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Poster 535 Spinal Cord Neuromodulation in the Management of HIV-Related Polyneuropathy: Case Report
PM&R
acupuncture, chiropractic treatments, and various medication regimens without resolution of the pain. Furthermore, the patient has a long history of vertigo managed with meclizine as needed. On physical exam, six trigger points were identified along the right side of the cervical paraspinals, upper trapezius, and along the medial boarder of the scapula, with reproducible pain, numbness, and tingling in the right arm, hand, as well as headache. These six trigger points were injected with a total of 10cc of 40mg triamcinolone, 5cc of 1% lidocaine, and 4cc of 0.25% bupivicaine, 1-2cc per point. Setting: Outpatient physical medicine and rehabilitation clinic of an academic medical center. Results or Clinical Course: The patient reported relief of her myofascial pain for approximately 3 months following the procedure. Furthermore, she also endorsed an unexpected resolution of her vertigo, as she has not had an episode since the injection. Discussion: A retrospective review of 94 patients with cervical myofascial pain syndrome revealed 35.1% of patients experienced vertigo with trigger point palpation. Additional studies have shown a successful resolution of vertigo in patients with cervical myofascial pain syndrome and Meniere’s disease with a myofascial component by both chiropractic and osteopathic manipulation techniques. Conclusions: There appears to be a relationship between vertigo and myofascial pain syndrome. It may be prudent to further evaluate patients presenting with vertigo for underlying myofascial pain syndrome of the cervical region, with possible treatments including trigger point injections as shown in this case report. Poster 534 The Importance of Rehabilitation (Physical Therapy) after Lumbar Spinal Injection for Spinal Pain Patient. A Retrospective Chart Review of 1600 Spinal Patients. Yung C. Chen, MD, MD (San Mateo Spine Center, San Mateo, CA, United States). Disclosures: Y. C. Chen MD, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Objective: To determine importance of physical therapy after spinal pain patient treated with epidural injection. Two groups of patients were compared: PT treated post-injection spine patient group vs. None-PT treated group post injection patient group. Design: Therapeutic lumbar spinal injections (lumbar epidural injection, medial branch blocks, SI joint blocks, facet joint injection) are often utilized to treat lumbar spine pain patients with or without sciatica. Physical therapy (PT) is often incorporated into post-spinal injection patients for stabilization program and functional gain. However, the post-procedural patients not receiving PT were observed to have less optimal functional outcomes. This study is a retrospective chart review of these two groups of patients. Setting: The study is conducted in the outpatient setting. Charts were reviewed and studied. Participants: This is a retrospective chart review of 1600 patients who suffer back with or without leg symptoms secondary to HNP, SI joint pain, facet joint pain, failed back surgery, lumbar sacral radiculopathy, spinal steosis, and radiculitis. 1600 electronic charts
Vol. 6, Iss. 9S, 2014
S373
were reviewed. Female ¼ 782, Avg age 66. Male # ¼ 818, Avg age 62. Main Outcome Measures: Patient satisfaction, functional gain, medication usage, and number of injetions performed were documented and calculated. Results or Clinical Course: 92% of PT treated group report functional gain in six months; 52% of None-PT treated group report minimum functional gain. 30% of PT treated group patients do not require second injection within six months; 68% of None-PT treated group require second injection within six months. PT treated group utilizes less oral pain medications vs. non-PT treated group by 60%. PT treated group reports higher satisfaction with specific spinal exercise vs. None PT treated group. Conclusions: This study supports the importance of physical therapy after spinal injections for patients suffering back pain with or without sciatica. PT should not be ignored as an integral part of spinal management to achieve maximum functional outcome. Spine surgeons, anesthesiologist or chiropractor may consider incorporating PT as part of spinal management. Poster 535 Spinal Cord Neuromodulation in the Management of HIV-Related Polyneuropathy: Case Report. George C. Chang Chien, DO (Rehabilitation Institute of Chicago, Chicago, IL, United States); Nebojsa Nick Knezevic, MD, PhD; Kenneth D. Candido, MD. Disclosures: G. C. Chang Chien, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Objective: To report successful use of spinal cord neuromodulation in the treatment of HIV-related neuropathy. Case Description: Due to the effectiveness of antiretroviral medication and a decline in central nervous system opportunistic infection and HIV-related dementia, HIV-associated neuropathies have become the most common neurological disorder associated with AIDS, affecting 1 in 3 patients. Patients with HIV-related polyneuropathy typically present with painful dysesthesias in a symmetrical, length dependent distribution which can be challenging to treat.We report a case of a 39-year-old man with a past medical history significant for Hepatitis C and depression, diagnosed with HIV six years prior who presented with worsening burning pain in all four limbs. His medication regimen at presentation included pregabalin 350 mg daily; acetaminophen with codeine 1300/10mg daily, gabapentin 400 mg twice daily, citalopram 20 mg daily, clonazepam 0.5 mg twice daily, and buspirone 20 mg twice daily. He continued to experience pain and side effects from his medication regimen and requested aggressive interventional therapy be considered on his behalf. He underwent a St. Jude’s dual lead spinal cord stimulator (SCS) trial wherein two 8-electrode leads were situated with the proximal-most contact at the cephalad margin of the T-10 vertebral body. On the third day post-procedure, the patient reported a 90-95% of improvement in pain. A decision was made to proceed with a permanent SCS implant, which was undertaken three weeks later. Program Description: Department of Anesthesiology and Pain Medicine. Setting: Outpatient Pain Management Office.
