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Piriformis Abscess - A Rare Cause of Sciatica: A Case Report
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improved to 4-/5 (baseline 5/5), but right shoulder adhesive capsulitis developed. Ambulation was supported with straight cane (no assistive device at baseline). Discussion: The incidence of spinal cord injection during ESI is unknown and the results can be devastating. Extremity weakness is a complication, but facial symptoms have not been reported. CN V spinal nucleus extends from the medulla to the mid cervical spinal cord and communicates with CNXI. We propose that cranial neuropathies must be considered as a possible risk during IC-ESI. Conclusions: We describe the first reported case of trigeminal and accessory nerve injury after IC-ESI.
Poster 465 Piriformis Abscess - A Rare Cause of Sciatica: A Case Report. Min Jeong Park (Montefiore Medical Center/ Albert Einstein College of Medicine, Bronx, NY, United States); Kevin Sperber, MD. Disclosures: M. Park, No Disclosures: I Have Nothing To Disclose. Case Description: A 23-year-old man presented with three days of left buttock pain radiating to posterolateral thigh. The pain was exacerbated by movement of left leg and relieved by lying supine. Low back pain, sensory dysfunction and bladder and bowel dysfunction were denied. No inciting factors other than heavy lifting the day before the symptoms started were reported. On admission, bed mobility and transfers were limited by pain. Physical examination was significant for focal tenderness in the left mid gluteal region. Bilateral straight leg raise and left hip range of motion reproduced pain. Admission blood tests showed normal blood count and elevated C reactive protein to 333.3 mg/ L. MRI of lumbosacral spine was essentially normal. The patient first became febrile five days into his hospital stay. MRI of pelvis revealed a large abscess in the left iliopsoas and piriformis muscles with inflammatory changes along the left sacral nerve roots. Setting: Tertiary care hospital Results or Clinical Course: During CT guided drainage, 37cc of frank pus was aspirated from left piriformis and iliopsoas muscles. Methicillin-sensitive Staphylococcus aureus grew from cultures. After two weeks of treatment with intravenous antibiotics, pain and CRP level decreased dramatically and after six weeks of intravenous cefazolin, only mild discomfort in left lateral hip remained. Discussion: A few cases of pelvic abscess as a cause of sciatica were reported in active sportsmen and as obstetric complications following abortions. Trauma to a muscle on a background of bacteremia has been suggested in the development of abscess. Considering the rarity of this condition, pelvic abscess is often diagnosed with difficulty, which can lead to further abscess formation, compressing the neurovascular bundle and causing severe sciatica pain. Conclusions: Pelvic muscle abscess should be considered as a differential diagnosis in patients with acute severe sciatica symptoms, since early diagnosis and intervention can relieve the symptom and prevent further deterioration.
PRESENTATIONS
Poster 466 Thoracic Epidural Varices: A Rare Cause of Nocturnal Back Pain: A Case Report. Christopher Connor, DO (Temple University Hospital, Philadelphia, PA, United States); Michael M. Weinik, DO; Vikram Arora, DO. Disclosures: C. Connor, No Disclosures: I Have Nothing To Disclose. Case Description: A 31-year-old man with no significant past medical history presented with a four month history of nocturnal inter-scapular back pain limiting his sleep. Reported pain begins within approximately four to six hours of sleep. Pain relieved by standing and walking. No other associated symptoms reported. Initial physical exam notable for 3þ muscle stretch reflexes and few beats of ankle clonus in bilateral lower extremities. Setting: Outpatient Musculoskeletal Clinic at an Academic Medical Center Results or Clinical Course: MRI with and without contrast revealed: Degenerative disc disease at T6-8 with small central disc herniation and T8/9 para-central disc herniation with enlarged, non-thrombosed posterior epidural vessels from T3-T8/9. Spinal angiogram confirmed a prominent dorsal epidural venous plexus. Furthermore, venous drainage from posterior fossa revealed an absent right internal jugular vein with collateral drainage via cervical venous plexus. Venogram negative for obstructed vena cava. Evaluation by neurosurgery concluded no surgical intervention. He underwent physical therapy, elevation of the head of his bed and prescribed one Percocet at night with improved nocturnal symptoms. Discussion: Symptomatic epidural varices have multiple potential causes. More commonly reported causes include: spinal degeneration/pathology, vena cava or jugular obstruction and heart failure with concomitant spinal stenosis (also known as Vesper’s Curse). Multiple case reports identify varices at the lumbar and cervical spine, with localization to anterior epidural venous plexus. However, we report thoracic spine involvement with posterior epidural venous varices. Conclusions: This is an example of a rare cause of back pain. In our patient, the findings of an absent right internal jugular vein with subsequent collateral flow raises the question of a more diffuse vascular variation as the etiology of our findings. Poster 467 Complex Regional Pain Syndrome Type 1 in a Patient with Cerebral Palsy: A Case Report. Pamela Summers, MD (Eastern Virginia Medical School, Norfolk, VA, United States); Qi Lin, MD; Jean E. Shelton, MD; Antonio Quidgley-Nevares, MD. Disclosures: P. Summers, No Disclosures: I Have Nothing To Disclose. Case Description: A 19-year-old female with spastic quadriplegic cerebral palsy (CP) Gross Motor Function Classification System V with a history of dysarthria, poor communication, oligoarticular juvenile idiopathic arthritis (JIA), Mitrofanoff procedure, cecostomy, gastrostomy tube, intrathecal baclofen pump, and scoliosis with rod placement presented with over a four month history of left ankle pain and erythematous rashes. No injury was
improved to 4-/5 (baseline 5/5), but right shoulder adhesive capsulitis developed. Ambulation was supported with straight cane (no assistive device at baseline). Discussion: The incidence of spinal cord injection during ESI is unknown and the results can be devastating. Extremity weakness is a complication, but facial symptoms have not been reported. CN V spinal nucleus extends from the medulla to the mid cervical spinal cord and communicates with CNXI. We propose that cranial neuropathies must be considered as a possible risk during IC-ESI. Conclusions: We describe the first reported case of trigeminal and accessory nerve injury after IC-ESI.
