Patients or Programs:A 69-year-old man on long-term warfarin and with incomplete paraplegia secondary to a spontaneous intradural hematoma. Program Description: The patient, traveling via airplane, developed sudden onset of low back pain before landing. He developed progressive weakness of his bilateral lower extremities and a large intradural hematoma that stretched from the tenth thoracic vertebra (T10) to the first lumbar vertebra (L1) was found on magnetic resonance imaging. He underwent emergent T10-L1 laminectomy, with decompression of the hematoma. On angiogram, he was found to have a dural arteriovenous fistula at T10. His injury was classified as incomplete L2 paraplegia with an American Spinal Injury Association classification of C. 13 days after surgery, the patient developed a painful, vesicular rash oriented in the left first sacral dermatome, diagnosed as herpes zoster. Setting: Tertiary care hospital spinal cord injury unit. Results: The rash was treated with silver sulfadiazine topical cream and then covered. Within 4 days after onset, the pain had resolved and all lesions had crusted over. Within 10 days, all lesions had resolved. No further exacerbations were noted. Discussion: Occurrences of herpes zoster exacerbations after neurosurgical procedures, although rare, have been noted in the past. However, a search of the medical literature reveals no specific case reports of zoster after evacuation of spontaneous dural arteriovenous fistula hemorrhage in a dermatome unrelated to the surgical incision. This case is also unique in that the affected dermatome was several segments below the lower limit of the patient's hematoma and laminectomy site but still in a dermatome affected by the spinal cord injury. Conclusions: Although uncommon, herpes zoster exacerbation in the setting of acute spinal cord injury secondary to spontaneous hemorrhage from a dural arteriovenous fistula and subsequent laminectomy may occur in dermatomes unrelated to the surgical incision. Program Description: Previous attempts at functional retraining were limited by upper limb (UL) weakness and hypertonia (Modified Ashworth Scale scores 3, 2, 2, 1 in shoulder adductors, elbow flexors, forearm pronators, wrist flexors, respectively. He was dependent in all activities of daily living and used a head-controlled power wheelchair (PWC) with supervision. In spite of receiving intrathecal baclofen therapy (224 mcg/d) significant spastic hypertonia in bilateral UL interfered with driving the PWC by using the hand controls. Limited biceps electromyography revealed sustained activity at rest and more so during attempts to extend the elbow, which suggests inappropriate biceps-triceps co-contraction. Diagnostic musculocutaneous nerve block decreased biceps hypertonia and increased active elbow extension. He received onabotulinumtoxinA (bilateral brachialis-brachioradialis, 50 U each; right biceps, 50 U; trapezius 75 U; pectoralis major, 75 U; pronator teres, 50 U), followed by functional electrical stimulation to triceps, stretching, an...
