marrow Transplants in Incarcerated Patients with Plasma Cell Dyscrasias: A Case Series

Background The U.S.' incarcerated population aged 55 years or older is expected to increase to 400,000 by 2030. This aging population faces intensifying health issues, including an increase in cancer diagnosis rates without adequate healthcare infrastructure and access. Studies show that individuals who received a cancer diagnosis while incarcerated, or within one year of release, had higher rates of cancer-related and all-cause mortality, compared to the general population. Our research seeks to assess how a cohort of patients with plasma cell dyscrasias (myeloma, amyloidosis, plasma cell leukemia) were treated and managed while incarcerated. Methods We performed a retrospective chart review of three patients with plasma cell dyscrasias in the incarcerated population who have undergone bone marrow transplants. Patients' disease characteristics, treatment sequences and details, and clinical outcomes were described qualitatively. Results Case 1: a 48-year-old Black man diagnosed with multiple myeloma in 2019. He was treated with 5 cycles of CyBorD at an outside hospital and had a favorable response. Stem cells were collected but never transplanted and patient was lost to follow-up due to incarceration. In April 2021, he presented to us with bilateral lower extremity paralysis and difficulty walking while in prison. He received emergent radiation to spine, then underwent both DCEP and VDPAC. The patient was discharged for physical rehabilitation in prison with ixazomib maintenance and monthly lab work. 6 months later, he was sent to another outside hospital with acute renal failure and then transferred to us. He demonstrated relapsed myeloma, received DV-AC, and was discharged back to prison while we awaited banked stem cells from 2019. He was admitted a month later for melphalan and auto-SCT, which was well-tolerated. We were ultimately able to arrange lenalidomide maintenance with prison. Case 2: a 65-year-old Black man with abnormal cardiac imaging and lymph node biopsy concerning for amyloid in 2020 while in prison. No treatment was given at the time. In 2021, an outside hospital conducted a bone marrow biopsy showing monoclonal plasma cells consistent with primary amyloidosis. 3 months later, the patient began CyBorD but completed subsequent cycles at another outside hospital. Correctional authorities indicated transplant would ultimately need to occur at our facility. Patient began stem cell mobilization and was admitted to us for melphalan and auto-SCT in March 2022. Patient was discharged back to corrections but there was a delay in acquiring lenalidomide for maintenance therapy, which was not started until August 2022. Case 3: a 44-year-old Black man was diagnosed with plasma cell leukemia in 2009. That year, he received an auto-SCT and then an allo-SCT from his HLA-matched sister at an outside hospital. In 2016, he received radiation for a large mass in his brain, as well as lenalidomide and dexamethasone. Since then, records indicate limited follow-up until he presented to us in 2022 with leg pain and imaging showing progressing myeloma while in prison. He was given 1 cycle of DCEP, was discharged back to a correctional facility, and subsequently refused 2 nd cycle. He sought a second opinion from an outside hospital for CAR-T therapy but was told eligibility required failure of daratumumab. In January 2023, he was offered Dara-Pom-Dex-Carfilzomib though declined the pomalidomide portion. He has responded well and is continuing maintenance. The CAR-T center offered to see him for treatment if he progresses on this regimen. Discussion Our research suggests that incarcerated patients face multiple obstacles that delay or hinder treatment, including siloed care, poor record-keeping, lack of follow-up, and difficulty obtaining appropriate medications. All three patients were frequently transferred between correctional facilities, outside hospitals, and our institution, which led to incomplete records. Additionally, patients went months or even years without follow-up monitoring after initial treatment and would often re-enter the healthcare system only upon presenting with severe symptoms from relapsed disease. Correctional facilities faced issues procuring expensive medications only available through restricted distribution programs. Further analysis is warranted to understand the generalizability of our results and identify solutions to support this population.

S3013 Home Brew Gone Wrong: A Case Report on Potential Auto-Brewery Syndrome Sequelae

