Disclosures: Prathusha Maduri, DO: No financial relationships or conflicts of interest

Case Diagnosis: Hemi-Medullary (Reinhold) Syndrome

Case Description: A 9-year-old girl presented for evaluation of left hemiparesis. She was healthy until age 5 when she fell onto a pencil resulting in a penetrating trauma into her right neck. Neurosurgical evaluation deemed pencil extraction too risky and was left intact. After prolonged hospitalization complicated by coma, she was discharged home with therapy services.

Setting: Outpatient Academic Teaching HospitalAssessment/

Results: In the outpatient clinic, her exam showed a small scar on the right posterior neck, dysarthria, mild right tongue deviation, left-sided weakness (3/5) with lower extremity spasticity (Modified Ashworth Scale 3+ at gastroc-soleus), toe walking, left arm/hand dystonic movements, positive Hoffman’s sign and hyperreflexia 3+. Botulinum toxin injections improved her spasticity, but also unexpectedly improved her dystonic left-hand movements. Additionally, virtual reality (VR) use was a unique approach to pain control during her injections as she was initially having difficulty laying still. An AFO and resting left-hand splint also improved her range of motion and gait. She is now age 12 with only mild left-sided motor deficits, dystonia, and spasticity for which she continues to receive Botulinum toxin injections.

Discussion: This unusual mechanism of brain injury led to Hemi Medullary (Reinhold) syndrome, a rare disease, with about 10 reported cases. It is caused by medial and lateral medullary ischemia due to vertebral artery occlusion proximal to the anterior spinal artery. It presents with mixed lateral and medial medullary syndrome symptoms such as contralateral hemiparesis and hemi-sensory loss, ipsilateral ataxia, Horner’s syndrome, facial sensory loss, and dysarthria. Unexpectedly, this patient had concurrent spasticity and dystonic, writhing left-hand movements.

Conclusion: The mechanism of injury resulted in unusual dystonic spasticity for which botulinum toxins proved helpful. This case also suggests that the use of VR may be an alternative way to encourage cooperation in children who present with spasticity and dystonic movements.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/penetrating-neck-injury-by-a-pencil-in-a-child-causing-spasticity-and-dystonia-a-case-report/