S374
Results or Clinical Course: At follow up the patient reported 95-100% improvement in pain and over the course of many months was successfully weaned off of all his pain medications. At the 4-year follow up, he continued to report successful management of his painful peripheral neuropathy. Conclusions: The use of spinal cord stimulation should be judiciously considered in cases of severe neuropathic pain. In the carefully selected patient, SCS neuromodulation is a safe, viable, and efficacious option for patients whose HIV-related neuropathic type pain is refractory to conventional treatment modalities. Poster 536 Scalp Peripheral Nerve Stimulation for Intractable Headache. Joseph W. Smith, MD (Thomas Jefferson University, Philadelphia, PA, United States); Linqiu Zhou, MD; Nana Jen, Medical Student. Disclosures: J. W. Smith, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Objective: The aim of this research was to study the efficacy of scalp peripheral nerves (occipital, supraorbital and auriculotemporal) stimulation therapy for intractable headaches. Background: Intractable migraine and other headache syndromes affect approximately 38 million Americans and millions worldwide. There is estimated to be at least 5% of these headache sufferers with adverse effects on their lives and significant socioeconomic burden who do not respond to medications. Design: Retrospective study. Setting: Combined academic and private pain clinic. Participants: Twenty- two intractable headache patients (5 males, 17 females, age 23-66) were followed from 6 months to 7 years after scalp peripheral nerve stimulation implantation. All of these patients had failed conservative therapies including medication management and local injections. They were referred by headache specialists. Interventions: After a successful trial, all patients underwent percutaneous occipital with or without combined supraorbital or auriculotemporal nerve stimulator implantation using a minimally invasive technique. Main Outcome Measures: Primary outcome measures were assessed by an independent reviewer, which included Total Pain Index (TPI), opioid medication usage, patient satisfaction and ability to return to work. Results or Clinical Course: Nineteen patients reported good to excellent pain reduction with a TPI drop from an average of 486.1 to 48.9. One patient rated fair pain relief with TPI decrease from 364 to 140. Two patients required removal of the stimulator: one was due to skin hypersensitivity to the stimulation leads and the other for religious preferences. Three patients developed late on-set infection from superficial anchors/suture knots requiring lead revision. All twenty patients weaned or significantly reduced their pain medications and returned to work. There were no long-term complications. Conclusions: Scalp peripheral nerve stimulation therapy is an appropriate alternative treatment for intractable headache patients who fail conservative therapy. It can offer significant and prolonged pain relief. Complications of this modality are mild and manageable.
