US Service Members With Polytrauma
Case #1: History
A 33-year-old active duty soldier in the US Army fell from a height of 2 feet, hitting his low back on the edge of a bench 12 years ago. At the time, he complained of sharp pains in his left lower back brought on by running, and tingling in his left leg with prolonged standing, which did not improve with physical therapy or chiropractic sessions. A lumbar spine magnetic resonance imaging (MRI) performed 6 months after the fall demonstrated L5-S1 disc desiccation and a posterior disc bulge extending to the left and causing compression of the left S1 nerve root in the lateral recesses.
Over the next 6 months, the patient continued to have lower back pain and started complaining of urinary incontinence. Due to his worsening symptoms, he underwent an uncomplicated left lumbar L5-S1 microdiscectomy with hemilaminectomy 1 year after his initial injury. However, the patient’s lower back pain, left lower extremity numbness, and urinary incontinence continued post-surgery. Four years later, the patient was re-evaluated for persistent and worsening lower back pain that radiated down the posterior aspect of his left leg into the sole of his foot, with associated numbness in the sole of his left foot. The pain interfered with his daily routines, prevented him from working, and resulted in the use of a single point cane to ambulate short distances and a wheelchair to ambulate longer distances.
On examination, the patient had 5/5 motor strength throughout, decreased sensation to light touch in the distribution of the left S1 dermatome, hyperreflexia in the lower extremities except for an absent left ankle reflex, and a noticeably antalgic gait.
Workup and Treatment
The patient had a lumbar computed tomography (CT) myelogram, which showed a soft tissue density, consistent with a post-surgical scar, within the left lateral recess at L5-S1 with slight compression of the left S1 nerve root, demonstrated by lack of contrast around the nerve root, and degenerative disc disease at L5-S1. An MRI of the lumbar spine (Figure 1) corroborated this finding. Nerve conduction studies and electromyogram suggested left S1 radiculopathy. The patient was evaluated by a neurosurgeon, who recommended non-surgical treatment. He was prescribed hydrocodone and acetaminophen (Vicodin), ibuprofen, amitriptyline, and tramadol, which did not adequately relieve his pain. The patient was later started on gabapentin, which provided little additional relief.
Traumatic Brain Injury
The patient was involved in a motorcycle accident and sustained multiple injuries, including a severe traumatic brain injury (TBI), 10 years after his initial back injury. He had been driving with his helmet on, and was found unconscious in a ditch near his motorcycle. His Glasgow Coma Scale score at the scene was 6 and he was intubated in the field. CT of the head demonstrated a subdural hematoma in the parafalcine area. Full evaluation of the patient also revealed pneumomediastinum, right second and third and left first rib fractures, fracture of the distal end of the right clavicle, right adrenal hematoma, facial lacerations, right periorbital ecchymosis, and right elbow abrasions. The patient did not require any neurosurgical intervention. At the time of the accident, he was taking diclofenac (Voltaren), morphine controlled-release (MS Contin), and oxycodone for his ongoing lower back and left lower extremity pain.
One week after the patient’s accident, he was transferred to the Polytrauma Rehabilitation Center at the Richmond Veterans Affairs (VA) Hospital for continued care and rehabilitation. Early during the patient’s admission, his primary pain complaints were right shoulder pain from the fractured clavicle, and migraine headache. He denied any lower back or left lower extremity pain, although his home pain medications (morphine and oxycodone) were continued. His migraine headaches were pre-morbid and had been previously treated with sumatriptan (Imitrex). On the polytrauma unit, the patient was initially placed on topiramate (Topamax) for migraine prophylaxis, but sumatriptan was added for refractory and persistent migraine headaches. His right shoulder pain interfered most with his therapies and functional progress. For this injury, he wore a right arm sling and was started on a topical lidocaine patch (Lidoderm) with some relief. His physicians were able to wean down his dose of oxycodone.
Seventeen days post-injury, the patient’s post-traumatic amnesia (inability to form new memories) resolved. He started to remember more about his premorbid issues, such as his history of headaches and back pain. The patient recalled that he had headaches in the past and noted that they were still present. He stated that he remembered having lower back pain but that it was not as apparent anymore. It was also noted that he had much more insight into his brain injury and was remembering his day-to-day activities better, as well as seeming to be less confused. His main complaint continued to be right shoulder pain. The patient did complain of occasional back pain, for which he modified his activities. His dose of oxycodone was further weaned and his physicians were able to wean him off the morphine altogether.
The patient was transferred to the Polytrauma Transitional Rehabilitation Program for community reintegration. While participating in the program, he started experiencing worsening of his low back pain after no specific inciting event. As he gained more insight and awareness about his past history and current deficits, he voiced concerns of more pain. Upon further discussion with the program psychologists in addition to physical therapy, the patient’s pain improved. Five months after his discharge, his outpatient pain medication regimen consisted only of twice daily tramadol.
Case #2: History
A 38-year-old soldier whose vehicle was hit by an improvised explosive device (IED) while on patrol, resulting in right below the knee amputation (BKA), post traumatic stress disorder (PTSD), and mild TBI, was seen in our clinic with complaints of residual limb pain and headaches. On further questioning it was noted that he had difficulty sleeping and his PTSD interfered with many activities. The limb pain (neuroma) was present with or without his prosthesis, but was most painful when pressure was applied to the residual limb. His headaches began in his posterior neck and radiated forward, occasionally coming up to the temple area.
Past treatments for his headaches included massage with mild, but no lasting, benefit; occipital nerve injections without any benefit; botulinum toxin injections without benefit; as well as physical therapy with a home exercise program that did decrease the number of headache flairs. He was enrolled in the mental health clinic both while on active duty and upon transition to the VA. His treatment included duloxetine (Cymbalta) and psychological interventions. He improved with these interventions; however, he continued to experience very disrupted sleep primarily due to nightmares. He reported approximately 4 hours of interrupted sleep nightly. Initially, he underwent treatment with amitriptyline followed by zolpidem (Ambien); however, he requested discontinuation due to sedation and weight gain.