Jeffrey L. Cole

Piriformis syndrome, diagnosis and treatment

Piriformis syndrome (PS) is an uncommon cause of sciatica that involves buttock pain referred to the leg. Diagnosis is often difficult, and it is one of exclusion due to few validated and standardized diagnostic tests. Treatment for PS has historically focused on stretching and physical therapy modalities, with refractory patients also receiving anesthetic and corticosteroid injections into the piriformis muscle origin, belly, muscle sheath, or sciatic nerve sheath. Recently, the use of botulinum toxin (BTX) to treat PS has gained popularity. Its use is aimed at relieving sciatic nerve compression and inherent muscle pain from a tight piriformis. BTX is being used increasingly for myofascial pain syndromes, and some studies have demonstrated superior efficacy to corticosteroid injection. The success of BTX in treating PS supports the prevailing pathoanatomic etiology of the condition and suggests a promising future for BTX in the treatment of other myofascial pain syndromes. Muscle Nerve, 2009

Reinnervation of the Paralyzed Diaphragm: Application of Nerve Surgery Techniques Following Unilateral Phrenic Nerve Injury

BACKGROUND Unilateral phrenic nerve injury often results in symptomatic hemidiaphragm paralysis, and currently few treatment options exist. Reported etiologies include cardiac surgery, neck surgery, chiropractic manipulation, and interscalene nerve blocks. Although diaphragmatic plication has been an option for treatment, the ideal treatment would be restoration of function to the paralyzed hemidiaphragm. The application of peripheral nerve surgery techniques for phrenic nerve injuries has not been adequately evaluated. METHODS Twelve patients presenting with long-term, symptomatic, unilateral phrenic nerve injuries following surgery, chiropractic manipulation, trauma, or anesthetic blocks underwent a comprehensive evaluation, including radiographic and electrophysiologic assessments. Surgical treatment was offered following a minimum of 6 months of conservative management. Operative planning was based on preoperative and intraoperative testing using one or more established nerve reconstruction techniques (neurolysis, interpositional grafting, or neurotization). RESULTS Measures of postoperative improvement included pulmonary function testing, fluoroscopic sniff testing, and a standardized quality-of-life survey, from which it was determined that eight of nine patients who could be completely evaluated experienced improvements in diaphragmatic function. CONCLUSIONS Based on the favorable results in this small series, we suggest expanding nerve reconstruction techniques to phrenic nerve injury treatment and propose an algorithm for treatment of unilateral phrenic nerve injury that may expand the current limitations in therapy.

Investigating the Ability of Knee OA Patients to Maintain Targeted Knee Flexion Angles for Weight Bearing MRI

Knee osteoarthritis (OA) is the most common clinical presentation of osteoarthritis, and has been estimated to affect 12–16% of the population older than 60 years in the US [1]. A biomechanical risk factor that has been linked to knee OA is the changes in the local loading and the contact area between the cartilage surfaces [2]. Investigation of such factors requires precise measurement tools to determine knee joint positioning and contact areas. Clinically, MR images of the knee are most frequently acquired in the supine position; such images are not representative of the loading conditions experienced functionally in the weight bearing knee joint. With the advent of vertically open MRI (e.g. Upright MRI, Fonar Corporation, Melville, NY), it is now possible to scan the knee in fully upright weight bearing conditions representing truly functional positions. To measure sensitive variables such as joint positioning and cartilage contact, it is important to minimize subject movement in order to obtain high quality images. In MRI, increased scan times allow for data of improved signal to noise ratio and resolution; however, long scanning durations without subject movement are not feasible, particularly in individuals with symptomatic knee OA.Copyright

Poster 408: Patient-Administered Sphenopalatine Ganglia Block: A Case Report

Disclosures: Natasha Mehta: I Have No Relevant Financial Relationships To Disclose Case/Program Description: Sphenopalatine ganglia (SPG) is suspended in the pterygopalatine fossa with sympathetic, parasympathetic, and somatosensory contributions from the superior cervical ganglion, greater petrosal nerve, and maxillary nerve, respectively. This ganglion has been linked to trigeminal autonomic cephalgias and migraines. Few patients are refractory to conservative treatments. SPG blocks have been utilized for pain management in these cases. A 54-year-old woman presented with photo-oculodynia syndrome and cluster-type hemicephalgias that initially improved with vocational modifications. Over the years she failed monotherapies, including oxygen, but had partial relief with topirimate, oxcarbazepine, gabapentin, and naproxen. She still experienced functionally debilitating photophobia, atypical facial pain, and trigeminal neuralgia. Exam significant for photophobia producing severe right ocular headaches. Setting: Outpatient Rehabilitation Center. Results: Transnasal SPG blocks improved visual convergence and drilling facial pain. She was taught self-administration of SPG blocks with lidocaine applied with Q-Tips every other day and photo-oculodynia exacerbations gradual improved. Over the last 2 years she regained tolerance for sunlight and fluorescent lights without the need for shading. Discussion: The SPG is accessible via a transnasal approach posterior to the middle turbinate, lateral approach through the infratemporal fossa, or transoral approach through the greater palatine foramen. Adverse effects of intranasal approach with anesthetic include epistaxis, dysesthesia, and temporary diplopia. Due to the rare risk of anesthetic toxicity or infection, this patient started with 1% lidocaine solution. The transoral and lateral approaches are complex, sometimes done with imaging guidance. The transnasal approach is technically simpler and can be taught to the correctly selected patient. Conclusions: SPG blocks have been successfully performed for over a century, utilizing various agents or neuromodulation. Limitations to topical hydrophobic anesthetic are duration of effect and accuracy. There have been case reports of cumulative relief over time with repetitive SPG blocks. This person was able to learn the technique to perform independently as needed. Level of Evidence: Level V

