Madhuri Dholakia

Poster 323: Metastatic Tibial Lesion Presenting as Lumbar Stenosis: A Case Report

Case/Program Description: A 25-year-old man presents with severe constant sternum pain for 2 years following multiple sternotomies Setting: Tertiary-care academic medical center Results: Patient described constant severe pain localized over the sternum without any neuropathic pain originating from the thoracic spine and/or intercostal space towards the sternum. Pain was refractory to conservative measures (physical therapy) and high-dose oral opiates. Imaging studies did not reveal any acute pathology over the sternum, ribs, or thoracic spine. Review of operative reports and discussion with vascular surgeon revealed no significant findings explaining persistent symptoms. Discussion: Post-sternotomy pain syndrome is a common syndrome with variable incidence (as high as 66% per some reports) that occurs within 1-2 years after sternotomy. The etiology is multifactorial with literature indicating a wide differential diagnosis including intercostal neuropathy, costochondral injury, scar tissue at site of sternotomy, poor bone healing of sternum, sequelae of rib fractures, and/or allergy or bone irritation due to the metal wiring used. Reported treatments are similar to ‘post-thoracotomy syndrome’ including physical therapy, oral pain medications, and/or procedural interventions (epidural injection and/or intercostal blocks). However, there is not strong evidence to suggest that these interventions are effective for pain localized to the sternum without any neuropathic quality as in this patient. An alternative, novel approach for treatment would be consideration of removal of sternal wires which has demonstrated efficacy in multiple papers (one reported 83% complete relief in symptoms, the other reported 86% complete relief). Conclusions: Post-sternotomy pain syndrome is a difficult to treat syndrome with a variety of possible causative etiologies. As a result, consideration for removal of sternal wires as definitive treatment should be considered as a treatment option for refractory cases or those wanting to avoid chronic pharmacological interventions. Level of Evidence: Level V

Complex Regional Pain Syndrome Diagnostic Criteria

Over the past several decades, complex regional pain syndrome (CRPS) has gone through an evolution of its diagnostic criteria. The disorder was initially known as causalgia, then reflex sympathetic dystrophy, and then eventually termed CRPS; it has gone through many name changes to reflect the broader characterization of its symptomology. The Orlando criteria suggested two types of CRPS with four subsets. After further research and debate, the Budapest criteria were developed to classify CRPS with more specificity. This chapter provides a review of these guidelines and diagnostic criteria.

Diagnostic Testing in Complex Regional Pain Syndrome

Abstract The diagnosis of complex regional pain syndrome is based on clinical criteria; however, several diagnostic tests may be useful in supporting the diagnosis.

Poster 337 Atypical Presentation of Bilateral Atraumatic Femoral Stress Fractures in a Patient with History of Long Term Bisphosphonate Use: A Case Report

below acceptable levels (kappa 1⁄4 .15), suggesting very poor reliability of measurements. In contrast, following the interventions, the enhanced group 2 coefficient kappa increased to an acceptable level (kappa 1⁄4 .83). Conclusion: The results of this study suggest that in ultrasound measurements of the piriformis muscle in healthy controls, that reliability of measurement can be improved using additional education with a standard protocol, use of the same ultrasound machine, and completing measurements on the same day. These findings provide significant methodological considerations for studies involving ultrasound measurements.

Poster 145 Delayed Diagnosis of Bilateral Cervical Facet Dislocation: A Case Report

Disclosures: D. Park: I Have No Relevant Financial Relationships To Disclose. Objective: To determine the effects of graded lumbar stabilization exercises on lumbar stabilizing muscles. Design: Cross-sectional study. Setting: Tertiary teaching hospital. Participants: Ten healthy males. Interventions: Five common exercises for strengthening the lumbar stabilizing muscles were selected: curl up, dead bug, side bridge, superman and bird dog exercises. And each exercise was divided into five levels by varied level of intensity. Main Outcome Measures: Using superficial electromyography, the electrical activity of rectus abdominis (RA), external oblique abdominis (EO), multifidus (MF) and erector spinae (ES) muscles was recorded during the exercise. The areas under the curve which were adjusted to different duration and peak amplitude were calculated. The Kruskal Wallis test and the post-hoc test with Mann-Whitney test were used. Results or Clinical Course: As the level of intensity of each exercise increased, the activity of related lumbar stabilizing muscles was generally increased. In detail, the activity of RA and EO was distinctly increased when trunk curl was added to neck flexed or supine position in the curl up exercise. However the posture of upper extremities didn’t influence the activity change of recorded lumbar stabilizing muscles. In the dead bug posture, the activities of RA, EO and MF were more increased while performing both arm and leg movements rather than arm or leg movement alone. In the side bridge posture, when leg abduction was added, mean area of MF was significantly increased. In the prone posture, lengthening the duration of the superman exercise increased the mean area of MF, ES and RA. In the bird dog posture, the activities of ES and MF were more increased while performing both arm and leg lifts rather than arm or leg lift alone. Conclusion: The graded lumbar stabilization exercises could be effective ways to strength muscles and increase the patient compliance. According to the physical ability of patients, they will be prescribed the proper level of the exercise intensity, and also only small numbers of exercise were needed to educate, instead of various kinds of different lumbar stabilization exercises.

