Maury Ellenberg

What you always wanted to know about the history and physical examination of neck pain but were afraid to ask

Diagnoses of most cases of neck pain can be made on the basis of a careful history and physical examination. Any tests must be interpreted only in the context of the clinical examination. The clinician must be cognizant of signs or symptoms that may indicate a more serious disorder by attending to the red flags and examining the lower extremities for spasticity that could indicate cervical myelopathy.

Complete hemidiaphragmatic paralysis in a patient with multiple sclerosis

We present a case history of a patient with definite multiple sclerosis who developed an abrupt onset of unilateral diaphragmatic paralysis, minor increase in lower extremity spastidty and complaint of marked neck stiffness. Her vital capacity during this episode was 600 mL and she was in impending respiratory failure. The diaphragmatic paralysis was demonstrated by radiographic plain films and fluoroscopy. Phrenic nerve stimulation was performed during fluoroscopy and the evoked motor response from the diaphragm recorded. There was a normal amplitude diaphragmatic twitch observed with an evoked motor response latency of 1 ms and amplitude of 300 juV. After high dose intravenous steroids, her neck stiffness and spasticity improved, her vital capacity improved to 1500 mL and her diaphragm regained its normal position and movement confirmed by followup radiographic plain films and fluoroscopy. We postulate the presence of a demyelinating plaque in the brainstem fibers descending to the phrenic nucleus as the etiology of the diaphragmatic paralysis. We are unaware of any other case reports of unilateral “upper motor neuron” phrenic nerve paralysis secondary to multiple sclerosis.

Poster 255: Comparison of Treatment Outcomes in Patients not on Opioids and those Weaned from Opioids During a Functional Restoration Program: A Case Series

men and women (62.6% vs 58.6%; P .33) and of opioidnaive and opioid-experienced patients (63.1% vs 57.2%; P .15). However, in the opioid-experienced subgroup, patients who received oxycodone previously were significantly less likely to complete titration than those who had received hydrocodone (45.6% vs 61.5%; P .03). Conclusions: The majority of patients with moderate to severe CLBP were successfully titrated to a twice-daily oxymorphone ER dose that provided effective, generally welltolerated analgesia. Seniors and patients switching from oxycodone may require more careful titration to optimize success.

Poster 100: Evaluation of the visual analog scale as an outcome measure in patients with chronic pain1

Abstract Objective: To assess the reliability of the visual analog scale (VAS) as an outcome measure in patients with chronic pain. Design: Retrospective chart review of patients in a functional restoration program (Functional Recovery Program [FRP]). Setting: Community-based FRP. Participants: 16 patients enrolled in the FRP. Interventions: Not applicable. Main Outcome Measures: The Oswestry Disability Questionnaire (ODQ) for low back pain, Illness Effects Questionnaire (IEQ), and VAS were compared with each other and with 2 functional measures; the 65-foot dash and time on the treadmill. A Pearson 2-tailed correlation analysis was used for the analysis. The correlation coefficients and P values were calculated for the ODQ compared with the VAS, the IEQ compared with the VAS, and each measure compared with the functional activity gains. The difference in scores on admission and at the end of treatment were used for the VAS, ODQ, and IEQ to evaluate change in level of pain and disability perception while the time difference required for completion of the 65-foot dash and aerobic exercise time were used to assess change in functional status. Results: Significant correlation was present between the VAS and IEQ (coefficient=.836, P P P Conclusions: The VAS correlated well with other subjective disability-related scales. However, it did not correlate with actual measured improvement in functional ability. This brings into question the value of the VAS in chronic pain populations as it relates to treatment outcomes. Clearly, patients can functionally perform well despite self-reported pain complaints and some continued perception of disability.