Zack McCormick

Long-term Intrathecal Baclofen: Outcomes After More than 10 Years of Treatment

To report outcomes of intrathecal baclofen (ITB) therapy for spasticity management in a cohort of patients who had received this treatment for at least 10 years.

Lumbosacral transforaminal epidural steroid injections are equally effective for treatment of lumbosacral radicular pain in the obese compared to non-obese population: a pilot study.

BACKGROUND AND OBJECTIVES Current evidence suggests that lumbosacral transforaminal epidural steroid injection (TFESI) is an effective treatment for lumbosacral radicular pain. However, practitioners may be reluctant to attempt this intervention in obese patients because of a perceived reduction in the chance of providing pain relief due to the increased technical difficulty of TFESI in individuals with a larger body habitus. No study to date has compared the effectiveness of TFESI in groups stratified by BMI. We report pilot data addressing whether lumbosacral transforaminal epidural steroid injection is as effective in treating lumbosacral radicular pain in the obese and overweight population as it is in the non-overweight population. MATERIAL AND METHODS This study consisted of 9 normal weight (18.5 < BMI < 25), 9 overweight (25 < BMI < 30), and 6 obese (BMI > 30) patients who presented with lumbosacral radicular pain and received a TFESI. For each group, percent reduction in pain and the proportion of individuals with a 50% or greater reduction in pain 2-4 weeks after TFESI was determined. RESULTS Comparing the overweight and obese groups to the normal weight group, no significant differences were found in the percent improvement in pain after TFESI (p=0.7154, p=0.4566) or in the proportion of each group with a 50% or greater reduction in lower back pain after TFESI (p=0.2968). CONCLUSION Our pilot data indicates that lumbosacral TFESI is as effective in providing short-term relief of lumbosacral radicular pain in obese and overweight patients as it is in non-overweight patients. However, our sample size was not large enough to find a significant difference at a power of 80%. We plan to perform a larger prospective study to confirm the findings of this study. LEVEL OF EVIDENCE Case-control study, Level II-2.

Is Hip Abduction Strength Asymmetry Present in Female Runners in the Early Stages of Patellofemoral Pain Syndrome

Background: The current literature indicates that hip abduction weakness in female patients is associated with ipsilateral patellofemoral pain syndrome (PFPS) as part of the weaker hip abductor complex. Thus, it has been suggested that clinicians should consider screening female athletes for hip strength asymmetry to identify those at risk of developing PFPS to prevent the condition. However, no study to date has demonstrated that hip strength asymmetry exists in the early stages of PFPS. Purpose: To determine whether hip abduction strength asymmetry exists in female runners with early unilateral PFPS, defined as symptoms of PFPS not significant enough to cause patients to seek medical attention or prevent them from running at least 10 miles per week. Study Design: Controlled laboratory study. Methods: This study consisted of 21 female runners (mean age, 30.5 years; range, 18-45 years) with early unilateral PFPS, who had not yet sought medical care and who were able to run at least 10 miles per week, and 36 healthy controls comparably balanced for age, height, weight, and weekly running mileage (mean, 18.5 mi/wk). Study volunteers were recruited using flyers and from various local running events in the metropolitan area. Bilateral hip abduction strength in both a neutral and extended hip position was measured using a handheld dynamometer in each participant by an examiner blinded to group assignment. Results: Patients with early unilateral PFPS demonstrated no significant side-to-side difference in hip abduction strength, according to the Hip Strength Asymmetry Index, in both a neutral (mean, 83.5 ± 10.2; P = .2272) and extended hip position (mean, 96.3 ± 21.9; P = .6671) compared with controls (mean, 87.0 ± 8.3 [P = .2272] and 96.6 ± 16.2 [P = .6671], respectively). Hip abduction strength of the affected limb in patients with early unilateral PFPS (mean, 9.9 ± 2.2; P = .0305) was significantly stronger than that of the weaker limb of control participants (mean, 8.9 ± 1.4; P = .0305) when testing strength in a neutral hip position; however, no significant difference was found when testing the hip in an extended position (mean, 7.0 ± 1.4 [P = .1406] and 6.6 ± 1.5 [P =.1406], respectively). Conclusion: The study data show that early stages of unilateral PFPS in female runners is not associated with hip abduction strength asymmetry and that hip abduction strength tested in neutral is significantly greater in the affected limb in the early stages of PFPS compared with the unaffected limb. However, when tested in extension, no difference exists. Further studies investigating the early stages of PFPS are warranted. Clinical Relevance: Unlike patients with PFPS seeking medical care, early PFPS does not appear to be significantly associated with hip abduction strength asymmetry.