PRESENTATIONS
Poster 537 Refractory Painful Spasms in the Setting of Transverse Myelitis Successfully Managed with Carbamazepine: A Case Report. Regan Royer, MD, MPH (University of Virginia, Charlottesville, VA, United States); Geoffrey Smith, MD. Disclosures: R. Royer, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: The patient initially presented with weakness and numbness in the left arm, which progressed to lower extremity weakness and right foot drop. MRI revealed a nonspecific cord lesion in her cervical spine favored to represent transverse myelitis. She was initially treated with high dose steroids and PLEX, followed by acute inpatient rehabilitation for tetraparesis. During inpatient rehabilitation she developed severe co-contraction spasms in the bilateral upper limbs, accompanied by severe pain in those limbs radiating to the neck during each spasm. The episodes lasted approximately 30 seconds and gradually increased both in frequency (to every 1-2 minutes) and in severity (10/10 pain). Due to the refractory nature of the symptoms, she was transferred back to the acute care hospital on the Neurology Service. The symptoms continued to worsen despite various combinations of Baclofen, Tizanidine, Gabapentin, PO and IV benzodiazepines, and PO and IV opioids. The patient developed hemodynamic instability from these medications, still without controlling symptoms. Intubation and sedation were being seriously considered for symptom control. PM&R Consult Service continued to be involved, ultimately recommending PO Carbamazepine. Setting: Acute rehabilitation hospital. Participants: 49-year-old female with progressive tetraparesis. Results or Clinical Course: The Carbamazepine was increased from 100 mg BID to 300 mg BID over 4 days; this titration correlated with a dramatic improvement in the patient’s painful spasms. She was able to return to and successfully complete her acute inpatient rehabilitation course, followed by discharge to home with assistance of family. A later attempt to decrease the dose of Carbamazepine resulted in temporary worsening of the spasms and associated pain until the dose was returned to 300 mg BID. Discussion: This case demonstrates the potential role of Carbamazepine for treatment of spasms and associated pain refractory to multiple medications. Conclusions: Carbamazepine should be considered as a treatment option in cases of severe refractory spasms with associated severe pain. Poster 538 Gender Differences versus Genotype Risk of CoMorbidities in Chronic Pain Patients. Dan Schwarz, MD (Proove Biosciences, Irvine, CA, United States); John Hubbard, PT; Tobore Onojighofia, MD, MPH; Meshkin Brian, BA; Bilikis Akindele, MD; Derrick Holman, MD; Nate Alderson, PhD; Matthew Doust, MD; Juetong Chen, MMCI. Disclosures: D. Schwarz, Proove Biosciences, Employment (full or part-time) Objective: To evaluate whether there are gender differences in mesolimbic genetic predispositions associated with risk for opioid
acupuncture, chiropractic treatments, and various medication regimens without resolution of the pain. Furthermore, the patient has a long history of vertigo managed with meclizine as needed. On physical exam, six trigger points were identified along the right side of the cervical paraspinals, upper trapezius, and along the medial boarder of the scapula, with reproducible pain, numbness, and tingling in the right arm, hand, as well as headache. These six trigger points were injected with a total of 10cc of 40mg triamcinolone, 5cc of 1% lidocaine, and 4cc of 0.25% bupivicaine, 1-2cc per point. Setting: Outpatient physical medicine and rehabilitation clinic of an academic medical center. Results or Clinical Course: The patient reported relief of her myofascial pain for approximately 3 months following the procedure. Furthermore, she also endorsed an unexpected resolution of her vertigo, as she has not had an episode since the injection. Discussion: A retrospective review of 94 patients with cervical myofascial pain syndrome revealed 35.1% of patients experienced vertigo with trigger point palpation. Additional studies have shown a successful resolution of vertigo in patients with cervical myofascial pain syndrome and Meniere’s disease with a myofascial component by both chiropractic and osteopathic manipulation techniques. Conclusions: There appears to be a relationship between vertigo and myofascial pain syndrome. It may be prudent to further evaluate patients presenting with vertigo for underlying myofascial pain syndrome of the cervical region, with possible treatments including trigger point