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(130) Lumbar epidural lipomatosis causing symptomatic central canal stenosis: a case report
S8
Abstracts
The Journal of Pain
(128) A case of adrenal insufficiency secondary to chronic opioid use- keep this diagnosis in mind!
(130) Lumbar epidural lipomatosis causing symptomatic central canal stenosis: a case report
J Rabi; University of Illinois-Advocate Christ Medical Center, Oak Lawn, IL
A Patel and R Miranda; Nassau University Medical Center, East Meadow, NY
With the increase use of opioids for chronic pain, the incidence of adrenal insufficiency is increasing; therefore, it is imperative that a pain physician recognize the clinical signs and symptoms of adrenal insufficiency and make appropriate judgment for diagnostic work up and treatment. Opioid induced adrenal insufficiency should be clinically suspected in patients taking 100 mg of morphine equivalent for greater than 1 year if clinical symptoms and signs are present. Clinical judgment should be used for diagnostic work up and treatment. Treatment approaches include opioid rotation, wean opioids, modalities/interventional pain techniques and, if these fail, steroid and hormonal supplements should be given to patients explaining the risks and benefits. A case is presented of a 24 year old female with sickle cell disease on morphine sulfate 90mg daily for greater than 3 years who developed amenorrhea, hypotension, nausea and vomiting due to opioid endocrinopathy causing adrenal insufficiency. The opioid endocrinopathy symptoms resolved with opioid rotation and steroid supplements. Further studies need to be done to determine the incidence of opioid endocrinopathy and which opioids are more likely to cause opioid endocrinopathy.
Spinal epidural lipomatosis is a rare accumulation of adipose in the epidural space which has been linked to corticosteroid use or Cushing’s disease which can progress clinically from mild stenosis to cord compression. We present a 54 year old male with past medical history of asthma, on daily inhaled corticosteroids, who presented with progressively worsening low back pain, bilateral radicular leg pain and claudication. Initial lumbar spine MRI showed disc bulge with mild narrowing of left L5-S1 neural foramen, L5-S1 facet hypertrophy, and minimal fat accumulation consistent with early signs of epidural lipomatosis. Patient attempted physical therapy along with NSAIDs and muscle relaxants, which provided minimal relief. Repeat MRI two years later showed significant progression of epidural lipomatosis causing multilevel central canal stenosis, worse at L5-S1. Interestingly, the classic ‘‘Y-shaped’’ phenomenon found in epidural lipomatosis was enhanced secondary to the fat overgrowth revealing a deformity of the dural sac. This finding is usually invisible on MRI unless there is mass effect from the excessive adipose. This radiographic finding exposes meningovertebral ligaments as a possible cause for low back pain. With worsening MRI findings, recommendation for neurosurgical evaluation for surgical decompression was considered. Patient declined and opted to continue conservative management. Electrodiagnostic testing suggestive of chronic left S1 radiculopathy. Causes of epidural lipomatosis were reviewed including prolonged corticosteroid use secondary to asthma and a work up for metabolic derangements including Cushing’s disease. This case presents a unique diagnosis with radiographic and concordant clinical manifestations. Literature suggests that hypertrophy of the adipose tissue can be reversed with physical therapy, medical management, and lifestyle modifications such as weight loss resulting in improved quality of life and pain relief. (Fassett, Neurosurg Focus, 2004; Geers, AJNR Am J Neuroradiol 2003; Bashline, J Manipulative Physiol Ther, 1996.)
(129) Refractory pain as a diagnostic symptom in uterine artery hematoma formation following vaginal labor: a case report
A06 Epidemiology
A Doshi and T Vogel; West Penn Allegheny Health System, Pittsburgh, PA Spontaneous rupture of uterine arteries and their branches with hematoma formation are a rare, but known complication during vaginal labor. A hallmark feature of this complication is intense rectal pain immediately following delivery that is atypical of patients receiving epidural analgesia. In this case report, we discuss the refractory nature of this pain and its potential as a diagnostic symptom. Patient was a 31 year old G1P0 parturient at 37 +3 weeks of being induced for oligohydraminos and had a history of exercise-induced asthma, GERD, and L4-L5/L5-S1 disc herniations treated with steroid injections peripartum. Epidural was placed prior to forceps assisted vaginal delivery complicated by right sidewall laceration. Immediately after delivery, patient experienced 10/10 rectal pain and urge to valsalva, and was given IV morphine and ketorolac, and epidural 2% lidocaine. Pelvic x-ray was negative for sacral fracture; patient reported the return of intense pain within 20 minutes. She was taken to the OR for EUA, vaginal/rectal packing performed with epidural lidocaine 2% w/epinephrine, and IV midozolam and ketamine for sedation. Patient was then taken to IR for pelvic angiogram and found to have pelvic hematoma of right inferior gluteal artery origin, which was embolized utilizingmultiple doses of epidural lidocaine 2% w/epinephrine, and IV midazolam and ketamine as her anesthetic. Postoperatively, she was placed on a continuous epidural infusion of 0.2% ropivicaine with fentanyl and PCA pump of hydromorphone. PPD#1 patient complained of rectal pain; oral ibuprofen and acetaminophen were started, and PCA boluses were increased. The dosage of the continuous epidural was weaned by PPD#3. PCA was weaned by PPD#5 and patient was transitioned to oral oxycodone, acetaminophen, and ibuprofen prior to discharge. Although rupture of the uterine artery or its branches is rare, refractory pain following delivery should be carefully evaluated for hematoma formation.