Transforaminal epidural steroid injection in the treatment of lumbosacral radicular pain caused by epidural lipomatosis: A case series and review

BACKGROUND Spinal epidural lipomatosis (SEL) can cause radicular pain due to spinal nerve root impingement. While SEL decompression surgery can provide symptom relief, these patients are often poor surgical candidates due to elevated BMI or immunosuppression. Transforaminal epidural steroid injection (TFESI) has been attempted as an alternative treatment for patients with SEL who are unable to tolerate conservative medical treatment. To date, only two such cases have been reported in the literature. OBJECTIVES We report three additional cases of radicular pain associated with SEL, review the current literature on this condition, and describe the risks and benefits of using TFESI to treat radicular pain due to SEL. METHODS We measured changes on the pain visual analogue scale (VAS) and pain disability index (PDI) from presentation to 1-5 weeks after treatment with sequential TFESIs. RESULTS Pain VAS scores improved by 50-75% and PDI scores improved 13-44 points. CONCLUSIONS This case series suggests that TFESI can provide modest short-term symptom relief of lumbosacral radicular pain and improvement in disability caused by SEL. Further study of non-operative management of SEL is warranted, given the high risk associated with surgery in this population.

A Mediastinal Mass Presenting With Unilateral Periscapular and Arm Pain

We describe a case of a patient with mediastinal lymphoma who presented with arm and scapular pain, which is an atypical referral pattern for pain originating from the mediastinum. We use this case as a platform to discuss mediastinal pain referral patterns and the importance of maintaining a broad differential diagnosis of arm and scapular pain, especially when symptoms atypical of pure neuromusculoskeletal structural disease are present.

Fever After Traumatic Spinal Cord Injury: A Case of Brucella Sepsis

Fever during acute rehabilitation in patients with a spinal cord injury is a common problem. Infection, typically of the urinary or respiratory tract, is the most frequent cause of fever in these circumstances. We report a case of Brucella sepsis as a cause of fever in a patient with a spinal cord injury who was undergoing acute rehabilitation. We discuss the epidemiology, differential diagnosis, and evaluation of fever in persons with Brucella infection, as well as fever in patients with a spinal cord injury in the acute rehabilitation setting.

Poster 34 Intrathecal Versus Oral Baclofen; a Comparative Matched Cohort Study of Long-term Spasticity, Pain, Sleep, Fatigue and Quality of Life

Design: Case-control study using electronic medical records as a quality improvement (QI) initiative between IPR, Antimicrobial Stewardship, and Infection Control Council. Setting: Acute IPR Units within a University-Affiliated Academic Medical Center. Participants: Random selection of 165 patients admitted to IPR between November 2011 and August 2014; 81 were diagnosed with spinal cord injury (SCI) and 84 had a general rehabilitation diagnosis. Interventions: Descriptive review of acute rehabilitation patients focused on practices surrounding urinary testing, diagnosis, and management of UTIs. Main Outcome Measures: Comparison of SCI vs. general rehabilitation for symptomatology at time of obtaining urinary testing, catheter use and duration, and antibiotic appropriateness. Results or Clinical Course: Of 81 SCI patients, 80.2% were male and Escherichia coli was the most common urinary pathogen. A trend towards more frequent urine testing was observed among SCI; however, this was not statistically significant (P1⁄4.06). Moreover, a greater number of SCI patients had documentation of signs/symptoms of UTI to justify urine testing and treatment (P<.0001): cloudy or malodorous urine, urinary incontinence or retention, spasm/autonomic dysreflexia, dysuria, urinary frequency, pain, nausea, vomiting, fever, and altered mental status. Of the 46 (56%) SCI patients treated for a presumed UTI, 30 (65%) received unnecessary antibiotics for asymptomatic bacteriuria (ASB) based on IDSA criteria; this practice was analogous to the general rehabilitation population (P1⁄4.79). Conclusion: The differentiation between ASB and UTI among SCI patients is difficult to discern. There is a significant difference in urinary symptoms outlined by IDSA and those considered in IPR clinical practice. This QI project highlights the importance of continued multispecialty involvement to close the gaps in diagnosis and management of this common dilemma.

