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Poster 358 Diagnosis and Treatment of Musculoskeletal and Neuropathic Pain After Cardiothoracic Surgery: A Case Report
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Design: Prospective randomized controlled study. Setting: Urban, academic physical medicine and rehabilitation residency program. Participants: Physical medicine and rehabilitation residents (n⫽17), control group (n⫽8) and treatment group (n⫽9). Interventions: All residents were given an examination of neuroanatomy that included a multiple choice portion (written) and a plexus labeling portion (drawing) at baseline and at 5 weeks. Residents in the control group received only lecture notes. Residents in treatment group received lecture notes as well as four interactive neuroanatomy lectures including visual aids, such as plexus drawings, supplemented with pneumonic devices given over a 5-week period. Main Outcome Measures: Post-test performance on the total exam score (max⫽80), written exam score (max⫽20), and drawing exam score (max⫽60) adjusted for baseline scores. Results: Both the treatment and control groups improved in the total exam score (32.6⫾11.0 and 22.4⫾20.6, respectively) and drawing exam score (30.7⫾10.7 and 23.1⫾19.1, respectively). The treatment group improved in the written exam (1.9⫾2.6) whereas the control group performed worse at follow-up (⫺0.8⫾3.3). At 5 weeks, there was no significant difference between treatment group verses control group in the total exam score (P⫽.2) or the drawing exam score (P⫽.6), but there was a significant difference in the written exam score (P⫽.03). Conclusions: The interactive neuroanatomy lecture series was associated with higher written exam scores at 5 weeks than those for residents who received lecture notes only. The interactive neuroanatomy lectures were associated with non-significantly higher scores in drawing exam score and the total exam score. Poster 357 Assessing Medical Students’ Ability to Learn Ultrasound-Guided Interventional Procedures. Zachary T. Hafez, MS (University of Missouri School of Medicine, Columbia, MO, United States); Reza Farid, MD; Fred Murdock, PhD. Disclosures: Z. T. Hafez, No Disclosures. Objective: The objective of this study was to determine the ability of medical students to learn and perform ultrasound (US)guided needle interventions under simulated clinical conditions. Setting: The procedures were performed in a clinical outpatient setting using a clinical US instrument and standard clinical equipment. The interventions were performed on a gelatin based, tissuemimicking phantom with buried targets to visually simulate cystic structures under US. The procedure was monitored and approved by an experienced physician who performs US-guided needle interventions. Participants: Nine medical students who recently completed their 1st year of medical education with no prior US-guided procedure experience. Results: The average time in seconds per injection ⫾ standard deviation decreased from 69⫾26 for the first injection to 47⫾25 for the 4th injection (P⫽.038). The average accuracy for all medical students was 86% (95% confidence interval: 70.5 ⫺95.3) with 5 of 9 students scoring 100%. The difference in average time to inject between 100% accuracy and 75% accuracy groups trended toward significance based on the Kruskai-Wallis test (P⫽.05). Of 9 students, 7 felt moderately comfortable with the US procedures after
PRESENTATIONS
the tutorial and all students thought that this type of intervention should be taught in a medical school curriculum. Conclusions: Students were able to achieve a high degree of accuracy and relatively rapid injection times with limited training. US-guided techniques can be learned by medical students early in their training. Integration of these techniques into medical curriculum may reduce the need for future specialized training.
PAIN REHABILITATION Poster 358 Diagnosis and Treatment of Musculoskeletal and Neuropathic Pain After Cardiothoracic Surgery: A Case Report. Abhishek Gowda, MD (Stanford University, Redwood City, CA, United States); Alpana Gowda, MD. Disclosures: A. Gowda, No Disclosures. Case Description: A 61-year-old man, status post mitral valve repair for mitral valve regurgitation, describes full body dysesthesias that started immediately upon awakening from sternotomy. Initially, the patient described truncal pain wrapping around the thoracic spine and referring cephalad into the neck and upper chest wall area. Due to the pruritis of the sternotomy scar, he was treated by dermatology for dermatographia. As time went on, the patient’s pain was more and more severe and debilitating. The patient described the pain as itchy, hot, throbbing and stabbing in nature. Multiple treatment modalities including peripheral nerve blocks, opioid and non-opioid medication trials and cognitive behavioral therapies were initiated. Patient continued to have decline in daily function. Setting: Tertiary outpatient pain management clinic. Interventions: Injections of the sternotomy scar with alcohol and local anesthetic in a series. Results or Clinical Course: Series of injection treatments and follow-up evaluations over a 2-year time frame. One year after initiating treatment, a scar injection with local anesthetic produced mild analgesia for several hours. This injection was then followed up by chemodenervation of scar with increasing concentrations of alcohol in a series of injections over a 6-month period. The patient reports decrease in overall pain by 60%. Patient was able to decrease his opioid medications by 75%. Objective measurement of daily functional improvement showed dramatic improvement in activities including ability to self-groom. Conclusions: Patient with full body pain and thoracic dysesthesias post sternotomy was noted to have decrease in overall pain complaints post chemodenervation with alcohol injections to the sternotomy scar. This gives some indication that scar neuroma pain when treated can potentially translate to a decrease in a more centralized cause of this patient’s pain problems. Poster 360 Epidural Hematoma and Paraplegia After Spinal Cord Stimulator Removal: A Case Report. Alberto Panero, DO (University of Miami, Miami, FL, United States); Jamil Bashir, MD; Jackson Cohen, MD; Kevin L. Dalal, MD; Jose Mena, MD. Disclosures: A. Panero, No Disclosures. Case Description: A 63-year-old woman with history of thoracic myelopathy secondary to calcified disks at T6-7 and T7-8 that
