Poster 101: Refer to abstract 48 in the musculoskeletal poster grand rounds for full abstract. e-mail: [email protected]

2004 Academy Annual Assembly Abstracts puted tomography scan of the pelvis showed mature calcification in the right vastus lateralis and iliopsoas without involvement of the hip joint. Triple-phase bone scan revealed active heterotopic ossification (HO). Management included indomethacin, tramadol (Ultram) and acetaminophen as needed, physical therapy, and osteopathic manipulation. Further developments will be discussed. A follow-up bone scan is planned to evaluate the activity of the lesion and consideration for surgery. Discussion: This is the first reported case, to our knowledge, of periarticular HO after gunshot wound without evidence of trauma to bone. HO has been known to occur after fractures of various etiology. Conclusions: HO should be considered in the differential diagnosis of persistent pain after gunshot wound. Key Words: Ossification, heterotopic; Rehabilitation; Wounds, gunshot. Poster 97 Upper-Limb Pain and Weakness Secondary to Pancoast Tumor: A Case Report. Kevin A. Miles, DO, MS (Mayo Clin, Rochester, MN); Robert Yang, MD, e-mail: miles.kevin@ mayo.edu. Disclosure: K.A. Miles, None; R. Yang, None. Setting: Academic tertiary care multispecialty group practice. Patient: A 75-yo woman. Case Description: The patient presented on referral from her internist with approximately 7mo of slowly progressive right-sided upper back and shoulder pain with intermittent radiation into the posterior aspect of the arm, which had not resolved with conservative treatment. Initial radiographs showed degenerative changes in the cervical spine with normal shoulder findings. On evaluation, her symptoms were attributed to rotator cuff dysfunction. She was provided with an injection and rotator cuff rehabilitation program. At 1-mo follow-up, she complained of significant pain radiating down the medial aspect of her right arm, forearm, and into the fingers, with weakness in her finger extensors and interosseus muscles. Assessment/Results: Cervical and thoracic spine magnetic resonance imaging (MRI) was essentially normal. Electromyography revealed a chronic right C8-T1 radiculopathy. She continued to have worsening pain and weakness over the ensuing 2- to 3-wk period. Cervical and thoracic spine MRI was repeated along with a chest computed tomography scan, which demonstrated an abnormal soft tissue mass in the right lung apex with some destructive changes in the first rib. A needle biopsy revealed adenocarcinoma and aggressive radiation was provided. She subsequently had invasion of the tumor into the neck, which involved the brachial plexus and caused ulnar nerve involvement resulting in claw hand deformity and fixed contractures. Surgical services were consulted regarding further treatment, but she was uninterested in a forequarter amputation or any chemotherapy. The patient died 6mo after presentation to her physiatrist. Discussion: The presentation of a Pancoast tumor can mimic more common shoulder or cervical radicular complaints. Conclusions: This case emphasizes the importance of continued investigation when conservative treatments and initial studies fail to aid in symptom relief and definitive diagnosis. Key Words: Pain; Pancoast’s tumor; Rehabilitation. Poster 98 Avascular Necrosis as a Source of Knee Pain in a Patient With Multiple Sclerosis: A Case Report. Yvette Ju, DO (Univ of Maryland/James Lawrence Kernan Hosp, Baltimore, MD); Peter H. Gorman, MD, e-mail: [email protected]. Disclosure: Y. Ju, None; P.H. Gorman, None Setting: A comprehensive inpatient rehabilitation unit. Patient: A 37-yo woman with 9-y history of multiple sclerosis (MS) exacerbations treated with both intravenous (IV) and oral steroids; she had had chronic bilateral knee pain for 5 to 6y. The patient at baseline was ambulatory with a cane until several weeks before admission. Case Description: The patient was admitted to the acute care hospital with the new onset of double vision, bilateral facial and upper-extremity numbness, tremors, and worsening bilateral lower-extremity weakness. Magnetic resonance imaging (MRI) of the brain was consistent with active MS involving the cerebellum, medulla, and pons. Lowerextremity radiographs revealed a right lateral condyle effusion. Lower-extremity MRI demonstrated bilateral avascular necrosis (AVN) of the distal femur, proximal tibia, and proximal fibula. Nonetheless, the patient was treated with IV dexamethasone. Moderate improvement in strength and tremor was noted by day 5. Inpatient rehabilitation was initiated 22d after admission. The patient was weight bearing as tolerated but required narcotic analgesia for knee pain and high-dose antispasmotics. Ultimately, right total knee arthroplasty (TKA) was performed for pain management. Assessment/Results: The patient had temporary pain relief after surgery. She was discharged to home with analgesia at a wheelchair level, despite her leg strength being otherwise considered adequate for ambulation. Left TKA was under consideration. Discussion: Steroid use is a common cause of AVN of the hip; but AVN is an unusual cause of knee pain in patients with MS. The combination of weakness, spasticity, and AVN-related joint pain could adversely affect rehabilitation outcomes. Conclusions: AVN of the knee can occur in patients with MS who are treated with steroids. Further studies are needed to assess the incidence of AVN in this population. Key Words: Avascular necrosis of bone; Multiple sclerosis; Rehabilitation; Steroids. Poster 99: Cancelled. Poster 100 Low Back Pain and Bilateral Pure Motor Paraparesis Induced by Retroperitoneal Hematoma. Leon Margolin, MD, PhD (AECOM, Bronx, NY); Miriam Segal, MD; Avital Fast, MD, e-mail: [email protected]. Disclosure: L. Margolin, None; M. Segal, None; A. Fast, None. Setting: Tertiary care hospital. Patient: A 65-yo white woman. Case Description: The patient was hospitalized because of severe low back pain and lower-extremity weakness that developed gradually over 3 to 4wk prior to admission. She was started on low dose of warfarin (Coumadin) because of deep vein thrombosis that developed after a surgical procedure 3mo prior to the admission. Her international normalized ratio was 3.1 on admission. Computed tomography scan of the retroperitoneum was compatible with a chronic retroperitoneal and left perinephric hematoma. Physical exam showed proximal lower-extremity weakness 3⫺/5 without any sensory findings; femoral and ankle jerk were 1⫹ bilaterally. Coumadin was stopped and the patient was treated with vitamin K; the hematoma gradually resolved, with significant improvement of the weakness on

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physical therapy program. Assessment/Results: The clinical presentation of bilateral pure motor paraparesis is very uncommon and, to the best of our knowledge, has not been reported in connection with retroperitoneal and perinephric hematoma. Discussion: This unusual finding might be related to the difference of myelinization ratio of the motor versus sensory fibers that makes them more vulnerable to the oxidative and free radical damage associated with the chronic rebleeding process that caused the hematoma formation. Conclusions: Vigilance of the syndrome and with use of Coumadin is advocated. Key Words: Hematoma; Paraparesis; Rehabilitation. Poster 101: Refer to Abstract 48 in the Musculoskeletal Poster Grand Rounds for full abstract. e-mail: [email protected]. Poster 102 Interspinous Bursitis: An Unusual Etiology of Low Back Pain. Sheryl L. Oleski, MD; Michael J. DePalma, MD (Penn Spine Ctr, Hosp Univ Pennsylvania, Philadelphia, PA); Amit Bhargava, MD; Kingsley R. Chin, MD; Larry H. Chou, MD; Curtis W. Slipman, MD, e-mail: [email protected]. Disclosure: S.L. Oleski, None; M.J. DePalma, None; A. Bhargava, None; K.R. Chin, None; L.H. Chou, None; C.W. Slipman, None. Setting: Academic spine center. Patients: 2 subjects presenting with symptoms consistent with lumbar spondylolysis. Case Descriptions: Each subject presented with midline lumbar pain and lumbar extension sensitivity. Conservative management including 2mo of physical therapy, avoidance of provocative activities, and use of oral anti-inflammatory agents provided no symptom amelioration. Neither single-photon emission tomography nor magnetic resonance imaging (MRI) of the lumbar spine demonstrated an osseous abnormality. However, in both instances, the T2weighted sagittal images revealed a single focal area of increased uptake localized in the potential space between the 2 spinous processes. Each patient underwent a fluoroscopically guided diagnostic interspinous injection in which a firm end point was reached while observing a cotton