Introduction: Auto-Brewery Syndrome (ABS) is a condition not often seen in medical practice. It involves the conversion of carbohydrates to alcohol by the intestinal microbiome in a subset of patients. However, when these patients deny any consumption of alcohol, they are often brushed off or worked up for other etiologies, including stroke or hypoglycemia. There are also many possible medical sequelae that are not as widely reviewed due to the rarity of this disease. These include symptoms of chronic alcohol consumption such as increased alcohol cravings addiction, possible neuropathy, and liver disease such as fatty liver disease or cirrhosis. Case Description/Methods: In this case, we present a 26-year-old male with a history of auto-brewery syndrome presenting with bilateral lower extremity paralysis, sensation loss, and neuropathy. These symptoms were similar to an episode which was inconclusive. He consumed alcohol occasionally but was sober at that time. During that stay, he was diagnosed with auto-brewery syndrome. In ED, his blood alcohol was 493mg/dL, although he was sober for 1 year, and his liver function tests were significantly elevated with AST twice the level of ALT, consistent with findings of alcoholic liver injury. There was some return of neurological and hepatic function over the hospital stay with supportive care. He was placed on a consistent carbohydrate diet and his LFTs subsequently improved. Discussion: While there is data on potential causes and causative organisms for this condition, there is little in the literature on the potential sequelae associated with auto-brewery syndrome. Chronic alcoholism and its effects are widely seen and studied. From alcohol neuropathy to cirrhosis, the effects of consistent alcohol consumption are deleterious to one’s health. The question that needs to be asked is: are patients with chronic exposure to endogenous alcohol at risk for the same complications seen in chronic alcoholism? Cirrhosis, which is seen as a risk factor for ABS, may actually be a consequence of ABS. In this patient, his AST and ALT were mildly elevated, even during previous admission. Therefore, the patient may have been experiencing chronic liver injury from alcohol use while sober, placing him at increased risk for NASH and eventually cirrhosis at a much earlier onset than expected. It would be imperative in this case to ensure that the patient is on a limited intake of carbohydrates, or antifungals if necessary.

Chronic nerve health following implantation of femoral nerve cuff electrodes

BackgroundPeripheral nerve stimulation with implanted nerve cuff electrodes can restore standing, stepping and other functions to individuals with spinal cord injury (SCI). We performed the first study to evaluate the clinical electrodiagnostic changes due to electrode implantation acutely, chronic presence on the nerve peri- and post-operatively, and long-term delivery of electrical stimulation.MethodsA man with bilateral lower extremity paralysis secondary to cervical SCI sustained 5 years prior to enrollment received an implanted standing neuroprosthesis including composite flat interface nerve electrodes (C-FINEs) electrodes implanted around the proximal femoral nerves near the inguinal ligaments. Electromyography quantified neurophysiology preoperatively, intraoperatively, and through 1 year postoperatively. Stimulation charge thresholds, evoked knee extension moments, and weight distribution during standing quantified neuroprosthesis function over the same interval.ResultsFemoral compound motor unit action potentials increased 31% in amplitude and 34% in area while evoked knee extension moments increased significantly (p < 0.01) by 79% over 1 year of rehabilitation with standing and quadriceps exercises. Charge thresholds were low and stable, averaging 19.7 nC ± 6.2 (SEM). Changes in saphenous nerve action potentials and needle electromyography suggested minor nerve irritation perioperatively.ConclusionsThis is the first human trial reporting acute and chronic neurophysiologic changes due to application of and stimulation through nerve cuff electrodes. Electrodiagnostics indicated preserved nerve health with strengthened responses following stimulated exercise. Temporary electrodiagnostic changes suggest minor nerve irritation only intra- and peri-operatively, not continuing chronically nor impacting function. These outcomes follow implantation of a neuroprosthesis enabling standing and demonstrate the ability to safely implant electrodes on the proximal femoral nerve close to the inguinal ligament. We demonstrate the electrodiagnostic findings that can be expected from implanting nerve cuff electrodes and their time-course for resolution, potentially applicable to prostheses modulating other peripheral nerves and functions.Trial registrationClinicalTrials.govNCT01923662, retrospectively registered August 15, 2013.

Acute Bilateral Lower Extremity Paralysis Secondary to Acute Thrombosis of an Infrarenal Abdominal Aortic Aneurysm

We present the case of a 64-year-old male who presented to the emergency department with bilateral limb ischemia and paralysis for approximately 1 hour. Computed tomographic angiography demonstrated occlusion of the infrarenal aorta beginning just above the patient’s known abdominal aortic aneurysm (AAA) and extending into both common iliac arteries. He was emergently treated via open repair of the AAA with a Gore-Tex tube graft, bilateral common iliac thrombectomies, and bilateral lower extremity four-compartment fasciotomies. Post-operatively, he had monophasic signals in both posterior tibial arteries, neither of which was present before the operation. During recovery, he developed an ileus but otherwise did not have complications. He was discharged to rehabilitation on post-operative day 15.

