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Poster 114 Multifocal Acquired Demyelinating Sensory and Motor (MADSAM) Neuropathy Secondary to Infliximab Infusion: A Case Report
PM&R
surgery may include nerve traction, nerve compression secondary to taut ligaments and nerve transection. Poster 114 Multifocal Acquired Demyelinating Sensory and Motor (MADSAM) Neuropathy Secondary to Infliximab Infusion: A Case Report. Anupam Sinha, DO (Rothman Institute, Philadelphia, PA, United States); Madhuri Dholakia, MD. Disclosures: A. Sinha, No Disclosures. Case Description: A 69-year-old man with a history of ulcerative colitis, status post C4-C7 fusion (secondary to myelopathy over 10 years ago), presented with a 1-year history of right upper extremity pain and paresthesia. Recent MRI of the cervical spine showed evidence of a well-healed fusion from C4-C7 with findings of degenerative changes at C3-4 and C7-T1. The patient did have an MRI of the brachial plexus, which was unremarkable. The patient denied any lower extremity symptoms; however, he did have some paresthesias in the sole of his feet. The patient noted that most of his symptoms began after infliximab infusion therapy for ulcerative colitis. His last infliximab infusion was 8 weeks prior to this appointment. He denied any bowel or bladder dysfunction. On physical examination, the patient was neurologically intact, except for except for 4/5 strength in the right hand intrinsics. There were no upper motor neuron signs. Setting: Outpatient spine practice. Results or Clinical Course: Electrodiagnostic studies of the upper and lower extremities showed prolonged latencies, diminished amplitudes and conduction velocities, in multiple nerves in a non-focal distribution. Diminished recruitment and polyphasic potentials were found in the majority of muscles in the upper and lower extremities. The patient was diagnosed with multifocal acquired demyelinating sensory and motor (MADSAM) neuropathy. He was referred to neurology where he was advised to begin intravenous immunoglobulin (IVIg) therapy. Discussion: Multifocal acquired demyelinating sensory and motor (MADSAM) neuropathy is defined clinically by a multifocal pattern of motor and sensory loss, with nerve conduction studies showing conduction block and features of demyelination. Also known as Lewis-Sumner syndrome, this neuropathy is a rarely reported complication in patients undergoing treatment with the antitumor necrosis factor ␣ (TNF-␣) monoclonal antibody infliximab. Symptoms may resolve after cessation of the antibody treatment; however IV Ig infusion therapy is the treatment of choice if symptoms persist. Conclusions: We present a rarely reported case of MADSAM, or Lewis-Sumner syndrome, following infliximab treatment. Clinicians should be aware that electrodiagnostic studies are essential in the diagnosis of this complex neuropathy. Poster 115 Improving Electrodiagnostic Medicine Skills & Competency in Physical Medicine and Rehabilitation Residents Utilizing a Peer to Peer Teaching Module. Brite J. Chalunkal, DO, DPT (NYPH Cornell/Columbia University, Yonkers, NY, United States); Christopher Visco, MD. Disclosures: B. J. Chalunkal, No Disclosures.
