Unique Rehabilitation Challenges in a Pediatric Spinal Cord Injury and Brachial Plexopathy related to Malignancy and Subsequent Oncologic Treatment: a case report
Conlee E, Smither F, Pirius L, Cossette K, Brandenburg J, Driscoll S
Mayo Clinic, Rochester, MN, United states
Introduction: A 17 year old right handed male with metastatic Ewing Sarcoma sustained a non-traumatic, incomplete cervical spinal cord injury (SCI) and right brachial plexopathy (BP). The combination of deficits and ongoing oncology treatment presented unique challenges for our pediatric patient.
Presentation: Initial right arm pain progressed to weakness all extremities. Imaging revealed a paraspinal C7 vertebral mass extending into the spinal canal and right brachial plexus. Pathology from surgical resection returned Ewing sarcoma. Bilateral lung metastases were identified.
Upon admission, the patient was unable to stand due to leg weakness and had a flaccid right arm though retained left hand function. His exam was consistent with an incomplete C4 injury (comparable to AIS D) with patchy sensation and increased lower extremity tone. His neurogenic bladder had been managed with an indwelling catheter. He was incontinent of stool. Comprehensive pediatric rehabilitation was initiated for his SCI while he was underwent chemotherapy. Working closely with the Pediatric Oncology team, he was admitted to acute inpatient rehabilitation with ongoing chemotherapy.
Therapeutic: Independence in self-cares and mobility was impacted by both his SCI and severe right BP. He was unable to catheterize himself even with adaptive aids. Although sterile technique was preferred, non-sterile technique was ultimately allowed by his Oncology team. Additional intermittent use of an indwelling catheter during chemotherapy was allowed because of significant diuresis. He was also intermittently neutropenic throughout his inpatient rehabilitation course. He developed urosepsis and anal mucositis, both of which were managed in coordination with Pediatric Oncology and Pediatric Infectious Disease.
Likewise, despite his immunocompromised state, the risk of infection with stool incontinence was felt to be higher than bowel management with rectal stimulation and enemas so his Oncology team also permitted this bowel regimen.
Follow-up: He transitioned to intermittent catheterization with modified independence or family assistance. He was continent of stool with every other day rectal stimulation and an enema. Furthermore, he experienced significant improvement in his physical functioning during an extended schedule of therapy.
Discussion: Not only was his SCI complicated by a near complete right BP, his chemotherapy predisposed him to infection risk associated with typical management strategies for neurogenic bladder and bowel. The communication between multiple medical and nursing services and the therapy team orchestrated chemotherapy during inpatient rehabilitation, maintaining appropriate therapy hours and patient participation, and avoiding need for transfer to acute hospital during episodes of acute medical issues.
As rates of cancer are lower in the pediatric population and responsible for fewer non-traumatic SCI, initial resistance to established practices of neurogenic bladder and bowel management was encountered. After shared discussion amongst care teams, a safe and manageable regimen was developed which facilitated early admission to inpatient rehabilitation, establishment of significant functional improvement, and continence of bowel and bladder.
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