ball appearing collection of contrast. An adjacent control level was injected in the first case, which exhibited the expected fascial spread and a soft end point. After infusion of 1mL of 2% lidocaine into the suspected bursa, complete symptom relief was reported; there was no change in the visual analog scale (VAS) rating after local anesthetic injection into the control level. The first subject received 2 steroid injections and the second received 4. Assessment/Results: Both subjects returned for follow-up at 2mo. The first subject returned at 1y and the second at 4.5mo. At 2mo, the VAS score decreased from 6 to 2 in the first subject and from 9 to 3 in the second. The 2 subjects remained pain free at 1y and 4.5mo, respectively. Discussion: To our knowledge, this is the first reported use of fluoroscopically guided diagnostic and therapeutic injections to evaluate and treat lumbar interspinous bursitis. Conclusions: Younger patients with refractory lumbar pain provoked by extension may be experiencing symptoms of interspinous bursitis that can be specifically diagnosed and treated with a spinal injection procedure. Key Words: Bursitis; Fluoroscopy; Rehabilitation. Poster 103: Refer to Abstract 46 in the Musculoskeletal Poster Grand Rounds for full abstract. e-mail: [email protected]. Poster 104 An Unusual Case of Radicular Pain Secondary to a Mucinois Cystadenoma: A Case Report. Kenneth Botwin, MD (Florida Spine Inst, Clearwater, FL); Robert Savarese, DO; Robert Gruber, DO; C.P. Shah, MD, e-mail: [email protected]. Disclosure: K. Botwin, None; R. Savarese, None; R. Gruber, None; C. Shah, None. Setting: Multidisciplinary spine care center. Patient: A 41-yo woman. Case Description: The woman presented with a 3-mo history of left-sided buttock pain radiating into her left calf and lateral foot. This pain was associated with some numbness in her left popliteal fossa, extending to the dorsum of the left foot. On physical examination, palpation revealed tenderness over the left sciatic notch. Range of motion of the lumbar spine was normal, but did reproduce the patient’s left leg symptoms. Neurologic examination was significant for decreased sensation in the L5 and S1 dermatomes and a positive left straight-leg raising test. Assessment/Results: The pain continued to worsen over 2wk despite anti-inflammatory medications and physical therapy. Magnetic resonance imaging (MRI) of the lumbar spine was negative. The patient refused electromyography and nerve conduction study, therefore an MRI of the pelvis and sacrum was ordered. The MRI of the pelvis and sacrum demonstrated a cystic benign appearing intrapelvic mass on the left measuring 6⫻5⫻4cm, with mass effect on the left lumbosacral plexus. The patient was referred to her gynecologist for definitive diagnosis and possible excision. Subsequently, the patient underwent surgical excision; biopsy revealed an ovarian mucinous cystadenoma. 3mo postoperatively, the patient’s pain had decreased by approximately 80%. Discussion: This is the first published report of a mucinous cystadenoma presenting as buttock pain radiating into the foot. Lumbosacral plexopathy is an infrequent cause of gluteal pain with radicular symptoms. It is difficult to diagnose because its symptoms are similar to those of more frequent causes of sciatica. Conclusions: To our knowledge, this is also the first reported case on lumbosacral plexus compression as a result of ovarian neoplasm. Key Words: Lumbosacral plexus; Ovarian neoplasms; Rehabilitation.

Poster 105 Radiculopathy as a Complication of Vertebroplasty With Polymethylmethacrylate: A Case Report. Maria A. Bastien, MD (Temple Univ Hosp, Philadelphia, PA); Richard Rosenstein, DO, e-mail: [email protected]. Disclosure: M.A. Bastien, None; R. Rosenstein, None. Setting: Acute inpatient rehabilitation unit in a community hospital. Patient: 82-yo woman, with a history of osteoporosis and recurrent lumbar compression fractures, was admitted to a community hospital after a fall, with severe back pain described as 9/10 on the visual analog scale. She also complained of right buttock and right leg pain. Workup including magnetic resonance imaging of the lumbosacral spine, which revealed old compression fractures at L1-3 and new compression fractures at L4-5. Physiatry was consulted and recommended vertebroplasty. Neuro-

Arch Phys Med Rehabil Vol 85, September 2004