injections as shown in this case report. Poster 534 The Importance of Rehabilitation (Physical Therapy) after Lumbar Spinal Injection for Spinal Pain Patient. A Retrospective Chart Review of 1600 Spinal Patients. Yung C. Chen, MD, MD (San Mateo Spine Center, San Mateo, CA, United States). Disclosures: Y. C. Chen MD, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Objective: To determine importance of physical therapy after spinal pain patient treated with epidural injection. Two groups of patients were compared: PT treated post-injection spine patient group vs. None-PT treated group post injection patient group. Design: Therapeutic lumbar spinal injections (lumbar epidural injection, medial branch blocks, SI joint blocks, facet joint injection) are often utilized to treat lumbar spine pain patients with or without sciatica. Physical therapy (PT) is often incorporated into post-spinal injection patients for stabilization program and functional gain. However, the post-procedural patients not receiving PT were observed to have less optimal functional outcomes. This study is a retrospective chart review of these two groups of patients. Setting: The study is conducted in the outpatient setting. Charts were reviewed and studied. Participants: This is a retrospective chart review of 1600 patients who suffer back with or without leg symptoms secondary to HNP, SI joint pain, facet joint pain, failed back surgery, lumbar sacral radiculopathy, spinal steosis, and radiculitis. 1600 electronic charts
Vol. 6, Iss. 9S, 2014
S373
were reviewed. Female ¼ 782, Avg age 66. Male # ¼ 818, Avg age 62. Main Outcome Measures: Patient satisfaction, functional gain, medication usage, and number of injetions performed were documented and calculated. Results or Clinical Course: 92% of PT treated group report functional gain in six months; 52% of None-PT treated group report minimum functional gain. 30% of PT treated group patients do not require second injection within six months; 68% of None-PT treated group require second injection within six months. PT treated group utilizes less oral pain medications vs. non-PT treated group by 60%. PT treated group reports higher satisfaction with specific spinal exercise vs. None PT treated group. Conclusions: This study supports the importance of physical therapy after spinal injections for patients suffering back pain with or without sciatica. PT should not be ignored as an integral part of spinal management to achieve maximum functional outcome. Spine surgeons, anesthesiologist or chiropractor may consider incorporating PT as part of spinal management. Poster 535 Spinal Cord Neuromodulation in the Management of HIV-Related Polyneuropathy: Case Report. George C. Chang Chien, DO (Rehabilitation Institute of Chicago, Chicago, IL, United States); Nebojsa Nick Knezevic, MD, PhD; Kenneth D. Candido, MD. Disclosures: G. C. Chang Chien, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Objective: To report successful use of spinal cord neuromodulation in the treatment of HIV-related neuropathy. Case Description: Due to the effectiveness of antiretroviral medication and a decline in central nervous system opportunistic infection and HIV-related dementia, HIV-associated neuropathies have become the most common neurological disorder associated with AIDS, affecting 1 in 3 patients. Patients with HIV-related polyneuropathy typically present with painful dysesthesias in a symmetrical, length dependent distribution which can be challenging to treat.We report a case of a 39-year-old man with a past medical history significant for Hepatitis C and depression, diagnosed with HIV six years prior who presented with worsening burning pain in all four limbs. His medication regimen at presentation included pregabalin 350 mg daily; acetaminophen with codeine 1300/10mg daily, gabapentin 400 mg twice daily, citalopram 20 mg daily, clonazepam 0.5 mg twice daily, and buspirone 20 mg twice daily. He continued to experience pain and side effects from his medication regimen and requested aggressive interventional therapy be considered on his behalf. He underwent a St. Jude’s dual lead spinal cord stimulator (SCS) trial wherein two 8-electrode leads were situated with the proximal-most contact at the cephalad margin of the T-10 vertebral body. On the third day post-procedure, the patient reported a 90-95% of improvement in pain. A decision was made to proceed with a permanent SCS implant, which was undertaken three weeks later. Program Description: Department of Anesthesiology and Pain Medicine. Setting: Outpatient Pain Management Office.