Does Long-term Intrathecal Baclofen Dose Impact Spasticity Pain, Sleepiness, Fatigue, and Life Satisfaction?

high-frequency stepping gait training program within the intensities defined. Stepping data indicated that subjects received an average daily stepping dosage of 2000-8000 steps per day, well above previously reported values. Conclusions: It is possible to implement a high-intensity, highfrequency stepping gait training program within an acute inpatient rehabilitation setting for the stroke population. However, future research concerning therapy intensity and frequency of stepping should be designed with a larger sample size.

A Case of Progressive Multifocal Leukoencephalopathy due to HIV/AIDS with Functional Improvement After Acute Inpatient Rehabilitation

Disclosures: A. Reddy, No Disclosures: I Have Nothing To Disclose. Case Description: Patient was an 83-year-old woman with thoracic myelopathy due to recurrent thoracic intradural cavernous lymphangioma. Patient had initial presentation of progressive gait ataxia and weakness in her lower extremities. MRI revealed a cystic structure found inside the thecal sac with compression of spinal cord. Patient underwent resection of cystic lesion in May 2012 with improvement in her symptoms thereafter. Pathology report confirmed an intradural cavernous lymphangioma. Approximately 4 months later, symptoms began to worsen with imaging revealing recurrence of lymphangioma in proximity of the original site. The patient underwent a second surgical intervention with T4-T9 laminectomies and resection in September 2012. She was then transferred to acute in-patient rehabilitation unit for functional upgrading of severe ataxia and neurogenic bladder. Shortly after this rehabilitation course, patient had a third recurrence of the cyst, requiring cysto-peritoneal shunting and subsequent re-enrollment in acute inpatient rehabilitation finally resulting in stabilization and mild improvement in her symptoms. Setting: Acute In-patient rehabilitation unit in a community hospital. Results or Clinical Course: With each of the three presentations, patient was noted to have moderate paresis and significant sensory impairments, specifically with proprioception, sensation to light touch, and pinprick in lower extremities, resulting in severe gait ataxia. Other barriers to rehabilitation included neurogenic bowl/bladder and neuropathic pain. All symptoms returned within a few months with surgical resection, ultimately requiring cystoperitoneal shunting which resulted in stabilization and improvement of impairments. Discussion: Only a few cases of lymphangioma of the spine have been reported. This is the first reported case, to our knowledge, of a patient with intradural cavernous lymphangioma in an acute inpatient rehabilitation setting. Conclusions: Intradural lymphangioma requires close clinical follow up for recurrence. If not responsive to surgical resection, a combination of cysto-peritoneal shunting and acute inpatient rehabilitation may result in improved functional status.

Poster 258 B Cell Lymphoma Initially Presenting as Cervical Radiculitis: A Case Report

balmed cadaveric specimen. The location of the anomalous tendon was atypical for the traditionally described peroneus quartus and therefore would present a potential diagnostic pitfall if encountered during the sonographic evaluation of a patient presenting with posterolateral ankle pain. Setting: Tertiary care hospital. Results or Clinical Course: During a scanning session on an unembalmed cadaveric specimen the authors encountered 3 tendons in the right retromalleolar region. The peroneus longus and brevis tendons appeared normal in size, echo texture, origin, and insertion. The third tendinous structure was located just posterior to the fibula, adjacent and lateral to the peroneus brevis and anterior to the peroneus longus. This third tendon had a normal tendinous echo texture, was smaller than the peroneus brevis and longus, and when traced proximally and distally appeared to represent an anomalous muscle-tendon. When scanned proximally, the tendon was seen to originate from the upper half of the leg, adjacent to the proximal musculotendinous junction of the peroneus longus. Distally, the tendon’s course was complex. After passing the fibular tip, the tendon bifurcated, sending a small slip to a normal-sized retrotrochlear eminence and a larger slip toward the inferior peroneal retinaculum. Sonographically, this latter slip appeared to blend into the retinaculum itself. These sonographic observations were confirmed on subsequent dissection, which further clarified the intimate relationship of the anomalous muscle-tendon’s origin with the peroneus longus. Contralateral left limb scanning revealed normal anatomy. Conclusions: In conclusion, we report the sonographic and anatomic appearance of an apparently rare but clinically important peroneal tendon variation presenting as “3 tendons” in the retromalleolar groove. Sonologists and sonographers should consider this variation when scanning patients with suspected peroneal tendon disorders to avoid misdiagnosis of a peroneus brevis split tear.