Acute Aortic Dissection Presenting as Bilateral Lower Extremity Paralysis: A Case Report

BackgroundFirst described by Morgagni in 1761, aortic dissection (AD) is an acute life-threatening and time-sensitive disease process with an increasing mortality approaching 1% for every 1-hour delay in diagnosis within the first 48 hours. Despite continued surgical advancement, overall in-hospital mortality remains significant (27.4%). Case ReportA 56-year-old woman presented to an outlying emergency department with a complaint of isolated lumbar pain associated with right lower extremity paresthesia and paralysis that progressed to the left. Her medical history and a review of symptoms were significant for chronic obstructive pulmonary disease and tobacco abuse. The initial evaluation in the emergency department included laboratory values and a computed tomography scan of the lumbar spine that revealed minimal disease. After transfer to our tertiary care center for an emergent magnetic resonance imaging scan of the lumbar spine, her vital signs were as follows: blood pressure, 176/84 mm Hg; heart rate, 76 beats/min; respiratory rate, 24 breaths/min; afebrile; and oxygen saturation 98% on room air. A repeat examination revealed cold extremities with mottling, bilateral symmetric lower extremity flaccid paralysis, and a loss of pulses and reflexes. She was insensate below the T10 dermatome. Her upper extremities and cranial nerves were normal. She underwent computed tomography angiography, revealing an extensive Stanford type A AD with interim thrombus formation. After successful endograft stenting, she died 24 hours later. Why Should an Emergency Physician Be Aware of This?Comprising <2% of all ADs, the pathophysiology of paraplegia as the initial presentation of AD is caused by compression of the anterior spinal artery, resulting in ischemia of the spinal cord. Acute AD is a life-threatening medical emergency that requires a high clinical level of suspicion because of its often variable presentation and high incidence of mortality.

FES-Rowing and Long-Term Reversal of Osteoporosis Following Spinal Cord Injury

Among the long-term consequences of spinal cord injury (SCI) is severe osteoporosis due to immobility and subsequent mechanical unloading of the paralyzed limbs. In fact, all individuals with motor complete SCI develop osteoporosis below the level of the injury. Unfortunately, physical therapy does not appear to have proven efficacy and there is no conclusive evidence supporting effective pharmacologic intervention for prevention and treatment. Recent advances in the application of functional electrical stimulation (FES) for rowing exercise provide a new and exciting opportunity to improve bone metabolism and to provide mechanical strain to the paralyzed lower limbs. Specifically, FES-row exercises use electrical stimulation of the paralyzed quads and hamstrings to actively engage both the arms and the legs in a full rowing cycle. However, while FES rowing exercise appears to be sufficient to stimulate new bone formation acutely, there are no longitudinal assessment of its long-term osteogenic effect. PURPOSE: To provide a case study of the longterm osteogenic effects of FES-Rowing after SCI resulting in bilateral lower extremity paralysis. METHODS: We obtained volumetric CT scans of proximal tibia and distal femur of an adult male (36 years old, normal BMI, T4 AIS A complete SCI, 13 years post-injury) who uses a wheelchair as primary mode of mobility and enrolled in an FES rowing program, at baseline and after 6 and 66 months of rowing exercise (12 days/month, 30 minutes/day at 150 bpm HR in the first 6 months, and 9 days/month, 25 minutes/day at 132 bpm in months 6–66). Subsequently, we estimated compressive bone strength via finite element analysis (9% margin of error). RESULTS: Compared to baseline, both femur and tibia were stronger (respectively, 37%/37% [Left/Right] and 55%/38%) after 6-months of FES-row exercise. Remarkably, this improvement was not only preserved, but also continued throughout the five years of exercise (46%/87% and 67%/54%, compared to baseline). CONCLUSION: These results suggest that FES rowing exercise is a sufficiently robust osteogenic stimulus for long-term prevention and reversal of osteoporotic changes after lower extremity paralysis, and warrant further long-term cohort studies. Supported by the Ellen R. and Melvin J. Gordon Center for the Cure and Treatment of Paralysis

A Unique Cutaneous Presentation of Burkitt Lymphoma

Few reports of cutaneous Burkitt lymphoma exist in the literature. Here, the authors describe the case of a human immunodeficiency virus-positive individual with the rare diagnosis of cutaneous Burkitt lymphoma. Three weeks before the development of his cutaneous lesions, the patient experienced bilateral lower extremity paralysis, and an epidural mass was found. Bone marrow biopsy findings and serum protein electrophoresis seemed consistent with multiple myeloma. The visible appearance of the skin lesions raised concern for cutaneous involvement by myeloma; however, the skin biopsy showed morphological and immunohistochemical features of Burkitt lymphoma. In this case report, the authors discuss the histopathologic findings of the cutaneous lesions in consideration with the bone marrow biopsy findings.