(131) High prevalence of falls, fear of falls, and impaired balance among older adults with pain in the United States: findings from the 2011 National Health and Aging Trends Study K Patel, E Phelan, S Leveille, R Wallace, C Missikpode, S Lamb, J Guralnik, and D Turk; University of Washington, Seattle, WA Chronic pain is strongly associated with decreased mobility function in older adults, but the role of chronic pain in falls occurrence has received limited attention. We sought to determine the prevalence of clinically relevant fallsrelated outcomes according to pain status in the older population of the United States. Cross-sectional data from the 2011 National Health and Aging Trends Study were analyzed. Adults ages $65 years were sampled from the Medicare enrollment file (response rate= 71.0%). In-person interviews and assessments were conducted in the homes of 7,601 participants, representing 35.3 million Medicare beneficiaries. Participants were asked whether they had been bothered by pain and the location of pain as well as questions about balance/coordination, fear of falls, and falls. Pain was reported by 52.9% of the population. Comparing participants with pain than without pain, the prevalence of multiple falls in the past year was 19.5% and 7.4%, respectively [age- and sex-adjusted prevalence ratio (PR)=2.63; 95% confidence interval (CI):2.28-3.05]. For fear of falls that limits activity, prevalence was 18.0% and 4.4% in those with and without pain, respectively (adjusted PR=3.98; 95% CI:3.24-4.87). In terms of absolute numbers, there were 3.6 million older adults with pain who reported multiple falls in the past year compared with 1.2 million older adults without pain (P<0.0001). Prevalence of falls-related outcomes increased with the total number of pain sites. For example, prevalence of problems with balance/coordination that limited activity among participants with 0, 1, 2, 3, and $4 sites of pain was 6.6%, 11.6%, 17.7%, 25.0%, and 41.4%, respectively (P<0.001 for trend). Associations were robust to adjustment for several potential confounders, including objectively measured physical performance. In summary, older adults with pain comprise the majority of fallers who are at high risk of fall-related injury. Accordingly, pain management strategies should be developed and evaluated for falls prevention.
Abstracts
The Journal of Pain
(128) A case of adrenal insufficiency secondary to chronic opioid use- keep this diagnosis in mind!
(130) Lumbar epidural lipomatosis causing symptomatic central canal stenosis: a case report
J Rabi; University of Illinois-Advocate Christ Medical Center, Oak Lawn, IL
A Patel and R Miranda; Nassau University Medical Center, East Meadow, NY
With the increase use of opioids for chronic pain, the incidence of adrenal insufficiency is increasing; therefore, it is imperative that a pain physician recognize the clinical signs and symptoms of adrenal insufficiency and make appropriate judgment for diagnostic work up and treatment. Opioid induced adrenal insufficiency should be clinically suspected in patients taking 100 mg of morphine equivalent for greater than 1 year if clinical symptoms and signs are present. Clinical judgment should be used for diagnostic work up and treatment. Treatment approaches include opioid rotation, wean opioids, modalities/interventional pain techniques and, if these fail, steroid and hormonal supplements should be given to patients explaining the risks and benefits. A case is presented of a 24 year old female with sickle cell disease on morphine sulfate 90mg daily for greater than 3 years who developed amenorrhea, hypotension, nausea and vomiting due to opioid endocrinopathy causing adrenal insufficiency. The opioid endocrinopathy symptoms resolved with opioid rotation and steroid supplements. Further studies need to be done to determine the incidence of opioid endocrinopathy and which opioids are more likely to cause opioid endocrinopathy.
Spinal epidural lipomatosis is a rare accumulation of adipose in the epidural space which has been linked to corticosteroid use or Cushing’s disease which can progress clinically from mild stenosis to cord compression. We present a 54 year old male with past medical history of asthma, on daily inhaled corticosteroids, who presented with progressively worsening low back pain, bilateral radicular leg pain and claudication. Initial lumbar spine MRI showed disc bulge with mild narrowing of left L5-S1 neural foramen, L5-S1 facet hypertrophy, and minimal fat accumulation consistent with early signs of epidural lipomatosis. Patient attempted physical therapy along with NSAIDs and muscle relaxants, which provided minimal relief. Repeat MRI two years later showed significant progression of epidural lipomatosis causing multilevel central canal stenosis, worse at L5-S1. Interestingly, the classic ‘‘Y-shaped’’ phenomenon found in epidural lipomatosis was enhanced secondary to the fat overgrowth revealing a deformity of the dural sac. This finding is usually invisible on MRI unless there is mass effect from the excessive adipose. This radiographic finding exposes meningovertebral ligaments as a possible cause for low back pain. With worsening MRI findings, recommendation for neurosurgical evaluation for surgical decompression was considered. Patient declined and opted to continue conservative management. Electrodiagnostic testing suggestive of chronic left S1 radiculopathy. Causes of epidural lipomatosis were reviewed including prolonged corticosteroid use secondary to asthma and a work up for metabolic derangements including Cushing’s disease. This case presents a unique diagnosis with radiographic and concordant clinical manifestations. Literature suggests that hypertrophy of the adipose tissue can be reversed with physical therapy, medical management, and lifestyle modifications such as weight loss resulting in improved quality of life and pain relief. (Fassett, Neurosurg Focus, 2004; Geers, AJNR Am J Neuroradiol 2003; Bashline, J Manipulative Physiol Ther, 1996.)
