Scott R. Laker

The Effects of Epidural Betamethasone on Blood Glucose in Patients with Diabetes Mellitus

To determine the effects of lumbosacral transforaminal and caudal epidural betamethasone injections on blood glucose levels in diabetic subjects. The hypothesis is that epidural steroid injections result in transient elevation of blood glucose levels in diabetic subjects.

Neuropsychological Testing Point/Counterpoint

intervenEditor’s Note: Christopher Randolph, PhD, ABPP-CN, is a board-certified clinical neuropsychologist. He is a clinical pr neurology and the director of the neuropsychology service at Loyola University Medical Center. He has extensive expe neuropsychological test development and has published on its use and limitations for various applications. He also has a long research interest in traumatic brain injury, including sports-related concussion. Mark Lovell, PhD, has published more than 150 peer-reviewed articles and is an international authority on concussion and neur logical testing. He is the developer and chief executive officer of ImPACT Applications, Inc, and professor of orthopaedic and neu surgery at the University of Pittsburgh. He has worked with the National Football League, National Hockey League, U.S. Olymp and Major League Baseball to develop concussion management strategies. The respondents were asked how they would approach and/or manage neuropsychological testing and other neurophysiological tions during the course of these players’ recovery.

Thoracic Outlet Syndrome

A 44-year-old woman presents with a chief complaint of neck pain with radiation of paresthesias into her left medial forearm, and fourth and fifth digits. She was involved in a rear end motor vehicle collision 2 years prior. Her symptoms are exacerbated by work (eg, typing, mousing), and combing her hair, and have remained relatively constant at 3 of 10 average, and 8 of 10 at its worst by visual analogue scale (VAS) scale. Her current physical examination reveals a moderate cervicothoracic kyphosis, head forward, rounded shoulder posture. She has a normal neurologic examination with absence of extremity edema, normal pulses, and no bruits with auscultation over the supraclavicular fossae. Spurling maneuver recreates local pain into the upper trapezius only. Roos, Wright, and Adson tests are positive bilaterally for reproduction of her medial forearm and digit paresthesias without diminished pulses. Cervical radiographs reveal elongated C7 transverse processes bilaterally without cervical ribs and magnetic resonance imaging 6 months after the injury showed mild to moderate spondylosis at C5-6 and C6-7 without central or foraminal stenosis. A Doppler ultrasound study performed 8 months after the injury was negative for upper extremity deep vein thrombosis and an electrodiagnostic test 8 months after the injury was negative for radiculopathy, plexopathy, or ulnar entrapment neuropathy. Treatment has included 3 months of chiropractic and 12 visits of physical therapy immediately after the accident including ultrasound, massage, electricl stimulation, and cervical traction, with each treatment offering only mild temporary relief. In total, her presentation is suggestive for thoracic outlet syndrome, but there is no distinct evidence for neurological or vascular impairments. Her primary care provider has suggested that this problem may be “in her head.” What is your clinical impression and what further assessment and treatment do you recommend? Guest Discussants:

Radiologic Evaluation of the Neck: A Review of Radiography, Ultrasonography, Computed Tomography, Magnetic Resonance Imaging, and Other Imaging Modalities for Neck Pain

The patient with neck pain may pose a diagnostic dilemma for the treating physician. As with other areas of medicine, imaging is guided by the history and physical examination. The steady advance of 3-dimensional, functional, and nuclear medicine studies make it increasingly important that the ordering physician be aware of the potential benefits and disadvantages of imaging options. This article reviews the current literature on imaging for the patient with neck pain, illustrates several imaging abnormalities, and discusses the workup of commonly seen patient populations.

Poster 197-C Epidemiology of Cervical Spine Injuries in High School Athletes

Design: Data regarding purchase of new ultrasound devices in the southeastern United States was obtained from the leading ultrasound device manufacturer, Sonosite Fujifilm, during the period of January 2014 to December 2015. We included outpatient musculoskeletal practices in the southeastern United States, specifically covering the states of Georgia, Alabama, Florida, and South Carolina. Hospitals and inpatient services were excluded, as was the purchase of used ultrasound devices. Data were collected from the practices on whether they had received manufacturer training, loaned a device, or were trained in ultrasound during residency, fellowship, or in a prior job. Setting: Primary investigators all from academic setting. Participants: Fifty-two outpatient musculoskeletal practices were included in this study. Interventions: Not applicable. Main Outcome Measures: Percentage of musculoskeletal practice which received manufacturer training, loaned a device, or were trained in ultrasound during residency, fellowship, or in a prior job. Results: Thirty-six devices (61%) were bought by practices where the physicians were trained to use ultrasound during residency, fellowship, or a prior job. Ten devices (17%) were bought by practices where the manufacturer trained physicians, and 7 of these devices were also loaned to the practices after training. Fifteen devices (25%) were bought by practices where the physicians had no prior training with ultrasound nor loaned a device before purchase. Only 12% of practices loaned a device before purchase, and this was not associated with an increased likelihood of purchasing an ultrasound device (P>.05). Conclusions: Our data suggest that ultrasound training during residency, fellowship, or a prior job is more strongly associated with the purchase of new ultrasound devices in outpatient musculoskeletal clinics than other factors, including training by the manufacturer or loaning the device. Thus, earlier exposure to ultrasound seems to promote continued use of ultrasound later in a physiatrist’s career. Level of Evidence: Level III