Poster 258 Preserved Bulbocavernosus Reflex in a Patient with Tethered Cord Syndrome: A Case Report

Participants: Patient with brachial plexopathy of non-dominant upper extremity, patient’s wife, a team of 5 seniors majoring in Mechanical Engineering with 1 member double majoring in fine arts, a nurse specialist in rehabilitation, an occupational therapist with expertise in assistive technology, and a physiatrist. Interventions: Face-to-face encounters supplemented by video conferences. SolidWorks computer program was used to create images of the various iterations. 3D printing was used to fabricate the parts to be assembled. Main Outcome Measures: Patient perception of ease of use. Results or Clinical Course: A novel combination of magnets and interlocking parts were created to make a simple and reliable means for bringing the two ends of the jacket or coat together to bring the zipper ends together. The two-piece system is small enough to carry in a pocket of a jacket or coat. Total expenditures to make the device were less than

Poster 234 Vaginal Numbness and Sexual Dysfunction as Presenting Symptoms of a Grade III L6-S1 Spondylolisthesis: A Case Report

1000 dollars and the project was completed within 16 weeks. Conclusion: A one handed system for zipping up a jacket or coat was successfully accomplished by a team of mechanical engineering students. Employing computer aided designs and 3D printing to make prototypes that could be tested and refined, they made a simple and reliable device for a one-armed man to use. Investigations are underway to explore the usefulness of the device for other patients such as stroke survivors and amputees.

Evaluation of Diaphragm Dysfunction in a Patient with Dyspnea: A Case Report

Disclosures: I. P. Syrop: I Have No Relevant Financial Relationships To Disclose. Case Description: For the treatment of recurrent well-differentiated liposarcoma of the abdomen, a 65-year-old man was treated with a course of intravenous (IV) gemcitabine/docetaxel. Following infusion of docetaxel via a left antecubital IV catheter, the patient noticed redness surrounding the IV insertion site. Erythema worsened over the next week, associated with pain and weakness in the left hand, specifically in the first and second digits. Over the next month, the erythema improved while the weakness worsened. At four weeks post extravasation, the patient presented to an outpatient rehabilitation center. Physical examination was pertinent for LUE strength of 4/5 in wrist extension/flexion, 4-/5 in extension/flexion of digits 1, 2, 3 and near normal strength of digits 4 and 5. Sensation was decreased in both the palmar and dorsal aspects of the left hand, most noticeably in digits 1 and 2. The patient was prescribed OT for strengthening and ROM of the LUE and referred for electrodiagnostic studies. Setting: Academic outpatient rehabilitation center. Results or Clinical Course: At 6 weeks post extravasation, the patient had electrodiagnostic studies performed. Findings were consistent with chronic, incomplete, left median and radial mononeuropathies at the elbow, with the median more affected compared to the radial nerve. These findings were superimposed over a mild, more generalized, sensorimotor polyneuropathy. Discussion: This is the first reported case, to our knowledge, of a median and radial neuropathy secondary to docetaxel extravasation. Compressive peripheral neuropathy has been shown to occur with IV extravasation, however there is sparse literature describing neuropathy resulting from chemically noxious injuries from extravasation of chemotherapeutic agents. This case adds to the overall literature of vesicant chemotherapy complications. Conclusion: Median and radial neuropathies are a potential side effect secondary to extravasation of docetaxel when infused using antecubital IV access.

Poster 104 Chronic Hoarseness as Isolated Presentation for Early Motor Neuron Disease: A Case Report

Case Description: We present a case series of 3 patients with severe, non-traumatic rotator cuff arthropathy, who were not responsive to conservative pharmacological treatment, occupational therapy, and were either not amenable to orthopedic surgical interventions or declined by patients. Each of these patients also had contraindications to use of repeated corticosteroid injections (for example, further risk of rotator cuff atrophy, worsening tendinopathy, rupture or delayed pressure ulcer wound healing and increased risk for infection in a spinal cord injury patient). Setting: Musculoskeletal outpatient clinic. Results or Clinical Course: After a series of 3 to 5 hyaluronic acid ultrasound-guided glenohumeral joint injections, each patient reported near complete resolution of their chronic shoulder pain and gained greater range of motion, tolerance to occupational therapy, and improved activities of daily living. Discussion: The existing literature for viscosupplementation for chronic shoulder pain secondary to shoulder osteoarthritis has been encouraging, but inconclusive. Moreover, there is limited data on the effect of hyaluronic acid on patients who have severe arthropathy with complete, full thickness rotator cuff tears. Conclusions: Viscosupplementation is a viable treatment option and adjunct for patients with chronic rotator cuff arthropathy who are not surgical candidates, decline surgery, or have pain refractory to traditional conservative measures.

Treatment of Extensor Digitorum Brevis Manus Myalgia With Botulinum Toxin

In addition, a nonsystemic vasculitis in childhood is even rarer. Conclusions: Asymmetric sensory or motor symptoms that develop in previously healthy children may suggest an acute vasculitis. Electrodiagnostic evaluation can determine the extent and nature of the possible neuropathic process. Sural nerve biopsy can identify vasculitic disorders. Prompt initiation of immunosuppressive therapy with a rehabilitation program offers the best opportunity of functional recovery.