Design: Prospective randomized controlled study. Setting: Urban, academic physical medicine and rehabilitation residency program. Participants: Physical medicine and rehabilitation residents (n⫽17), control group (n⫽8) and treatment group (n⫽9). Interventions: All residents were given an examination of neuroanatomy that included a multiple choice portion (written) and a plexus labeling portion (drawing) at baseline and at 5 weeks. Residents in the control group received only lecture notes. Residents in treatment group received lecture notes as well as four interactive neuroanatomy lectures including visual aids, such as plexus drawings, supplemented with pneumonic devices given over a 5-week period. Main Outcome Measures: Post-test performance on the total exam score (max⫽80), written exam score (max⫽20), and drawing exam score (max⫽60) adjusted for baseline scores. Results: Both the treatment and control groups improved in the total exam score (32.6⫾11.0 and 22.4⫾20.6, respectively) and drawing exam score (30.7⫾10.7 and 23.1⫾19.1, respectively). The treatment group improved in the written exam (1.9⫾2.6) whereas the control group performed worse at follow-up (⫺0.8⫾3.3). At 5 weeks, there was no significant difference between treatment group verses control group in the total exam score (P⫽.2) or the drawing exam score (P⫽.6), but there was a significant difference in the written exam score (P⫽.03). Conclusions: The interactive neuroanatomy lecture series was associated with higher written exam scores at 5 weeks than those for residents who received lecture notes only. The interactive neuroanatomy lectures were associated with non-significantly higher scores in drawing exam score and the total exam score. Poster 357 Assessing Medical Students’ Ability to Learn Ultrasound-Guided Interventional Procedures. Zachary T. Hafez, MS (University of Missouri School of Medicine, Columbia, MO, United States); Reza Farid, MD; Fred Murdock, PhD. Disclosures: Z. T. Hafez, No Disclosures. Objective: The objective of this study was to determine the ability of medical students to learn and perform ultrasound (US)guided needle interventions under simulated clinical conditions. Setting: The procedures were performed in a clinical outpatient setting using a clinical US instrument and standard clinical equipment. The interventions were performed on a gelatin based, tissuemimicking phantom with buried targets to visually simulate cystic structures under US. The procedure was monitored and approved by an experienced physician who performs US-guided needle interventions. Participants: Nine medical students who recently completed their 1st year of medical education with no prior US-guided procedure experience. Results: The average time in seconds per injection ⫾ standard deviation decreased from 69⫾26 for the first injection to 47⫾25 for the 4th injection (P⫽.038). The average accuracy for all medical students was 86% (95% confidence interval: 70.5 ⫺95.3) with 5 of 9 students scoring 100%. The difference in average time to inject between 100% accuracy and 75% accuracy groups trended toward significance based on the Kruskai-Wallis test (P⫽.05). Of 9 students, 7 felt moderately comfortable with the US procedures after
PRESENTATIONS
the tutorial and all students thought that this type of intervention should be taught in a medical school curriculum. Conclusions: Students were able to achieve a high degree of accuracy and relatively rapid injection times with limited training. US-guided techniques can be learned by medical students early in their training. Integration of these techniques into medical curriculum may reduce the need for future specialized training.
PAIN REHABILITATION Poster 358 Diagnosis and Treatment of Musculoskeletal and Neuropathic Pain After Cardiothoracic Surgery: A Case Report. Abhishek Gowda, MD (Stanford University, Redwood City, CA, United States); Alpana Gowda, MD. Disclosures: A. Gowda, No Disclosures. Case Description: A 61-year-old man, status post mitral valve repair for mitral valve regurgitation, describes full body dysesthesias that started immediately upon awakening from sternotomy. Initially, the patient described truncal pain wrapping around the thoracic spine and referring cephalad into the neck and upper chest wall area. Due to the pruritis of the sternotomy scar, he was treated by dermatology for dermatographia. As time went on, the patient’s pain was more and more severe and debilitating. The patient described the pain as itchy, hot, throbbing and stabbing in nature. Multiple treatment modalities including peripheral nerve blocks, opioid and non-opioid medication trials and cognitive behavioral therapies were initiated. Patient continued to have decline in daily function. Setting: Tertiary outpatient pain management clinic. Interventions: Injections of the sternotomy scar with alcohol and local anesthetic in a series. Results or Clinical Course: Series of injection treatments and follow-up evaluations over a 2-year time frame. One year after initiating treatment, a scar injection with local anesthetic produced mild analgesia for several hours. This injection was then followed up by chemodenervation of scar with increasing concentrations of alcohol in a series of injections over a 6-month period. The patient reports decrease in overall pain by 60%. Patient was able to decrease his opioid medications by 75%. Objective measurement of daily functional improvement showed dramatic improvement in activities including ability to self-groom. Conclusions: Patient with full body pain and thoracic dysesthesias post sternotomy was noted to have decrease in overall pain complaints post chemodenervation with alcohol injections to the sternotomy scar. This gives some indication that scar neuroma pain when treated can potentially translate to a decrease in a more centralized cause of this patient’s pain problems. Poster 360 Epidural Hematoma and Paraplegia After Spinal Cord Stimulator Removal: A Case Report. Alberto Panero, DO (University of Miami, Miami, FL, United States); Jamil Bashir, MD; Jackson Cohen, MD; Kevin L. Dalal, MD; Jose Mena, MD. Disclosures: A. Panero, No Disclosures. Case Description: A 63-year-old woman with history of thoracic myelopathy secondary to calcified disks at T6-7 and T7-8 that