Vertebral Metastasis as the Initial Manifestation of Colon Cancer

Introduction: Traditionally, colon cancer is not thought to metastasize to bone, unlike breast, prostate, or lung cancers. In fact, both United States and European cancer society guidelines recommend against endoscopy in the work-up of adenocarcinoma of unknown primary, unless otherwise suggested by clinical symptoms, laboratory, or imaging findings. We would like to present 2 cases of colorectal cancer that presented solely as bony metastases. Case 1: A 34-year-old female presented with bilateral lower extremity paralysis and numbness for 1 day. The patient had an 8-month history of back pain. An MRI 1 month prior at an outside hospital showed a T11 vertebral lesion causing spinal canal stenosis and cord compression. She received outpatient follow-up until this new onset of symptoms, when she was transferred to our hospital for further management. Upon presentation, she was taken emergently for T10-11 laminectomy with biopsy of the vertebral lesion, which revealed adenocarcinoma. Subsequent CT of the chest, abdomen, and pelvis showed a 4.5-cm ascending colon mass, but no other signs of metastases. Colonoscopy with biopsy confirmed primary colonic adenocarcinoma. Case 2: A 61-year-old female presented with worsening pain and numbness of her upper extremities. Two months prior in Russia, she experienced severe neck pain, leading to discovery of a C5-6 compression fracture. She underwent decompression with a vertebral biopsy, which revealed adenocarcinoma. CT scans then revealed several pulmonary nodules, enlarged mediastinal lymph nodes, and lytic skull foci. Upon presentation to our hospital, spine MRI revealed cervical lesions and a T3 lesion with cord compression. CT scans for staging of her adenocarcinoma of unknown primary again revealed pulmonary nodules, as well as 4 hepatic metastases up to 2 cm and a 15-cm sigmoid colonic thickening concerning for neoplasm. Colonoscopy with biopsy confirmed primary colonic adenocarcinoma. Discussion: Based on the medical literature, colorectal cancer rarely metastasizes to bone. Studies with chart review of medical or autopsy records have reported an incidence of 2-24% and even lower, 1-2%, for isolated bony metastasis. Further, the bone metastases were almost always discovered after initiation of treatment for the colorectal cancer. Herein, we present 2 patients without gastrointestinal symptoms who both presented with spinal cord compression from vertebral metastases of adenocarcinoma, later revealed to originate from a colonic source. While we acknowledge its rare occurrence, these 2 cases underscore the importance of having colon cancer on the differential diagnosis for adenocarcinoma of unknown primary in the bone.

Two patients presenting with lower extremity paralysis and abnormal electrocardiogram

Acute bilateral lower extremity paralysis is a medical emergency frequently caused by spinal cord pathology. A few systemic diseases including metabolic and endocrine abnormalities, however, can also present with lower extremity paralysis. In such cases, an abnormal electrocardiogram can immediately point to a likely systemic etiology. In this report, we present 2 patients with a near carbon-copy presentation where previously healthy Hispanic men woke up in the morning not being able to get out of bed because of severe lower extremity weakness. In both cases, abnormal electrocardiograms on presentation pointed to the most likely diagnosis, which was quickly confirmed by simple laboratory testing. The appropriate evaluation and management of such patients are discussed.

診断治療に難渋した肥厚性硬膜炎の１例

We report a case of hypertrophic pachymeningitis in a 64 year-old female. On August, 1994, She developed headache and pyrexia and after two months, back and low back pain appeared. Pyogenic pachymeningitis was diagnosed by analysis of spinal fluid in an other hospital. Despite antibiotic treatment, paresis of bilateral lower extremities and dysuria appeared progressively. Manual muscle testing revealed grade 4-5 strength. Sensory disturbance occurred at S2-3 level. MRI showed compression on the left anterior side at Th11-L1. Laminectomy of Th11 to L1 was performed, but the patient's symptoms didn't improve. Sixteen days postoperatively, paralysis of bilateral lower extremities suddenly appeared. Repeat surgery with laminectomy of Th9 to L2 was performed. Markedly thickened dura compressing the cord was noted and this was partially excised. Hypertrophic dura was infiltrated by pathological lymphocytes and plasmacytes, and the pathological diagnosis was chronic hypertrophic pachymeningitis. After re-operation, steroids were administered and inflammation disappeared, however bilateral lower extremity paralysis didn't improve.This is a report of hypertrophic pachymeningitis which was difficult to diagnose and illustrates that steroids were effective in suppressing inflammation.

Painless dissection of the thoracic aorta

A 64-year-old man presented to an emergency department with a two-week history of intermittent, bilateral lower extremity paralysis without associated chest, abdominal, or back pain. He subsequently deteriorated and died as a result of a thoracic aortic dissection. This unusual case is reported, and the pathophysiology, diagnosis, and management of aortic dissection are discussed.