(129) Refractory pain as a diagnostic symptom in uterine artery hematoma formation following vaginal labor: a case report
A06 Epidemiology
A Doshi and T Vogel; West Penn Allegheny Health System, Pittsburgh, PA Spontaneous rupture of uterine arteries and their branches with hematoma formation are a rare, but known complication during vaginal labor. A hallmark feature of this complication is intense rectal pain immediately following delivery that is atypical of patients receiving epidural analgesia. In this case report, we discuss the refractory nature of this pain and its potential as a diagnostic symptom. Patient was a 31 year old G1P0 parturient at 37 +3 weeks of being induced for oligohydraminos and had a history of exercise-induced asthma, GERD, and L4-L5/L5-S1 disc herniations treated with steroid injections peripartum. Epidural was placed prior to forceps assisted vaginal delivery complicated by right sidewall laceration. Immediately after delivery, patient experienced 10/10 rectal pain and urge to valsalva, and was given IV morphine and ketorolac, and epidural 2% lidocaine. Pelvic x-ray was negative for sacral fracture; patient reported the return of intense pain within 20 minutes. She was taken to the OR for EUA, vaginal/rectal packing performed with epidural lidocaine 2% w/epinephrine, and IV midozolam and ketamine for sedation. Patient was then taken to IR for pelvic angiogram and found to have pelvic hematoma of right inferior gluteal artery origin, which was embolized utilizingmultiple doses of epidural lidocaine 2% w/epinephrine, and IV midazolam and ketamine as her anesthetic. Postoperatively, she was placed on a continuous epidural infusion of 0.2% ropivicaine with fentanyl and PCA pump of hydromorphone. PPD#1 patient complained of rectal pain; oral ibuprofen and acetaminophen were started, and PCA boluses were increased. The dosage of the continuous epidural was weaned by PPD#3. PCA was weaned by PPD#5 and patient was transitioned to oral oxycodone, acetaminophen, and ibuprofen prior to discharge. Although rupture of the uterine artery or its branches is rare, refractory pain following delivery should be carefully evaluated for hematoma formation.
(131) High prevalence of falls, fear of falls, and impaired balance among older adults with pain in the United States: findings from the 2011 National Health and Aging Trends Study K Patel, E Phelan, S Leveille, R Wallace, C Missikpode, S Lamb, J Guralnik, and D Turk; University of Washington, Seattle, WA Chronic pain is strongly associated with decreased mobility function in older adults, but the role of chronic pain in falls occurrence has received limited attention. We sought to determine the prevalence of clinically relevant fallsrelated outcomes according to pain status in the older population of the United States. Cross-sectional data from the 2011 National Health and Aging Trends Study were analyzed. Adults ages $65 years were sampled from the Medicare enrollment file (response rate= 71.0%). In-person interviews and assessments were conducted in the homes of 7,601 participants, representing 35.3 million Medicare beneficiaries. Participants were asked whether they had been bothered by pain and the location of pain as well as questions about balance/coordination, fear of falls, and falls. Pain was reported by 52.9% of the population. Comparing participants with pain than without pain, the prevalence of multiple falls in the past year was 19.5% and 7.4%, respectively [age- and sex-adjusted prevalence ratio (PR)=2.63; 95% confidence interval (CI):2.28-3.05]. For fear of falls that limits activity, prevalence was 18.0% and 4.4% in those with and without pain, respectively (adjusted PR=3.98; 95% CI:3.24-4.87). In terms of absolute numbers, there were 3.6 million older adults with pain who reported multiple falls in the past year compared with 1.2 million older adults without pain (P<0.0001). Prevalence of falls-related outcomes increased with the total number of pain sites. For example, prevalence of problems with balance/coordination that limited activity among participants with 0, 1, 2, 3, and $4 sites of pain was 6.6%, 11.6%, 17.7%, 25.0%, and 41.4%, respectively (P<0.001 for trend). Associations were robust to adjustment for several potential confounders, including objectively measured physical performance. In summary, older adults with pain comprise the majority of fallers who are at high risk of fall-related injury. Accordingly, pain management strategies should be developed and evaluated for falls prevention.