Poster 364 Transient Osteoporosis of the Hip Progressing to Avascular Necrosis: A Case Report

Disclosures: P. Panchang: I Have No Relevant Financial Relationships To Disclose. Case Description: 20-year-old M athlete presents with pain and weakness in the left shoulder, which began about three weeks ago during swimming practice. The pain initially began in the superiorposterior left shoulder over the trapezius and supraspinatus region. Pain improved over time but the weakness persisted. Specifically seen with external rotation of the L shoulder. Denied paresthesias in the upper extremities. No issues with the RUE. Electrodiagnostic study showed evidence of left Suprascapular neuropathy with findings suggestive of possible entrapment the left spinoglenoid notch. MRI revealed a paralabral ganglion cyst in the left spinoglenoid notch/ infraspinatus fossa. Setting: Academic sports medicine clinic. Results or Clinical Course: Patient underwent aspiration of the paralabral cyst with ultrasound guidance, however only insignificant amount of clotted blood was extracted. He was then treated with Russian stimulation over the infraspinatus and Thera band exercises. Strength and endurance are improving with therapy and he continues to swim competitively. We will continue to monitor him and may consider surgery if symptoms worsen. Discussion: The Suprascapular nerve is a mixed motor and sensory nerve arising from the upper trunk of the brachial plexus. Suprascapular neuropathy is an uncommon injury typically caused by compression or traction at the suprascapular notch or spinoglenoid notch. Differentials include upper trunk brachial plexopathy, C5-C6 radiculopathy and rotator cuff impingement. Treatment options for Suprascapular neuropathy include Physical Therapy, anesthetic/ corticosteroid injection, ultrasound guided aspiration of the paralabral cyst and surgery. Conclusion: Suprascapular neuropathy should be considered in athletes with vague posterior shoulder pain. Patients may present with weakness and decreased endurance in performing overhead, sport specific activities. Management remains controversial and mostly depends on the cause, duration, severity of symptoms and patient preference. Aspiration of the paralabral cyst is an acceptable alternative to surgery although it is not definitive and majority of the cysts do recur.

Poster 387 A Ventral Epidural Facet Cyst Causing Central Canal Stenosis and Lumbar Nerve Compression in a Woman With Radicular Type Low Back Pain: A Case Report

Disclosures: M. Miedema, No Disclosures. Case Description: The patient presented with 6 weeks of gradual onset, constant sharp low back pain radiating into both legs without inciting trauma. Her symptoms worsened with weight bearing and were relieved with sitting. History was otherwise unremarkable and her examination was notable for positive dural tension signs. Radiograph of the lumbar spine revealed facet arthropathy at L5-S1. Initial lumbar MRI without contrast was obtained and showed severe L4-5 facet arthrosis, a high T2-weighted, multilocular lesion in the ventral epidural space at L4-5 creating moderate to severe central spinal canal narrowing and right L5 nerve compression within the right lateral recess. Subsequently, an MRI with contrast was obtained which again demonstrated the anterior epidural multilocular cystic mass with linear enhancement and confirmed the suspicion of a dissecting synovial cyst arising from the adjacent right L4-5 facet, and ruling out neoplasm. She was treated with a CT-guided rupture of the facet cyst and right L4-5 transforaminal epidural steroid injection. Setting: Outpatient spine rehabilitation clinic. Results or Clinical Course: At 3 weeks after facet cyst rupture the patient had significant improvement in her pain. Discussion: This is the first reported case, to our knowledge, of a ventral epidural multilocular lesion arising from a dissecting synovial cyst. Conclusions: Although uncommon, dissecting synovial cysts should be considered in the differential diagnosis of ventral epidural lesions in the setting of known facet arthropathy.

Poster 385 The Impact of MRI on Physician Decision Making Prior to Initial Lumbar Spinal Intervention

Disclosures: J. I. Tilghman, No Disclosures. Case Description: The patient was 2 years status post a C4-C6 anterior cervical diskectomy and fusion. It was thought the patient had a new left C7 radiculopathy. Setting: Tertiary obstetric/gynecologic and pediatric hospital. Results or Clinical Course: A C7-T1 translaminar epidural steroid injection (ESI) was successfully performed with a catheter directed to the left C6-7 neuroforamen for targeted drug delivery. The patient tolerated the procedure well. Discussion: Complications associated with cervical transforaminal epidural steroid injections though rare can be catastrophic, ie, spinal cord injury, death. This technique, however, offers both diagnostic and therapeutic value and is used for the management of cervical radiculopathy. Complications can be avoided by injecting only non-particulate steroid, using digital subtraction imaging, and compromising targeted drug delivery by taking a translaminar approach entering only at the C7-T1 level or below. A C7-T1 translaminar ESI, though safer, does not allow for targeted drug delivery like the transforaminal approach and lacks any diagnostic credibility. However, guidance of epidural catheters using translaminar epidural access allows for not only precision drug delivery but has diagnostic utility as well. The potential complications of this approach are far more benign than those of the cervical transforaminal approach. Conclusions: Entering the cervical epidural space using a non directable catheter via a translaminar approach at the C7-T1 level has been established in the literature. We propose that directing the catheter for targeted drug delivery allows for specificity and diagnostic utility equal to a cervical transforaminal approach but with the safety profile of a translaminar approach.

Characterization of Injuries During Hardcourt Bike Polo Participation: A Descriptive Survey

To describe injury rates and patterns in the emerging sport of hardcourt bike polo (HBP).