Thomas Chai

Diaphragm Dysfunction Due to Remote Poliomyelitis in a Patient With Unexplained Dyspnea

Late onset of new neuromuscular symptoms occurring many years after the initial illness is the hallmark of postpolio syndrome (PPS) [1]. In PPS, the new onset of motor weakness usually involves muscles that were previously affected; however, new symptoms also may occur in muscles that were clinically asymptomatic. This new weakness is thought to be due in part to overuse and excessive metabolic stress on the remaining motor neurons, eventually leading to their deterioration [1]. Respiratory compromise as a late feature of PPS has been reported and typically is associated with the following risk factors: history of ventilator assistance during the onset of poliomyelitis, central causes of hypoventilation, cranial nerve involvement, and/or musculoskeletal deformities [1-3]. Although respiratory involvement is seen in only a small minority of patients with PPS, it poses a potentially life-threatening complication that presents a challenge to those who manage it. We describe a patient with a history of remote poliomyelitis with no initial respiratory involvement who was evaluated at our clinic; he had a 3-year history of exertional dyspnea and an elevated left hemidiaphragm revealed on a chest radiograph.

Poster 344: Severe Axial Neck Pain and Stiffness due to Crowned Dens Syndrome in a Patient with Multiple Myeloma

concerning for a C7 radicular pain pattern. He was prescribed a methylprednisolone dose pack and a cervical spine magnetic resonance imaging (MRI) study was ordered. MRI demonstrated multilevel cervical spondylosis most pronounced at C3-4 and C6-7 with varying degrees of stenosis and a partially visualized right apical lung mass. Chest computed tomography (CT) was then obtained which showed a spiculated mass in the right lung apex measuring 4.7 3.5 cm in axial dimension and 4 cm in craniocaudal dimension invading the posterior chest wall with bony destruction of the right second posterior rib. The patient was immediately set up with oncology for next steps in care. Discussion: Shoulder pain can be a common presentation in apical lung tumors. As the tumor spreads to the ribs or brachial plexus, patients may present with pain in shoulder blades, armpit, and neuropathic pain along the ulnar nerve distribution. Horner syndrome can also develop if the sympathetic chain is affected. Studies have shown that shoulder pain and arm pain commonly present in Pancoast tumors ranging from 19%-65% of the time, which have led to delay in diagnosis of up to 7.5 months. Conclusions: Pulmonary malignancies should be carefully considered in the differential diagnosis of any patient who presents with scapular pain refractory to standard treatment. Level of Evidence: Level V

Poster 436: Chemotherapy-Induced Peripheral Neuropathy Pain and Postmastectomy Pain Syndrome in a Breast Cancer Patient Managed with Neurostimulation: A Case Report

patella, and bilateral medial/lateral ankles. Range of motion, strength, reflexes, and sensation were normal. X-rays of bilateral knees/ankles and DEXA scan were unremarkable. Bone scan showed diffuse mildly increased tracer uptake in bilateral distal femurs and proximal tibias. MRI showed bilateral patellofemoral and medial chondral disease. Setting: Outpatient. Results: Patient was suspected to have calcineurin inhibitor induced pain syndrome (CIPS). Due to hepatic steatosis, she couldn’t be switched to another immunosuppressant. Patient reported improved pain and standing/walking tolerance with calcitonin-salmon nasal spray and increased dose of gabapentin 800-mg daily. Patient also started acupuncture and reported 90% improvement in pain after initial session. Discussion: CIPS is a rare disabling syndrome that should be considered in immunosuppressed patients with LE pain. This case illustrates a patient with previously reported characteristic clinical features of CIPS in addition to uncharacteristic neuropathic symptoms and imaging findings. There have been several proposed hypotheses for pain development including calcineurin inhibitor induced vascular disturbance, bone remodeling, and nociceptive modulation. These may all contribute to the development of pain and account for the variation in clinical symptoms and imaging findings. Also, there have been no previous reports of acupuncture treatment for CIPS which provided significant pain relief for our patient. Additional research into pain generating mechanisms of calcineurin inhibitors may identify further treatment options. Conclusions: Early recognition and management of CIPS can improve quality of life. Further research into CIPS may provide additional and more specific diagnosis/management guidelines. Level of Evidence: Level V

Poster 344 Upper Extremity Weakness Due to Bilateral Brachial Plexopathy from Guillain-Barre Syndrome in a Cancer Patient: A Case Report

completing comprehensive rehabilitation, including vestibular therapy, the patient was discharged home independent in ADLs and ambulating with a cane. One month later he presented with new-onset dysphagia, and worsening of left facial numbness and dizziness. A brain MRI confirmed acute left inferior cerebellar peduncle and lateral medullary infarct. Discussion: This patient initially presented with concern for occult central neurologic injury, but peripheral vertigo. We suspected left posterior cerebral circulation insufficiency including Anterior Inferior Cerebellar Artery (AICA). It was not until the second stroke that brain imaging confirmed clinical diagnosis. Conclusions: 1. Clinical evaluation remains the gold standard to diagnose stroke. 2. Patients with posterior circulation stroke might have vertigo of central or peripheral origin if the AICA is involved. Diagnosing uncompensated vestibular weakness, along with timely implementation of vestibular rehabilitation therapy has been proven to improve recovery and morbidity outcomes. Level of Evidence: Level V

