(Kiosk 1) Close Monitoring of Functional Gains of Medically and Surgically Complex Patients in Acute Inpatient Rehabilitation Settings May Be as Important as the Intensive Therapies They Receive: A Case Report

Case Diagnosis: 62-year-old male with a thoracic epidural mass with resultant spinal stenosis.

Case Description or Program Description: Patient presented to the acute care service with bilateral lower extremity weakness, sensory deficits below T5, and urinary retention. MRI demonstrated a mid-thoracic epidural mass causing severe spinal stenosis and cord compression. Thoracic laminectomy with biopsy and evacuation was performed. Pathology of the mass was negative for malignancy and operative cultures grew Serratia marcescens. The patient was started on antibiotics and discharged to acute inpatient rehabilitation. The multidisciplinary rehabilitation team noted improvement in lower extremity motor strength but less than expected functional gains in mobility, persistent neurogenic bladder and bowel, and recurrent autonomic dysreflexia. Following discussion, a repeat MRI was obtained and revealed T5/6 osteomyelitis, L3/4 septic facet arthritis, and severe L4/5 stenosis. The patient was readmitted to neurosurgery service for debridement, discectomy, laminectomy, and spinal fusion in the thoracic and lumbar spine. Upon return to the rehabilitation service, patient progressed well functionally and at the time of discharge was ambulatory and had regained bladder and bowel function.

Setting: 18-Bed Acute Inpatient Rehabilitation Unit

Assessment/Results: Poor functional gains observed by the multidisciplinary rehabilitation team resulted in additional diagnostic work up. The findings led to surgical intervention and a significantly better outcome than would have been achieved had the additional work up not been pursued.

Discussion (relevance): This case demonstrates that the close monitoring of functional gains through frequent multidisciplinary assessments and strong communication between team members can lead to further diagnostic work up and acute interventions that favorably impact outcome.

Conclusions: Frequent multidisciplinary assessments and strong communication between disciplines in the acute rehabilitation setting may be as important as the intensive therapies themselves in optimizing long-term functional outcome. Patients with complex medical and surgical needs should be referred to acute inpatient rehabilitation for their post-acute care needs.