Poster 113 Suprascapular Neuropathy Following Total Shoulder Arthroplasty: A Case Report

long-term care facility, she was weaned off the ventilator. She then presented to acute rehabilitation, and on examination, was tetraplegic and had poor oral and head control. She had significant atrophy of her bilateral tibialis anterior and gastrocnemius muscles and had a Cushingoid appearance. Subsequent electromyography and nerve conduction studies (EMG/NCS) demonstrated critical illness polymyopathy and critical illness polyneuropathy, but no evidence of steroid-induced myopathy. Steroid treatment was continued and the team optimized her rehabilitation program by avoiding resistance exercises to decrease the chance of muscle fiber loss. In approximately 5 weeks, the patient was able to slightly move her right upper extremity with gross movements at the shoulder, which helped her in using a power wheelchair. Program Description: A 39-year-old woman. Setting: Tertiary care rehabilitation center. Results or Clinical Course: EMG/NCS demonstrated critical illness polymyopathy (CIPM) and critical illness polyneuropathy (CIPN) but not steroid-induced myopathy in a patient on long-term steroids. Discussion: Tolosa-Hunt Syndrome is a rare disorder characterized by severe and unilateral headaches with extraocular palsies and impaired vision if there is a delay in treatment. This is the first reported case, to our knowledge, of a patient with Tolosa-Hunt and locked-in syndromes who developed critical illness polyneuropathy and critical illness polymyopathy. Optimization of her acute inpatient rehabilitation therapeutic and medication program was possible by identifying the cause of her weakness and atrophy with EMG/NCS. Conclusions: EMG/NCS is an important means of identifying the etiology of weakness in a patient who has visual impairment with Tolosa-Hunt syndrome who had been on long-term steroid therapy and locked-in syndrome with additional bilateral pontine infarct.

Poster 158 Isolated Teres Minor Atrophy in Quadrilateral Space Syndrome: A Case Report

edema within the anterior calcaneus. The patient was prescribed physical therapy with an occupation/ballet-focused therapist and told to follow-up as an outpatient. Setting: Quaternary care academic hospital. Results: The patient had an isolated posterior tibialis tenosynovitis without concurrent flexor hallucis longus injury that improved with focused therapy to strengthen her kinetic chain through strengthening of ankle inversion, intrinsic foot muscles, and external hip rotation to prevent pronation or “rolling out of foot.” Discussion: In ballet, posterior tibialis tendinopathy often arises from a combination of excessive pronation during jumping/propulsion and decreased peroneus longus strength which leads to “rolling out of foot.” Ballet dancers are classically known to have FHL “dancer’s tendinitis” injuries secondary to repetitive plantar flexion push-off maneuvers of the forefoot. Conclusions: To our knowledge, this is a unique case of an isolated posterior tibialis tenosynovitis causing the ballerina’s symptoms instead of the more common flexor hallucis longus injury with relief with focused therapy.

Poster 476 Metastatic Gastrinoma Presenting as a Thoracic Spinal Cord Tumor in Multiple Endocrine Neoplasia Type One (MEN-1): A Case Report

cord. After progressing in physical and occupational therapy, she was discharged from acute rehabilitation to home. Discussion: Spinal cord tethering is caused by tissue attachments limiting cord motion in the spinal column. Such attachments, perhaps due to the previous spine surgeries, may stretch the cord abnormally, inducing otherwise unexpected lesions. This case of tethered cervical spinal cord is the first, to our knowledge, to potentially provoke a constellation of neurological symptoms consistent with traditional thoracolumbar Brown-Sequard hemisection, as evidenced by right-sided spastic paresis with loss of proprioception and left lower extremity sensory loss. This could be due to strain on her spinal cord secondary to tethering, post-surgical changes, pregnancy-related pathology, or simply progression of spinal stenosis not detected by imaging. Conclusions: This patient uniquely presents with Brown-Sequard syndrome symptoms after cervical spinal cord untethering without correlating or obvious thoracolumbar pathology.

Poster 24 Brachial Plexopathy Caused by Pancoast Tumor From Recurrent Lung Cancer. A Case Report

without myokymic discharges were consistent with PTS overlying chronic C7-C8 radiculopathy and argued against solely RFinduced symptoms. Improvement of C7 metastases on MRI favored a diagnosis of PTS over worsening cervical spine compression. Conclusions: A diagnosis of PTS may be complicated by the likeness in the clinical course with CR secondary to expansile metastases and RF brachial plexopathy. EDX was vital in distinguishing PTS from other potential underlying causes of acute weakness in this cancer patient.

Poster 451 Thoracic Cord Arteriovenous Malformation: A Case Report

rin and with incomplete paraplegia secondary to a spontaneous intradural hematoma. Program Description: The patient, traveling via airplane, developed sudden onset of low back pain before landing. He developed progressive weakness of his bilateral lower extremities and a large intradural hematoma that stretched from the tenth thoracic vertebra (T10) to the first lumbar vertebra (L1) was found on magnetic resonance imaging. He underwent emergent T10-L1 laminectomy, with decompression of the hematoma. On angiogram, he was found to have a dural arteriovenous fistula at T10. His injury was classified as incomplete L2 paraplegia with an American Spinal Injury Association classification of C. 13 days after surgery, the patient developed a painful, vesicular rash oriented in the left first sacral dermatome, diagnosed as herpes zoster. Setting: Tertiary care hospital spinal cord injury unit. Results: The rash was treated with silver sulfadiazine topical cream and then covered. Within 4 days after onset, the pain had resolved and all lesions had crusted over. Within 10 days, all lesions had resolved. No further exacerbations were noted. Discussion: Occurrences of herpes zoster exacerbations after neurosurgical procedures, although rare, have been noted in the past. However, a search of the medical literature reveals no specific case reports of zoster after evacuation of spontaneous dural arteriovenous fistula hemorrhage in a dermatome unrelated to the surgical incision. This case is also unique in that the affected dermatome was several segments below the lower limit of the patient’s hematoma and laminectomy site but still in a dermatome affected by the spinal cord injury. Conclusions: Although uncommon, herpes zoster exacerbation in the setting of acute spinal cord injury secondary to spontaneous hemorrhage from a dural arteriovenous fistula and subsequent laminectomy may occur in dermatomes unrelated to the surgical incision.