Poster 437 Pain in Spinal Cord Injury - An Unusual Presentation of Complex Regional Pain Syndrome: A Case Report

Setting: Tertiary Care Hospital. Results: Clinical examination was consistent with anterior cord syndrome. The presence of hypotension and abrupt presentation were suggestive of a hypotensive etiology. Given the mid-thoracic localization and sparing of the posterior spinal column we surmised he experienced spinal cord infarction resulting from hypoperfusion of the artery of Adamkiewicz. A non-contrast CT scan was unrevealing. He could not undergo MR imaging for confirmation of acute ischemia due to a non-compatible pacemaker. Discussion: Anterior cord syndrome following hemodialysis is an extremely rare yet devastating complication. The anterior spinal artery supplies blood to the anterior two-thirds of the spinal cord. The artery receives its blood supply from segmental radicular arteries supplied from multiple sources depending on cervical, thoracic or lumbar location. The artery of Ademkiewicz can vary in its extension from midthoracic to lumbar levels and generally supplies the majority of blood flow to the thoracic and lumbar cord segments. Injury, thrombosis, embolism or occlusion of this artery can result in spinal cord ischemia. We report an unusual presentation of spinal cord ischemia resulting from profound systemic hypotension during hemodialysis. Conclusions: Clinicians should be aware of patients with a history of compromised vasculature and should be mindful of iatrogenic interventions that could lead to hypotension, compromising the blood flow to the spinal cord. Level of Evidence: Level V

Paraplegia due to Cord Compression in a Cancer Patient with Epidural Abscess after Vertebroplasty: A Case Report

Disclosures: T. Chai, No Disclosures: I Have Nothing To Disclose. Case Description: A 60-year-old woman with history of metastatic breast cancer to bone and pathologic thoracic vertebral compression fracture at T7.Program Description: The patient underwent T7 vertebroplasty under computed-tomography guidance for pathologic T7 vertebral compression fracture with associated intractable back pain. 5 days later, the patient was hospitalized at an outside facility for fever. Workup revealed an infected Port-aCath and bacteremia. During hospitalization, the patient developed increasing back pain, bilateral lower limb pain, numbness, and weakness. A magnetic resonance imaging study of the thoracic spine revealed a thoracic spinal epidural abscess extending from T4 to T9, with spinal cord compression. The patient subsequently underwent emergent thoracic laminectomy from T6 to T9 for decompression and abscess drainage. Setting: Tertiary Cancer Center Results or Clinical Course: The patient underwent inpatient physical therapy after decompressive surgery for thoracic spinal epidural abscess, with improvement in lower limb motor strength and functional capacity. Discussion: Vertebral augmentation is generally considered a safe and effective minimally-invasive procedure for the management of pain due to vertebral compression fracture. The cancer patient population, however, is known to be at higher risk for post-procedure complications. Complications related to vertebroplasty include extravertebral extravasation of cement, which may result in pulmonary cement emboli or spinal canal stenosis, although usually clinically asymptomatic. Infection after vertebral augmentation is a rare but serious complication, as osteomyelitis and epidural abscess may require aggressive treatment, to include neurosurgical intervention. In our patient’s case, the spinal epidural abscess appears to be due to hematogenous dissemination secondary to bacteremia. Conclusions: Patient characteristics and current oncologic treatment are important factors, among others, to consider during evaluation for vertebral augmentation in the cancer patient with pathologic vertebral compression fracture.

Poster 77: Diaphragm Dysfunction due to Remote Poliomyelitis in a Patient with Unexplained Dyspnea: A Case Report

was intact to light touch, pinprick, proprioception and vibration. Reflexes were reduced on the left biceps and deltoid. He had hyperreflexia on the left triceps and scapular muscles. Hoffmann’s was positive on the left. MRI of the cervical spine showed a large disk osteophyte complex occupying the right half of the spinal canal at C5-6. There was an abnormal hyperintense signal at this level, which was slightly increased compared to the prior study. Electromyography revealed normal sensory and motor nerve conduction studies. Fibrillations and positive sharp waves were present in the left deltoid and biceps. Setting: Inpatient acute rehabilitation unit. Results: Physical examination and electrodiagnostic studies revealed C5 nerve root involvement. Discussion: Postoperative paresis of the upper extremity occurs in 14.9% of patients following cervical laminectomy. Physical findings and EMG/NCV results revealed C5 radiculopathy. Several theories have been proposed regarding the cause of postoperative C5 palsy; however, none have been proven until the present time. Conclusions: A careful neurological examination, radiographic work-up and electromyography with nerve conduction studies may be helpful in the diagnosis of postoperative C5 nerve root palsy. Further investigations are needed to determine the pathophysiology. Patients with C5 palsy would benefit from continued rehabilitation since it is a transient weakness and most patients have been reported to recover.