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An intrathecal baclofen pump (ITB) can provide significant relief from excessive spasticity and pain that is difficult to control. However, it is not without its drawbacks. We present a case of a young quadriplegic male who underwent ITB pump placement, suffering four years of transient episodes of severe spasticity with withdrawal symptoms. Multiple adjustments were made to his ITB pump dosing without relief. Extensive workup including interrogation of the pump, serial abdominal radiographs, and fluoroscopic catheter dye study revealed no abnormalities. Intraoperatively, it was discovered that the initial catheter anchoring occurred directly adjacent to the vertebrae, leading to a position-dependent catheter occlusion. He underwent the replacement of his ITB pump and catheter. During surgical revision, emphasis was placed on reducing the length of the catheter outside the spine, anchoring to the supraspinous fascia with avoidance of bony prominences or post-laminectomy sites. After surgery, the patient's spasticity improved, and at the eight-month follow-up, he had no complications, resulting in a mean baclofen dose of 300.2 µg/day. This report highlights the potential risk of life-threatening intrathecal baclofen withdrawal secondary to postural changes, providing technical considerations to prevent recurrences. It also raises awareness regarding patients who are more susceptible to transient catheter occlusion after a spinal cord injury.
RESUMEN
The most common complication of dorsal column spinal cord stimulator implantation is hardware migration. Spinal cord injury following paddle or percutaneous lead implant is rarely reported, with an overall incidence of 0.42%. This report describes a case of immediate post-operative incomplete paraplegia following implantation of one thoracic paddle electrode to address post-laminectomy pain syndrome. Despite emergent removal of the electrode, post-operative corticosteroids, and a course of inpatient rehabilitation, the patient discharged with persistent incomplete paraplegia. Although there is rare occurrence of spinal cord injury with spinal cord neuromodulation, it is important to recognize risk factors which may lead to similar devastating complications.
RESUMEN
Introduction: Spinal cord stimulation (SCS) has been established as a safe and effective alternative treatment for many conditions. This is a unique case involving SCS in spinal cord injury (SCI) patients with recurrent episodes of autonomic dysreflexia (AD). AD is a sympathetically driven reflexive hypertension in response to a noxious stimuli below the neurological level of spinal cord injury. There is currently limited research and literature regarding SCS application for AD. We present a unique case where pain-induced AD was successfully treated with implantation of SCS, in order to avoid long term opioid use and improve quality of life. Case presentation: We present a 46-year-old female, with history of chronic incomplete traumatic quadriplegia, with increased frequency of symptomatic AD. After an extensive work-up, it was determined that the likely trigger for the AD episodes was neuropathic and nociceptive pain below the level of the spinal cord injury. Due to the frequency of AD episodes, uncontrolled pain, and concerns of long term opioid usage, she was referred for an evaluation for possible SCS placement. The patient ultimately underwent SCS implantation and battery revision. She had significant improvement of AD episodes after SCS implantation. Conclusion: This case identifies a unique approach to preventing AD episodes by addressing intractable neuropathic pain with SCS.
RESUMEN
INTRODUCTION: Spinal cord infarction in a young, otherwise healthy individual is a rare occurrence. The anterior spinal artery and posterior spinal arteries are the primary contributors to the vascular supply of the cervical supply, and these arteries arise as descending branches of the vertebral arteries. Historically, many cases have demonstrated individual variations in the vertebral arteries, such as differences in dominancy, patency, origin, and insertion. The clinical significance of these variations remains poorly understood. CASE PRESENTATION: We present a patient who sustained a spinal cord infarction at C2-C5 resulting in incomplete quadriplegia. The mechanism of injury was unclear, although the patient reported an awkward jumping motion earlier that day that preceded the onset of upper extremity weakness. After resolution of the acute phase, he was diagnosed with "Man-in-the-Barrel" syndrome. Angiographic evaluation revealed an anomalous non-dominant right vertebral artery with several pathological features: origin at the descending aorta, insertion into the right posterior inferior cerebellar artery, and impingement along its course by an anterior thoracic osteophyte. DISCUSSION: The vertebral arteries play an important role in the vascular supply of the cervical spine. While vertebral artery pathology such as dissection or occlusion have been documented in rare cases to result in spinal cord infarction, this case illustrates an example of clinically significant sequelae that can occur in the setting of anomalous vertebral arteries even in the absence of occlusion or dissection. Furthermore, to our knowledge this is the first reported case of a spinal cord infarction resulting from osteophytic vertebral artery impingement.