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Development of a Treatment Algorithm for Acute Flaccid Myelitis: A 31 Case-Series
Evelyn G Goodyear, BS1; Allison C Huffman, BS1; Tiam M Saffari, MD, PhD, MSc2; Julie West, PA3; Irina Kaptsan, MACPR2; Andrew L. O'Brien, MD, MPH2; Moore M Amy, MD4
1The Ohio State University, Columbus, OH; 2The Ohio State University Wexner Medical Center, Columbus, OH; 3Ohio State University Wexner Medical Center, Columbus, OH; 4Division of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, OH

Introduction: Acute flaccid myelitis (AFM) is a rare polio-like illness leading to weakness or paralysis of one or more limbs, largely affecting children. To date, AFM has affected an estimated 686 patients in the United States. An exact framework for treatment options of patients with AFM has not been established. The purpose of this study was to assess global care of a large cohort of AFM patients and establish a treatment algorithm for AFM patients based on time of presentation.
Materials and Methods A retrospective review was conducted to identify patients with AFM between 2014 to 2020 evaluated by the senior author. Demographic data, clinical disease course, multidisciplinary involvement and surgical details were extracted. Preoperative and postoperative outcomes were recorded. An algorithm was developed to describe treatment options for AFM patients based on time since diagnosis.
Results Thirty-one patients diagnosed with AFM were identified with an average age of 5.6 years. Twenty-three patients underwent surgical intervention at an average time from onset to nerve surgery of 11.7 4.6 months (average SD). At diagnosis, 48% of patients had all four extremities affected, 13% had bilateral lower extremities and 10% had bilateral upper extremities affected, respectively. Of the 23 surgical patients, 22 underwent nerve transfers for function, 19 underwent both nerve transfers and nerve decompression for function and pain, and one underwent nerve decompression only. Based on our clinical experience and the literature, a treatment algorithm was developed (Figure 1). Among our cohort, 9.7% presented to nerve clinic at less than 6 months, 48.4% presented between 6-12 months, and 41.9% presented after 12 months. Of the seven lower extremity surgical patients who were wheelchair-bound at presentation, five patients improved ambulation status. No complications were reported following surgical intervention.
Conclusions AFM patients may benefit from surgical treatment to reduce pain and improve function. Treatment options include nerve transfers and decompression depending on the time of presentation. Presentation timing is variable among patients and influences optimal management. A multi-disciplinary team is needed to provide long-term rehabilitation for limb length discrepancy, scoliosis and psychological therapy. Our proposed multidisciplinary framework supported by extensive clinical experience will provide physicians the necessary guidelines to treat patients based on their time from diagnosis. Figure 1: Treatment algorithm based on time of presentation


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