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Poster 482 Development of Gluteal Hematoma following Greater Trochanteric Bursa Injection: A Case Report
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Setting: Outpatient Pain Management and Rehabilitation Clinic Results or Clinical Course: At 6 weeks post-ablation, that patient’s sharp electric-like pain in the right jaw was greatly improved, and she was able to gain weight and eat without significant pain. She did perceive a continued dull ache in the same distribution that was not there prior to nerve ablation, requiring continuation of her pain medications, and scheduled maintenance nerve blocks. Discussion: While functional improvement and overall pain reduction was achieved, residual nociceptive pain necessitated continued medications and injections. Neuromodulation is currently being considered for refractory pain. Conclusions: RFA of the mandibular nerve is a viable alternative for treatment of refractory V3 trigeminal neuralgia in patients in whom conservative measures have failed, and when there is no identifiable nerve entrapment. Indications include the various etiologies of mandibular nerve pain, which include dental pain, post-traumatic, post-surgical, idiopathic, multiple sclerosis, or postherpetic pain. Poster 481 Improved Outcomes in Postconcussive Syndrome (PCS) with Implementation of Integrative Pain Program: Retrospective Review of Data. Brendan J. Polun, DO (Marianjoy Rehabilitation Hospital, Wheaton, IL, United States); Jeffrey E. Oken, MD; Kathleen Ruroede, PhD, MEd, RN. Disclosures: B. J. Polun, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Objective: To test hypotheses that people with post-concussive syndrome (PCS) benefit from undergoing a comprehensive integrative pain management protocol, with increase in perceived functional ability, physical activity capacity, endurance as well as decreased pain behaviors and neck disability index. Design: Retrospective study Setting: Full day outpatient Integrative Pain Management Program Participants: 3 recent subjects who underwent full day program for PCS Interventions: Each participant underwent group and individual physical therapy, psychology, biofeedback and were medically managed by a physiatrist. Physical therapy included functional ambulation groups, individualized exercises and flare up drills. Psychology and biofeedback included both group and individualized sessions focused on communication, depression, pain, relaxation and stress. Main Outcome Measures: We performed a series of subjective and objective outcome measure tests including our program developed Marianjoy Pain Functional Assessment Tool (MPFAT) which includes Visual analog scale (VAS), assessment of pain behavior with modified UAB scale, Rate of perceived exertion (RPE), assessment of current physical ability, as well as 8 physical activity capacity tests on initiation and discharge. Results or Clinical Course: From admission to discharge there was an overall reduction in UAB and VAS values, improvement in RPE and greater performance in normal and fast walking. There was also improved performance in lifting weights under all conditions and step ups. There are mixed results for physical abilities by case
PRESENTATIONS
with some variability in outcomes by individual. Fear avoidance and headache measures did not reflect much change across this population as a whole but individually there were improvements. Neck disability limitations showed marked improvement from admission to discharge. Conclusions: A comprehensive integrative pain program focused on an individualized but structured post-concussive protocol that addresses functionality, endurance, stress reduction, relaxation and coping mechanisms provides improvement in multiple areas including rate of perceived exertion, fear avoidance, physical activity, functional ability and pain behaviors. Poster 482 Development of Gluteal Hematoma following Greater Trochanteric Bursa Injection: A Case Report. Julie A. Ferris, MD (William Beaumont Hospital, Royal Oak, MI, United States); Louis Ostola, MD; Randi J. Long, MD. Disclosures: J. A. Ferris, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: The patient is an 85-year-old man admitted to inpatient rehabilitation (IPR) with a diagnosis of critical illness myopathy. He had a prolonged intensive care unit (ICU) stay with ventilator dependent respiratory failure. Medical complications included deep venous thrombosis (DVT) treated with Fondaparinux. While on IPR, the patient developed right lateral hip pain thought to be trochanteric bursitis. He received a steroid injection to the right greater trochanteric bursa. Three days following injection, the patient developed worsened right hip pain. MRI of the right hip noted extensive intramuscular edema with abnormal postcontrast enhancement involving the right gluteal, right obturator, and right adductor musculature. Multiple pockets of complex fluid collections were found in both the supratrochanteric and posterior peritrochanteric regions. The patient’s hemoglobin dropped from 8.0 g/dL to 4.9 g/dL. Follow up CT performed at that time noted significant enlargement of the fluid collections predominately in the right gluteus minimus and medius musculature concerning for intramuscular hemorrhage. Patient had no history of fall or trauma. Setting: Tertiary care hospital. Results or Clinical Course: The patient required multiple blood transfusions and eventually underwent irrigation/debridement with evacuation of the hematoma. Bacterial cultures taken during surgery were negative. Patient had a complicated acute hospital stay but was ultimately readmitted to IPR to complete his rehabilitation process. He was discharged to home at ambulatory level. He was restarted on anticoagulation for treatment of his DVT without further bleeding. Discussion: This is a rare case of development of a large right gluteal hematoma three days following right greater trochanteric bursa injection. The patient was on Fondaparinux for treatment of DVT at the time of the injection. He had no history of trauma. It is hard to ignore the close proximity of these two events without speculation of a causal relationship. Conclusions: Steroid injections are commonly performed for treatment of acute bursitis in hospitalized and non-hospitalized patients, including those on anticoagulation. Although these injections are usually benign, this case highlights the potential for devastating complications.
