11/121. self-injurious behavior as a challenge for the dental practice: a case report.patients who present self-injurious behavior (SIB) can be considered a treatment challenge in the dental office or hospital setting. Oral structures can play various roles in the process of self injury. In this paper, the authors report a case of SIB in the form of cheek-biting on an adolescent with a history of hydrocephalus and developmental delay, which was successfully treated with a modified standard maxillary orthodontic retainer. Early detection and intervention in SIB cases in patients with developmental disabilities influence the successful outcome of the therapeutic interventions, enhancing the patient's quality of life.- - - - - - - - - - ranking = 1keywords = injury (Clic here for more details about this article) |
12/121. baclofen withdrawal following removal of an intrathecal baclofen pump despite oral baclofen replacement.Intrathecal baclofen is used as a muscle relaxant and antispasmodic in cases of spasticity resulting from central nervous system trauma. The baclofen withdrawal syndrome may include hyperthermia, tachycardia, hypertension, seizures, altered mental status, and psychomotor agitation. We report a case in which the removal of a baclofen pump lead tothe development of severe withdrawal symptoms despite oral baclofen replacement therapy. In order to avoid the development of withdrawal, adequate doses of GABA agonist agents should be administered immediately prior to, and following, baclofen pump removal.- - - - - - - - - - ranking = 0.001830301005833keywords = trauma (Clic here for more details about this article) |
13/121. Bladder stones - red herring for resurgence of spasticity in a spinal cord injury patient with implantation of Medtronic Synchromed pump for intrathecal delivery of baclofen - a case report.BACKGROUND: Increased spasms in spinal cord injury (SCI) patients, whose spasticity was previously well controlled with intrathecal baclofen therapy, are due to (in order of frequency) drug tolerance, increased stimulus, low reservoir volume, catheter malfunction, disease progression, human error, and pump mechanical failure. We present a SCI patient, in whom bladder calculi acted as red herring for increased spasticity whereas the real cause was spontaneous extrusion of catheter from intrathecal space. CASE PRESENTATION: A 44-year-old male sustained a fracture of C5/6 and incomplete tetraplegia at C-8 level. Medtronic Synchromed pump for intrathecal baclofen therapy was implanted 13 months later to control severe spasticity. The tip of catheter was placed at T-10 level. The initial dose of baclofen was 300 micrograms/day of baclofen, administered by a simple continuous infusion. During a nine-month period, he required increasing doses of baclofen (875 micrograms/day) to control spasticity. X-ray of abdomen showed multiple radio opaque shadows in the region of urinary bladder. No malfunction of the pump was detected. Therefore, increased spasticity was attributed to bladder stones. Electrohydraulic lithotripsy of bladder stones was carried out successfully. Even after removal of bladder stones, this patient required further increases in the dose of intrathecal baclofen (950, 1050, 1200 and then 1300 micrograms/day). Careful evaluation of pump-catheter system revealed that the catheter had extruded spontaneously and was lying in the paraspinal space at L-4, where the catheter had been anchored before it entered the subarachnoid space. A new catheter was passed into the subarachnoid space and the tip of catheter was located at T-8 level. The dose of intrathecal baclofen was decreased to 300 micrograms/day. CONCLUSION: Vesical calculi acted as red herring for resurgence of spasticity. The real cause for increased spasms was spontaneous extrusion of whole length of catheter from subarachnoid space. Repeated bending forwards and straightening of torso for pressure relief and during transfers from wheel chair probably contributed to spontaneous extrusion of catheter from spinal canal in this patient.- - - - - - - - - - ranking = 5keywords = injury (Clic here for more details about this article) |
14/121. cyproheptadine for intrathecal baclofen withdrawal.OBJECTIVE: To evaluate the efficacy of cyproheptadine in the management of acute intrathecal baclofen (ITB) withdrawal. DESIGN: Descriptive case series. SETTING: University hospital with a comprehensive in- and outpatient rehabilitation center. PARTICIPANTS: Four patients (3 with spinal cord injury, 1 with cerebral palsy) with implanted ITB infusion pumps for treatment of severe spasticity, who had ITB withdrawal syndrome because of interruption of ITB infusion. INTERVENTIONS: patients were treated with 4 to 8mg of cyproheptadine by mouth every 6 to 8 hours, 5 to 10mg of diazepam by mouth every 6 to 12 hours, 10 to 20mg of baclofen by mouth every 6 hours, and ITB boluses in some cases. MAIN OUTCOME