Vol. 4, Iss. 10S, 2012
S229
Objective: This project sought to determine the effectiveness of a peer to peer EMG hands-on training course as an educational module including evaluation methodology to instruct residents in electrodiagnostic evaluation and to quantify acquired competencies in those electrodiagnostic skills through objective evaluation methodology. Design: One-way repeated measure ANOVA. Setting: Level 1 trauma center. Participants: 14 PM&R residents: 7 PGY2s and 7 PGY3s. Interventions: Fourteen residents participated in a course in which the senior third-year residents were assigned to teach the junior residents through technical training concepts. Prior to the hands-on course all residents were required to take a 36-question written examination, which tested basic aspects of EMG and clinical anatomy. All of the residents also completed a 20-question hands-on pre-course practical. After delivery of the educational module, knowledge acquisition and skill attainment were measured in clinical skill in diagnostic procedures via a procedure checklist and written exam. Main Outcome Measures: Objective measures compared resident pre and post course written and practical scores in electrodiagnostics (EDX) before and after institution of the comprehensive EDX competency module. Results: 14 of the 14 residents (100%) successfully demonstrated proficiency in every segment of the evaluation element of the educational module by the end of the electrodiagnostic course. There was a statistically significant difference in pre and post scores in both the written and practical overall with a P score less than .05 . In the PGY2 group N(7) there was an improvement of practical score from 27.5 ⫾ 10 to 77.5 ⫾ 15 (P⬍.0005) and an improvement in written from 41.6 ⫾ 4 to 63.43 ⫾ 11.3 (P⬍.0016). In the PGY3 group N(7) there was also an improvement of practical scores from 70.8 ⫾ 11 to 98.3 ⫾3 (P⬍.01) and an improvement in written from 45.8 ⫾ 7to 74.75 ⫾ 9.6 (P⬍.00012). Conclusions: The standardized educational peer to peer module and evaluation methodology provide a potential frame work for the definition of baseline competency in the clinical skill area of EDX. Poster 116 Riche-Cannieu Anastomosis Masquerading as Severe Median Neuropathy: A Case Report. Christopher J. Hess, MD (University of Virginia, Charlottesville, VA, United States); Jeffrey G. Jenkins, MD. Disclosures: C. J. Hess, No Disclosures. Case Description: A 45-year-old woman presented with insidious onset of right upper extremity pain over 8 months. She had been diagnosed with acute severe right-hand median neuropathy found on EMG/NCS performed 2 months after symptom onset by an outside provider. Specifically, the electrodiagnostic report showed severe reduction in median compound motor action potential (CMAP) amplitude and 3⫹ fibrillation potentials in the abductor pollicis brevis. The patient was referred for continued symptoms that were refractory to carpal tunnel injection. It was noted on examination that her thenar musculature was well preserved; this called into question the diagnosis of severe median neuropathy, prompting referral to our lab for repeat testing. Setting: Academic outpatient electromyography lab. Results or Clinical Course: Repeat EMG/NCS performed 8 months after symptom onset showed the following: Findings- 1.
surgery may include nerve traction, nerve compression secondary to taut ligaments and nerve transection. Poster 114 Multifocal Acquired Demyelinating Sensory and Motor (MADSAM) Neuropathy Secondary to Infliximab Infusion: A Case Report. Anupam Sinha, DO (Rothman Institute, Philadelphia, PA, United States); Madhuri Dholakia, MD. Disclosures: A. Sinha, No Disclosures. Case Description: A 69-year-old man with a history of ulcerative colitis, status post C4-C7 fusion (secondary to myelopathy over 10 years ago), presented with a 1-year history of right upper extremity pain and paresthesia. Recent MRI of the cervical spine showed evidence of a well-healed fusion from C4-C7 with findings of degenerative changes at C3-4 and C7-T1. The patient did have an MRI of the brachial plexus, which was unremarkable. The patient denied any lower extremity symptoms; however, he did have some paresthesias in the sole of his feet. The patient noted that most of his symptoms began after infliximab infusion therapy for ulcerative colitis. His last infliximab infusion was 8 weeks prior to this appointment. He denied any bowel or bladder dysfunction. On physical examination, the patient was neurologically intact, except for except for 4/5 strength in the right hand intrinsics. There were no upper motor neuron signs. Setting: Outpatient spine practice. Results or Clinical Course: Electrodiagnostic studies of the upper and lower extremities showed prolonged latencies, diminished amplitudes and conduction velocities, in multiple nerves in a non-focal distribution. Diminished recruitment and polyphasic potentials were found in the majority of muscles in the upper and lower extremities. The patient was diagnosed with multifocal acquired demyelinating sensory and motor (MADSAM) neuropathy. He was referred to neurology where he was advised to begin intravenous immunoglobulin (IVIg) therapy. Discussion: Multifocal acquired demyelinating sensory and motor (MADSAM) neuropathy is defined clinically by a multifocal pattern of motor and sensory loss, with nerve conduction studies showing conduction block and features of demyelination. Also known as Lewis-Sumner syndrome, this neuropathy is a rarely reported complication in patients undergoing treatment with the antitumor necrosis factor ␣ (TNF-␣) monoclonal antibody infliximab. Symptoms may resolve after cessation of the antibody treatment; however IV Ig infusion therapy is the treatment of choice if symptoms persist. Conclusions: We present a rarely reported case of MADSAM, or Lewis-Sumner syndrome, following infliximab treatment. Clinicians should be aware that electrodiagnostic studies are essential in the diagnosis of this complex neuropathy. Poster 115 Improving Electrodiagnostic Medicine Skills & Competency in Physical Medicine and Rehabilitation Residents Utilizing a Peer to Peer Teaching Module. Brite J. Chalunkal, DO, DPT (NYPH Cornell/Columbia University, Yonkers, NY, United States); Christopher Visco, MD. Disclosures: B. J. Chalunkal, No Disclosures.
