Introduction: Epidural hematoma has a double anatomopathological topography: intracranial and/ or spinal. Its etiology is complex: post-traumatic (spinal trauma, or lumbar puncture), iatrogenic (secondary to an inadequate anticoagulation or antiplatelet treatment), congenital or acquired disorders of coagulation (leukemia, hepatic cirrhosis), secondary to intense Valsalva maneuvers (e.g. during labor, or an intense physical effort), and idiopathic. The purpose of this article is to present a clinical case of acute spinal epidural hematoma (SEDH) with atypical clinical picture and a puzzled pathophysiological mechanism, and also a brief review of the relevant literature. Case presentation: An 80-years-old male patient, with locomotor disability (bilateral congenital foot deformity), and multiple cardiovascular comorbidities (chronic atrial fibrillation (AF), dilated cardiomyopathy and contractile dysfunction (chronic heart failure, with left ventricle ejection fraction 40 %), chronically anticoagulated with a vitamin K antagonist (acenocumarol). The elderly submitted a body-level fall without cranial trauma, event followed by a short loss of consciousness (without convulsions or sphincter relaxation). He suffered a low-energy cervical fracture (C7 vertebral injury) and a posterolateral acute SEDH at C3-Th2 vertebral levels. Decompressive hemilaminectomy at the C4-Th2 levels and evacuation of the SEDH, was performed during the early sub-acute phase. The patient was transferred in our rehabilitation clinic as C4 AIS-C tetraplegia (global motor score 50/100), neurogenic bladder and bowel, with post surgical wound dehiscence (healed per secundam). The subject had a favorable neurological evolution and was discharged as C7 AIS-D tetraplegia (global motor score 81/100). Discussion: The case particularity consists in a puzzled etiopathogenetic mechanisms and difficulty to accurately indicate the chronological chain of events generating the acute SEDH. An overdosed anticoagulant therapy might be incriminated as an iatrogenic cause for a "spontaneous" SEDH, but most probably its etiology is complex, probably traumatic, consequence of the cervical spine fracture due the low-intensity biomechanical impact. The complex predisposing circumstances to accidental fall in our elderly patient were due to the: -impaired, unstable locomotor function, secondary to his bilateral congenital clubfoot deformity / disability -chronic AF, contractile dysfunction and hypodiastolic phenomena, with cardiogenic syncope and global brain ischemia or transient ischemic cerebral attack. Despite the good immediate outcomes, his future functional prognosis might be poor, due to the advanced age, severe cardiovascular pathology and the complex disturbances of the neuro-myo-artro-kinetic apparatus (major impediments of the somatic / body functions and structure). This health-related condition had severe repercussions on the subject`s activity (related to tasks and basic activities of daily living) and participation, affecting the outcome of rehabilitat...
Introduction: The thoracolumbar junction (T11-L2) is biomechanically prone to spinal cord injuries (SCI), as it marks the transition from the rigid thoracic segment to the flexible lumbar spine. The damage of the spinal cord is due to a high-energy trauma (mainly motor vehicle accidents, falls from height, etc), in most cases resulting burst fractures of the lumbar region. The vertebral body is crushed in all directions, retro pulsed bony fragments are spread out towards the spinal canal, damaging the spinal cord, and causing neurologic injuries. Case report: This is a retrospective case study of a slim 43-year-old woman who suffered on 23.06.2018 a polytrauma (accidental fall from 3m height, from tree), associating thoraco-abdominal contusions, without cranial trauma and a severe L1 vertebral comminuted / burst fracture, followed by flaccid T12 AIS-A (complete) paraplegia. She underwent a complex neurosurgical approach, with a self-expandable metallic cage (Stryker) and posterior transpedicular stabilization for decompression and circumferential fusion in one stage, without cavity involvement. In an early post-acute stage she was admitted to the Rehabilitation Clinic (from 10.07.2018 until 31.08.2018) as a T12 AIS-C paraplegia (incomplete neurological lesion, with a global motor score 59/100; lower legs motor score 9/50 [4/25 R+5/25 L], with neurogenic bowel and bladder. The evolution was favorable and she was discharged as L2 AIS-D paraplegia (global motor score 70/100; lower legs motor score 20/50 [10/25 R+10/25 L]. Discussion: This case report emphasizes the benefits and functional outcomes after a comprehensive therapeutic approach, of a patient with unstable (burst) lumbar fracture, surgically managed with an expandable titanium vertebral cage implant with posterior transpedicular instrumentation, followed by a complex rehabilitation program, Stryker distractible vertebral body replacement implant is an expandable device, which can adapt to the patient`s anatomy, enabling the neurosurgeons to treat severe burst fractures. Rehabilitation objectives were focused on B-ADL independence (activity, component of the ICF-DH framework)-transfers, orthostatic posture, restore walking, bladder control. The vital prognosis and functional outcome were favorable. Although she was able to use a walking frame at discharge, there were a few drawbacks in what concerns the professional reintegration, due to specific external barriers (she was a military personnel, had neither driving licensee, nor an adapted car). Conclusions: This clinical case underlines the importance of a complex and multidisciplinary approach, prompt surgical intervention and rehabilitation during the early post-acute phase.