MEASURES: Clinical signs and symptoms of ITB withdrawal of varying severity were assessed by vital signs (temperature, heart rate), physical examination (reflexes, tone, clonus), and patient report of symptoms (itching, nausea, headache, malaise). RESULTS: The patients in our series improved significantly when the serotonin antagonist cyproheptadine was added to their regimens. fever dropped at least 1.5 degrees C, and heart rate dropped from rates of 120 to 140 to less than 100bpm. Reflexes, tone, and myoclonus also decreased. patients reported dramatic reduction in itching after cyproheptadine. These changes were associated temporally with cyproheptadine dosing. DISCUSSION: Acute ITB withdrawal syndrome occurs frequently in cases of malfunctioning intrathecal infusion pumps or catheters. The syndrome commonly presents with pruritus and increased muscle tone. It can progress rapidly to high fever, altered mental status, seizures, profound muscle rigidity, rhabdomyolysis, brain injury, and death. Current therapy with oral baclofen and benzodiazepines is useful but has variable success, particularly in severe cases. We note that ITB withdrawal is similar to serotonergic syndromes, such as in overdoses of selective serotonin reuptake inhibitors or the popular drug of abuse 3,4-methylenedioxymethamphetamine (Ecstasy). We postulate that ITB withdrawal may be a form of serotonergic syndrome that occurs from loss of gamma-aminobutyric acid B receptor-mediated presynaptic inhibition of serotonin. CONCLUSION: cyproheptadine may be a useful adjunct to baclofen and benzodiazepines in the management of acute ITB withdrawal syndrome.- - - - - - - - - - ranking = 30.952085706247keywords = brain injury, brain, injury (Clic here for more details about this article) |
15/121. Cutaneous stimulation improves function of a chronic patient with cerebellar damage.The prognosis of cerebellar hemorrhage with brain stem compression is known to be poor, and patients who can usually survive are severely disabled with limited benefit from conventional rehabilitation. An innovative cutaneous stimulation was administered to a chronic patient (2 years after the incidence) who has severe ataxia, gait imbalance and limb spasticity caused by cerebellar hemorrhage. After 8 months of intervention, patient's function as evaluated by two functional measures has improved by 40%. In addition, the patient's ataxia and hypotonia have improved significantly in which he has regained the abilities to grasp objects, sit upright, control his equilibrium, and monitor an electric wheelchair. The present case study demonstrated a significant improvement of a chronic severely disabled patient who received the intervention 2 years after the accident, suggesting that the cutaneous stimulation may be a possible effective neurologic intervention.- - - - - - - - - - ranking = 1.0120562068147keywords = brain (Clic here for more details about this article) |
16/121. Breathlessness associated with abdominal spastic contraction in a patient with C4 tetraplegia: a case report.A tetraplegic patient with C4 cervical cord injury reported breathlessness during episodes of spastic contraction of the abdominal muscles. To determine the mechanism, we performed electrophysiologic testing of the phrenic nerves. We measured abdominal pressure, esophageal pressure, and transdiaphragmatic pressure (Pdi) during a maximal inspiratory effort (Pdi max), a maximal sniff maneuver (sniff Pdi) during resting breathing, and during the episodes of breathlessness. Electrophysiologic testing of the phrenic nerves showed axonal neuropathy on the left. Sniff Pdi and Pdi max were 38cmH(2)O and 42cmH(2)O, respectively. Transient spastic contractions of abdominal muscles were associated with an increase in abdominal pressure greater than 30cmH(2)O, with a decrease in abdominal volume; this rise in abdominal pressure was transmitted to the esophageal pressure. Inspiration became effective only when esophageal pressure fell below the resting baseline value. Achieving this decrease required an increase in inspiratory effort, characterized by swings in esophageal pressure and Pdi of 30cmH(2)O and 40cmH(2)O (approximately 100% of Pdi max), respectively. During these periods, minute ventilation was markedly reduced. This is the first report that spastic abdominal muscle contractions can impose a significant load on the diaphragm, uncovering moderate diaphragmatic weakness. This has important clinical implications; abolition of the spastic abdominal muscle contraction in this patient completely resolved her intermittent respiratory symptoms.- - - - - - - - - - ranking = 1keywords = injury (Clic here for more details about this article) |