Vol. 4, Iss. 10S, 2012
S229
Objective: This project sought to determine the effectiveness of a peer to peer EMG hands-on training course as an educational module including evaluation methodology to instruct residents in electrodiagnostic evaluation and to quantify acquired competencies in those electrodiagnostic skills through objective evaluation methodology. Design: One-way repeated measure ANOVA. Setting: Level 1 trauma center. Participants: 14 PM&R residents: 7 PGY2s and 7 PGY3s. Interventions: Fourteen residents participated in a course in which the senior third-year residents were assigned to teach the junior residents through technical training concepts. Prior to the hands-on course all residents were required to take a 36-question written examination, which tested basic aspects of EMG and clinical anatomy. All of the residents also completed a 20-question hands-on pre-course practical. After delivery of the educational module, knowledge acquisition and skill attainment were measured in clinical skill in diagnostic procedures via a procedure checklist and written exam. Main Outcome Measures: Objective measures compared resident pre and post course written and practical scores in electrodiagnostics (EDX) before and after institution of the comprehensive EDX competency module. Results: 14 of the 14 residents (100%) successfully demonstrated proficiency in every segment of the evaluation element of the educational module by the end of the electrodiagnostic course. There was a statistically significant difference in pre and post scores in both the written and practical overall with a P score less than .05 . In the PGY2 group N(7) there was an improvement of practical score from 27.5 ⫾ 10 to 77.5 ⫾ 15 (P⬍.0005) and an improvement in written from 41.6 ⫾ 4 to 63.43 ⫾ 11.3 (P⬍.0016). In the PGY3 group N(7) there was also an improvement of practical scores from 70.8 ⫾ 11 to 98.3 ⫾3 (P⬍.01) and an improvement in written from 45.8 ⫾ 7to 74.75 ⫾ 9.6 (P⬍.00012). Conclusions: The standardized educational peer to peer module and evaluation methodology provide a potential frame work for the definition of baseline competency in the clinical skill area of EDX. Poster 116 Riche-Cannieu Anastomosis Masquerading as Severe Median Neuropathy: A Case Report. Christopher J. Hess, MD (University of Virginia, Charlottesville, VA, United States); Jeffrey G. Jenkins, MD. Disclosures: C. J. Hess, No Disclosures. Case Description: A 45-year-old woman presented with insidious onset of right upper extremity pain over 8 months. She had been diagnosed with acute severe right-hand median neuropathy found on EMG/NCS performed 2 months after symptom onset by an outside provider. Specifically, the electrodiagnostic report showed severe reduction in median compound motor action potential (CMAP) amplitude and 3⫹ fibrillation potentials in the abductor pollicis brevis. The patient was referred for continued symptoms that were refractory to carpal tunnel injection. It was noted on examination that her thenar musculature was well preserved; this called into question the diagnosis of severe median neuropathy, prompting referral to our lab for repeat testing. Setting: Academic outpatient electromyography lab. Results or Clinical Course: Repeat EMG/NCS performed 8 months after symptom onset showed the following: Findings- 1.