Poster 465 Piriformis Abscess - A Rare Cause of Sciatica: A Case Report. Min Jeong Park (Montefiore Medical Center/ Albert Einstein College of Medicine, Bronx, NY, United States); Kevin Sperber, MD. Disclosures: M. Park, No Disclosures: I Have Nothing To Disclose. Case Description: A 23-year-old man presented with three days of left buttock pain radiating to posterolateral thigh. The pain was exacerbated by movement of left leg and relieved by lying supine. Low back pain, sensory dysfunction and bladder and bowel dysfunction were denied. No inciting factors other than heavy lifting the day before the symptoms started were reported. On admission, bed mobility and transfers were limited by pain. Physical examination was significant for focal tenderness in the left mid gluteal region. Bilateral straight leg raise and left hip range of motion reproduced pain. Admission blood tests showed normal blood count and elevated C reactive protein to 333.3 mg/ L. MRI of lumbosacral spine was essentially normal. The patient first became febrile five days into his hospital stay. MRI of pelvis revealed a large abscess in the left iliopsoas and piriformis muscles with inflammatory changes along the left sacral nerve roots. Setting: Tertiary care hospital Results or Clinical Course: During CT guided drainage, 37cc of frank pus was aspirated from left piriformis and iliopsoas muscles. Methicillin-sensitive Staphylococcus aureus grew from cultures. After two weeks of treatment with intravenous antibiotics, pain and CRP level decreased dramatically and after six weeks of intravenous cefazolin, only mild discomfort in left lateral hip remained. Discussion: A few cases of pelvic abscess as a cause of sciatica were reported in active sportsmen and as obstetric complications following abortions. Trauma to a muscle on a background of bacteremia has been suggested in the development of abscess. Considering the rarity of this condition, pelvic abscess is often diagnosed with difficulty, which can lead to further abscess formation, compressing the neurovascular bundle and causing severe sciatica pain. Conclusions: Pelvic muscle abscess should be considered as a differential diagnosis in patients with acute severe sciatica symptoms, since early diagnosis and intervention can relieve the symptom and prevent further deterioration.
PRESENTATIONS
Poster 466 Thoracic Epidural Varices: A Rare Cause of Nocturnal Back Pain: A Case Report. Christopher Connor, DO (Temple University Hospital, Philadelphia, PA, United States); Michael M. Weinik, DO; Vikram Arora, DO. Disclosures: C. Connor, No Disclosures: I Have Nothing To Disclose. Case Description: A 31-year-old man with no significant past medical history presented with a four month history of nocturnal inter-scapular back pain limiting his sleep. Reported pain begins within approximately four to six hours of sleep. Pain relieved by standing and walking. No other associated symptoms reported. Initial physical exam notable for 3þ muscle stretch reflexes and few beats of ankle clonus in bilateral lower extremities. Setting: Outpatient Musculoskeletal Clinic at an Academic Medical Center Results or Clinical Course: MRI with and without contrast revealed: Degenerative disc disease at T6-8 with small central disc herniation and T8/9 para-central disc herniation with enlarged, non-thrombosed posterior epidural vessels from T3-T8/9. Spinal angiogram confirmed a prominent dorsal epidural venous plexus. Furthermore, venous drainage from posterior fossa revealed an absent right internal jugular vein with collateral drainage via cervical venous plexus. Venogram negative for obstructed vena cava. Evaluation by neurosurgery concluded no surgical intervention. He underwent physical therapy, elevation of the head of his bed and prescribed one Percocet at night with improved nocturnal symptoms. Discussion: Symptomatic epidural varices have multiple potential causes. More commonly reported causes include: spinal degeneration/pathology, vena cava or jugular obstruction and heart failure with concomitant spinal stenosis (also known as Vesper’s Curse). Multiple case reports identify varices at the lumbar and cervical spine, with localization to anterior epidural venous plexus. However, we report thoracic spine involvement with posterior epidural venous varices. Conclusions: This is an example of a rare cause of back pain. In our patient, the findings of an absent right internal jugular vein with subsequent collateral flow raises the question of a more diffuse vascular variation as the etiology of our findings. Poster 467 Complex Regional Pain Syndrome Type 1 in a Patient with Cerebral Palsy: A Case Report. Pamela Summers, MD (Eastern Virginia Medical School, Norfolk, VA, United States); Qi Lin, MD; Jean E. Shelton, MD; Antonio Quidgley-Nevares, MD. Disclosures: P. Summers, No Disclosures: I Have Nothing To Disclose. Case Description: A 19-year-old female with spastic quadriplegic cerebral palsy (CP) Gross Motor Function Classification System V with a history of dysarthria, poor communication, oligoarticular juvenile idiopathic arthritis (JIA), Mitrofanoff procedure, cecostomy, gastrostomy tube, intrathecal baclofen pump, and scoliosis with rod placement presented with over a four month history of left ankle pain and erythematous rashes. No injury was