Introduction. Disc herniation occurs most commonly in the lumbar region (95% of the cases). The current trend is to have surgery on patients with disc herniation if the kinetic treatment was not beneficial. The data from the literature suggest that early active recovery after lumbar disc herniation is more beneficial than a traditional, less active training program. Material and method. Having the patient's consent and the approval of the Ethics Committee of “Bagdasar-Arseni” Clinical Emergency Hospital, N.O. 17464 / 14.06.2019, the paper presents the case of a 75-year-old patient with paraparesis after multilevel lumbar disc herniation, spinal canal stenosis and spondylolisthesis iteratively operated, in pluripathological context (hyperplastic type II obesity, hypertension, prostate adenocarcinoma operated in 2015, Clostridium enterocolitis). The patient was clinically and functionally evaluated, according to the standardized protocols implemented in our clinic, through the assessment scales (ASIA, FIM, FAC, QoL, Ashworth and Penn) and also paraclinically, in order to evaluate his biological reserve and his bearing availability of the recovery program. Results and discussions. The patient presented a slowly favorable evolution (slowed down not only by his multiple above-mentioned comorbidities) from a dysfunctional point of view. Conclusions. Early active recovery after lumbar disc herniation surgery is more beneficial than a traditional, less active training program for operated herniated discs. Keywords: Schizophrenia, spinal cord injury, multidisciplinary, suicide attempt, rehabilitation,
Introduction: Traumatic fractures of the spine are most common at the thoracolumbar junction and can be a source of great disability. Most of them occur due to motor vehicle injuries and falls from a height. Since these are high-velocity injuries, thoracolumbar fractures are commonly associated with other injuries like rib fractures, pneumo-hemothorax, and rarely great vessel injuries, hemopericardium and diaphragmatic rupture. Materials and Methods: In this article - having the patient and the THEBA Bioethics Committee approval (no. 3159/30.01.2020) – it is presented the case of a 26-year-old patient who suffered a polytrauma due to defenestration from the 10th floor - about 30 m high -resulted in thoraco-lumbar SCI associated with other severe injuries, hospitalized in Neuromuscular Clinical Division by transfer from the Neurosurgery Clinic of our hospital, for neuromotor recovery, presenting a L1 AIS/ Frankel C quadriplegia and neurogenic bladder. During the hospitalization, the patient presented psychomotor agitation, food and medication rejection, which is why repeated psychiatric evaluations were requested and performed. Following the recovery program, the patient's evolution was favorable: recovered the weight deficit, improved the motor control and sensitivity, the urethral indwelling catheter was suppressed and the intermittent catheterization program was started with later regaining of the micturition control. The patient was assessed functionally using the following scales: AIS/Frankel, modified Ashworth, Functional Independence Assessment (FIM), Life Quality Assessment (QOL), FAC International Scale, Independence Assessment Scale in Daily Activities (ADL/IADL). Results:The patient benefited from a complex program of neuromuscular rehabilitation, with a favorable evolution, with the increasing scores from the evaluated scales and, thus, with a final performance of walking with support on short distances, as well as a sphincter reeducation with the neurogenic bladder remission. Conclusions: Associating interdisciplinary approach with a customized rehabilitation program in a patient with an onset of psychotic disorder, polytraumatized by defenestration from the 10th floor, with thoraco-lumbar SCI and other severe injuries led to neuromotor and psychiatric improvements, and sphincter function reeducation with an important improvement in patient's quality of life. Keywords: neuromuscular rehabilitation, traumatic spinal cord injury, psychiatric disorder, polytrauma,
Introduction. Schizophrenia is a surprisingly common chronic psychiatric illness in the general population affecting 1 in 100 people worldwide. Although the symptoms widely differ from one case to another, schizophrenia is quite difficult to recognize because the patient can behave normally and appropriately in different social situations. Studies in the literature highlight that the majority of the patients with SCI and pre-existing schizophrenia have suffered accidents as a result of voluntary height adjustments. Also, 37.5% of the suicide attempts with SCI are caused by schizophrenia and depression. The main difficulties encountered in the recovery of these patients are the psychiatric manifestations. At the same time, the risk of suicide in patients with schizophrenia after suffering from SCI is higher than those with SCI without schizophrenia. Therefore, the recovery of the patients with SCI and schizophrenia is a complex process which requires the control of the psychiatric symptoms. A multidisciplinary team is required for such a purpose. Material and method. Having the patient's consent and approval of the Ethics Committee of “Bagdasar-Arseni” Clinical Emergency Hospital, N.O. 3159/30.01.2020, the paper presents the case of a 23-year-old female patient with AIS/ Frankel B flaccid paraplegia after TVML after falling from height (affirmative through window-suicide attempt) operated on, in a polytraumatic context. The patient is known with schizophrenia and she was being monitored by a psychiatrist at the time of the accident, but she voluntarily discontinued treatment during that period. The patient was clinically and functionally evaluated, according to the standardized protocols implemented in our clinic, through the assessment scales (ASIA, FIM, FAC, QoL, Ashworth and Penn) and also paraclinically, in order to evaluate her biological reserve and her bearing availability of the recovery program. Results and discussions. The patient presented a slowly favorable evolution (slowed down by her severe motor deficit, but also by her psychiatric symptoms such as affective ability with depressive, negative behavior, depersonalization). Conclusions. The main difficulties encountered in the recovery of these patients are the psychiatric manifestations. Therefore, the recovery of patients with SCI and schizophrenia is a complex process that first requires the control of psychiatric symptoms. A multidisciplinary team is required for such a purpose. Keywords: Schizophrenia, spinal cord injury, multidisciplinary, suicide attempt, rehabilitation,
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