17/121. Atypical paraneoplastic syndrome associated with anti-Yo antibodies.OBJECTIVE: Polyneuropathy, myopathy and spasticity have not been described as a manifestation of a neurologic paraneoplastic syndrome (NPS) associated with anti-Yo antibodies (anti-Yo). CASE history: The patient is a 60-year-old woman with a history of ovarectomy, salpingectomy, hysterectomy and omentectomy because of ovarian cancer with peritoneal carcinosis. From May to September 1999, she received chemotherapy with carboplatin and docetaxel. In June 1999, weaknesses of the lower limbs began to appear. Neurologic investigation revealed bilateral ptosis with right-sided predominance, exaggerated deep tendon reflexes, discrete distal weakness, wasting of the upper limbs and diffuse weakness of the lower limbs. She had slight CK elevation, elevated lactate dehydrogenase and aldolase levels. Testing for anti-neuronal antibodies revealed high serum titers of antibodies against the cytoplasm of purkinje cells, confirmed as anti-Yo by immunoblot with recombinant proteins. CSF investigations showed 12/3 cells and positive oligoclonal bands. MRI of the brain showed bilateral, old ischemic basal ganglia lesions exclusively. Visually evoked potentials gave prolonged P100 latencies bilaterally. Nerve conduction studies and electromyography revealed motor polyneuropathy of the lower limbs. Muscle biopsy from the right anterior tibial muscle showed non-specific myopathic features. CONCLUSION: Polyneuropathy, myopathy and tetraspasticity may be the exclusive manifestations of an atypical NPS associated with anti-Yo. Anti-Yo may persist for years without relapse of the primary tumor.- - - - - - - - - - ranking = 1.0120562068147keywords = brain (Clic here for more details about this article) |
18/121. Managing spasticity in spinal cord injury: safe administration of bridge boluses during intrathecal baclofen pump refills.Intrathecal baclofen now plays an important role in the management of spasticity in a number of neurologic conditions including spinal cord disorders. Dosage errors can be a source of significant morbidity and the risk is greatest when the clinician is changing solution concentration. When changing concentrations, it is imperative to program the pump correctly by incorporating a bridge bolus to compensate for the residual baclofen solution in the pump and catheter. This paper reviews the appropriate methods to safely calculate the bridge bolus, with an illustrative example.- - - - - - - - - - ranking = 4keywords = injury (Clic here for more details about this article) |
19/121. Sectorial posterior rhizotomy, a new technique of surgical treatment for spasticity.After their experience of Foerster's operation and its technical modifications in 80 cases the authors report a new concept of analysis and treatment of spasticity in lower limbs. Spasticity of the different muscle groups is classified either as "useful spasticity" or "handicapping spasticity". The first has to be preserved, the second must be reduced. In order to achieve this purpose a new technique is presented, based on operative sectorial identification of the posterior rootlets subserving the "handicapping spasticity" by electrophysiological stimulation, muscle testing, and E.M.G. studies. The conus medullaris and cauda equina are exposed by T 11-L 1 laminectomy, performed in the lateral position. The clinical and E.M.G. evaluation of responses to stimulation enables the surgeon to establish a map of rootlet groups which are marked with coloured threads. Selective resection of "handicapping posterior rootlets" is then performed after several tests of the mapping. The rootlets subserving useful spasticity are carefully preserved. Ten cases are reported, comprising five cases of cerebral palsy operated upon since 1974 and five cases of posttraumatic spastic paraplegia from the same period. Pre and postoperative findings are summarized. The technical features of this procedure are discussed and compared with other surgical procedures. The problem of the rootlet reflex arch is considered in the light of the effects of stimulation of anterior and posterior rootlets at the same level.- - - - - - - - - - ranking = 0.001830301005833keywords = trauma (Clic here for more details about this article) |
20/121. clonidine in the treatment of brainstem spasticity. Case report.This report describes a patient who developed spasticity after a medullary infarct. No improvement in her spasticity was achieved by baclofen therapy and the side effects of the drug necessitated its gradual withdrawal. Recent reports of the success of clonidine in the management of spasticity due to spinal cord injury prompted an attempt at clonidine therapy. When clonidine therapy was initiated, the patient responded rapidly with both subjective and objective improvements in her spasticity. This case suggests a potential role for clonidine in the treatment of spasticity resulting from brainstem infarction.- - - - - - - - - - ranking = 6.0602810340736keywords = brain, injury (Clic here for more details about this article) |
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