Setting: Outpatient Pain Management and Rehabilitation Clinic Results or Clinical Course: At 6 weeks post-ablation, that patient’s sharp electric-like pain in the right jaw was greatly improved, and she was able to gain weight and eat without significant pain. She did perceive a continued dull ache in the same distribution that was not there prior to nerve ablation, requiring continuation of her pain medications, and scheduled maintenance nerve blocks. Discussion: While functional improvement and overall pain reduction was achieved, residual nociceptive pain necessitated continued medications and injections. Neuromodulation is currently being considered for refractory pain. Conclusions: RFA of the mandibular nerve is a viable alternative for treatment of refractory V3 trigeminal neuralgia in patients in whom conservative measures have failed, and when there is no identifiable nerve entrapment. Indications include the various etiologies of mandibular nerve pain, which include dental pain, post-traumatic, post-surgical, idiopathic, multiple sclerosis, or postherpetic pain. Poster 481 Improved Outcomes in Postconcussive Syndrome (PCS) with Implementation of Integrative Pain Program: Retrospective Review of Data. Brendan J. Polun, DO (Marianjoy Rehabilitation Hospital, Wheaton, IL, United States); Jeffrey E. Oken, MD; Kathleen Ruroede, PhD, MEd, RN. Disclosures: B. J. Polun, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Objective: To test hypotheses that people with post-concussive syndrome (PCS) benefit from undergoing a comprehensive integrative pain management protocol, with increase in perceived functional ability, physical activity capacity, endurance as well as decreased pain behaviors and neck disability index. Design: Retrospective study Setting: Full day outpatient Integrative Pain Management Program Participants: 3 recent subjects who underwent full day program for PCS Interventions: Each participant underwent group and individual physical therapy, psychology, biofeedback and were medically managed by a physiatrist. Physical therapy included functional ambulation groups, individualized exercises and flare up drills. Psychology and biofeedback included both group and individualized sessions focused on communication, depression, pain, relaxation and stress. Main Outcome Measures: We performed a series of subjective and objective outcome measure tests including our program developed Marianjoy Pain Functional Assessment Tool (MPFAT) which includes Visual analog scale (VAS), assessment of pain behavior with modified UAB scale, Rate of perceived exertion (RPE), assessment of current physical ability, as well as 8 physical activity capacity tests on initiation and discharge. Results or Clinical Course: From admission to discharge there was an overall reduction in UAB and VAS values, improvement in RPE and greater performance in normal and fast walking. There was also improved performance in lifting weights under all conditions and step ups. There are mixed results for physical abilities by case
PRESENTATIONS
with some variability in outcomes by individual. Fear avoidance and headache measures did not reflect much change across this population as a whole but individually there were improvements. Neck disability limitations showed marked improvement from admission to discharge. Conclusions: A comprehensive integrative pain program focused on an individualized but structured post-concussive protocol that addresses functionality, endurance, stress reduction, relaxation and coping mechanisms provides improvement in multiple areas including rate of perceived exertion, fear avoidance, physical activity, functional ability and pain behaviors. Poster 482 Development of Gluteal Hematoma following Greater Trochanteric Bursa Injection: A Case Report. Julie A. Ferris, MD (William Beaumont Hospital, Royal Oak, MI, United States); Louis Ostola, MD; Randi J. Long, MD. Disclosures: J. A. Ferris, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: The patient is an 85-year-old man admitted to inpatient rehabilitation (IPR) with a diagnosis of critical illness myopathy. He had a prolonged intensive care unit (ICU) stay with ventilator dependent respiratory failure. Medical complications included deep venous thrombosis (DVT) treated with Fondaparinux. While on IPR, the patient developed right lateral hip pain thought to be trochanteric bursitis. He received a steroid injection to the right greater trochanteric bursa. Three days following injection, the patient developed worsened right hip pain. MRI of the right hip noted extensive intramuscular edema with abnormal postcontrast enhancement involving the right gluteal, right obturator, and right adductor musculature. Multiple pockets of complex fluid collections were found in both the supratrochanteric and posterior peritrochanteric regions. The patient’s hemoglobin dropped from 8.0 g/dL to 4.9 g/dL. Follow up CT performed at that time noted significant enlargement of the fluid collections predominately in the right gluteus minimus and medius musculature concerning for intramuscular hemorrhage. Patient had no history of fall or trauma. Setting: Tertiary care hospital. Results or Clinical Course: The patient required multiple blood transfusions and eventually underwent irrigation/debridement with evacuation of the hematoma. Bacterial cultures taken during surgery were negative. Patient had a complicated acute hospital stay but was ultimately readmitted to IPR to complete his rehabilitation process. He was discharged to home at ambulatory level. He was restarted on anticoagulation for treatment of his DVT without further bleeding. Discussion: This is a rare case of development of a large right gluteal hematoma three days following right greater trochanteric bursa injection. The patient was on Fondaparinux for treatment of DVT at the time of the injection. He had no history of trauma. It is hard to ignore the close proximity of these two events without speculation of a causal relationship. Conclusions: Steroid injections are commonly performed for treatment of acute bursitis in hospitalized and non-hospitalized patients, including those on anticoagulation. Although these injections are usually benign, this case highlights the potential for devastating complications.