S374
Results or Clinical Course: At follow up the patient reported 95-100% improvement in pain and over the course of many months was successfully weaned off of all his pain medications. At the 4-year follow up, he continued to report successful management of his painful peripheral neuropathy. Conclusions: The use of spinal cord stimulation should be judiciously considered in cases of severe neuropathic pain. In the carefully selected patient, SCS neuromodulation is a safe, viable, and efficacious option for patients whose HIV-related neuropathic type pain is refractory to conventional treatment modalities. Poster 536 Scalp Peripheral Nerve Stimulation for Intractable Headache. Joseph W. Smith, MD (Thomas Jefferson University, Philadelphia, PA, United States); Linqiu Zhou, MD; Nana Jen, Medical Student. Disclosures: J. W. Smith, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Objective: The aim of this research was to study the efficacy of scalp peripheral nerves (occipital, supraorbital and auriculotemporal) stimulation therapy for intractable headaches. Background: Intractable migraine and other headache syndromes affect approximately 38 million Americans and millions worldwide. There is estimated to be at least 5% of these headache sufferers with adverse effects on their lives and significant socioeconomic burden who do not respond to medications. Design: Retrospective study. Setting: Combined academic and private pain clinic. Participants: Twenty- two intractable headache patients (5 males, 17 females, age 23-66) were followed from 6 months to 7 years after scalp peripheral nerve stimulation implantation. All of these patients had failed conservative therapies including medication management and local injections. They were referred by headache specialists. Interventions: After a successful trial, all patients underwent percutaneous occipital with or without combined supraorbital or auriculotemporal nerve stimulator implantation using a minimally invasive technique. Main Outcome Measures: Primary outcome measures were assessed by an independent reviewer, which included Total Pain Index (TPI), opioid medication usage, patient satisfaction and ability to return to work. Results or Clinical Course: Nineteen patients reported good to excellent pain reduction with a TPI drop from an average of 486.1 to 48.9. One patient rated fair pain relief with TPI decrease from 364 to 140. Two patients required removal of the stimulator: one was due to skin hypersensitivity to the stimulation leads and the other for religious preferences. Three patients developed late on-set infection from superficial anchors/suture knots requiring lead revision. All twenty patients weaned or significantly reduced their pain medications and returned to work. There were no long-term complications. Conclusions: Scalp peripheral nerve stimulation therapy is an appropriate alternative treatment for intractable headache patients who fail conservative therapy. It can offer significant and prolonged pain relief. Complications of this modality are mild and manageable.
PRESENTATIONS
Poster 537 Refractory Painful Spasms in the Setting of Transverse Myelitis Successfully Managed with Carbamazepine: A Case Report. Regan Royer, MD, MPH (University of Virginia, Charlottesville, VA, United States); Geoffrey Smith, MD. Disclosures: R. Royer, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: The patient initially presented with weakness and numbness in the left arm, which progressed to lower extremity weakness and right foot drop. MRI revealed a nonspecific cord lesion in her cervical spine favored to represent transverse myelitis. She was initially treated with high dose steroids and PLEX, followed by acute inpatient rehabilitation for tetraparesis. During inpatient rehabilitation she developed severe co-contraction spasms in the bilateral upper limbs, accompanied by severe pain in those limbs radiating to the neck during each spasm. The episodes lasted approximately 30 seconds and gradually increased both in frequency (to every 1-2 minutes) and in severity (10/10 pain). Due to the refractory nature of the symptoms, she was transferred back to the acute care hospital on the Neurology Service. The symptoms continued to worsen despite various combinations of Baclofen, Tizanidine, Gabapentin, PO and IV benzodiazepines, and PO and IV opioids. The patient developed hemodynamic instability from these medications, still without controlling symptoms. Intubation and sedation were being seriously considered for symptom control. PM&R Consult Service continued to be involved, ultimately recommending PO Carbamazepine. Setting: Acute rehabilitation hospital. Participants: 49-year-old female with progressive tetraparesis. Results or Clinical Course: The Carbamazepine was increased from 100 mg BID to 300 mg BID over 4 days; this titration correlated with a dramatic improvement in the patient’s painful spasms. She was able to return to and successfully complete her acute inpatient rehabilitation course, followed by discharge to home with assistance of family. A later attempt to decrease the dose of Carbamazepine resulted in temporary worsening of the spasms and associated pain until the dose was returned to 300 mg BID. Discussion: This case demonstrates the potential role of Carbamazepine for treatment of spasms and associated pain refractory to multiple medications. Conclusions: Carbamazepine should be considered as a treatment option in cases of severe refractory spasms with associated severe pain. Poster 538 Gender Differences versus Genotype Risk of CoMorbidities in Chronic Pain Patients. Dan Schwarz, MD (Proove Biosciences, Irvine, CA, United States); John Hubbard, PT; Tobore Onojighofia, MD, MPH; Meshkin Brian, BA; Bilikis Akindele, MD; Derrick Holman, MD; Nate Alderson, PhD; Matthew Doust, MD; Juetong Chen, MMCI. Disclosures: D. Schwarz, Proove Biosciences, Employment (full or part-time) Objective: To evaluate whether there are gender differences in mesolimbic genetic predispositions associated with risk for opioid