- Email: [email protected]
Poster 116
E26
2005 ACADEMY ANNUAL ASSEMBLY ABSTRACTS
diagnose secondary to apparent strong psychological components especially in early stages wherein patients are often categorized as malingering thereby delaying effective treatment. Electromyography is reported to be of some value. Definitive diagnosis may be made by anti-GAD autoantibody titer. Conclusions: In patients with generalized whole-body spasms, SMS should be in the differential diagnosis. Anti-GAD autoantibody titer is a better diagnostic tool than electromyographic examination. Pertinent literature will be discussed. Key Words: Muscle spasticity; Rehabilitation; Stiff-Man syndrome.
Poster 116 Cervical Dystonia After Head Trauma: A Case Report. Joy D. McIver, MD (University of Minnesota, Minneapolis, MN); Dennis D. Dykstra, MD, PhD, e-mail: [email protected]. Disclosure: Dykstra, Research grant from Allergan, Allergan Speakers Bureau; Other authors: None. Setting: Physical medicine and rehabilitation clinic. Patient: A 42-year-old man with painful neck. Case Description: The patient was injured at work when his head hit a stationary auger. He was stunned but did not lose consciousness. Immediately after the injury, he had difficulty turning his head to the right. A few weeks after the accident, this limitation in range of motion progressed until he was essentially fixed in a left turning position with left tilt. A neurologist obtained a cervical magnetic resonance imaging (MRI) reported as normal. 2 months after the injury, a second neurologist ordered a cervical radiograph read as minimal C1-2 subluxation. The brain, thoracic, and lumbar MRI were read as normal. A cervical MRI did not visualize C1-2. There was no evidence of radiculopathy on electromyography. 11 months postinjury, he was referred to a third neurologist who questioned the “organicity of his presentation” and referred him to a fourth neurologist. 13 months after the original accident the fourth neurologist recommended dynamic cervical computed tomography (CT), to evaluate “a structural abnormality versus a conversion disorder” and referred him to our clinic for botulinum toxin. On presentation to our clinic (15mo after injury), the physiatrist ordered a dynamic CT, which revealed approximately 50° of C1-2 rotatory subluxation. Subsequently, the patient underwent posterior C1-3 fusion, botulinum toxin injections, and physical therapy. Assessment/Results: He continues to receive botulinum toxin type A injections with 40% improvement in pain and 50% decrease in neck pulling to date. Discussion: When assessing potential for botulinum toxin, atlantoaxial subluxation should be considered in the differential diagnosis of posttraumatic cervical dystonia. Conclusions: Caution should be used when developing a plan of intervention in the patient with posttraumatic cervical dystonia to assure evaluation has excluded rotatory subluxation. Key Words: Atlantoaxial subluxation; Cervical dystonia; Rehabilitation.
Poster 117 Botulinum Toxin Type A for Nonsurgical Lateral Release in Patellofemoral Pain Syndrome: A Case Report. Andrew Hou, MD (Medical College of Virginia/Virginia Commonwealth University, Richmond, VA); David F. Drake, MD; Peter Pidcoe, PT, PHD; Jeff Ericksen, MD; Ralph Brutus, MD, e-mail: [email protected]. Disclosure: None. Setting: Outpatient rehabilitation clinic. Patient: A 37-year-old physically active man with patellofemoral pain syndrome (PFPS). Case Description: The patient presented with bilateral anterior knee pain that is worse on the left, exacerbated when climbing stairs, sitting with knees bent for a prolonged period, and when running. He had no focal deficits on examination except for lateral tracking patellae bilaterally with crepitus in the left knee worse than the right. We injected 150U of botulinum toxin type A into his left vastus lateralis. He was placed on a 12-week home exercise program performed 3 times per week consisting of strengthening exercises targeting the vastus medialis with short arc squats and wall sits with the feet externally rotated, and stretching of the iliotibial band, quadriceps, hip adductors, hamstrings, and gluteal muscles. Assessment/Results: visual analog scale decreased from 70 on a 150-mm scale to 0, from initial until 8 weeks postinjection. Functional Index Questionnaire increased from 11 to 16 over the same period. Knee torque and surface electromyographic findings showed increased activity of the vastus medialis during knee extension. Discussion: Improper tracking of the patella in the femoral groove due to muscle imbalance between the opposing forces of the vastus medialis and vastus lateralis is thought to be one of the causes of PFPS. We have attempted to weaken the vastus lateralis to allow focused strengthening of the vastus medialis, thus increasing the medial force on the patella, to improve patellar mechanics and decrease patellar pain. Conclusions: Strengthening of the quadriceps particularly the vastus medialis has been shown in the literature to reduce symptoms of PFPS. Botulinum injection in conjunction with vastus medialis strengthening may provide more effective treatment of PFPS. Further study is needed to explore this novel treatment of PFPS. Key Words: Botulinum toxin type A; Patellofemoral pain syndrome; Rehabilitation.
Poster 118 Right Peroneal Nerve Injury After Resection of Heterotopic Ossification From Right Hip: A Case Report. Ali I. Khawaja, MD (Nassau University Medical Center, East Meadow, NY); Glorisel Rodriguez-Villegas, MD; Martin Ferrillo, DO; A. Sohal, MD; Lyn D. Weiss, MD, e-mail: [email protected]. Disclosure: None. Setting: Outpatient rehabilitation unit. Patient: A 51-year-old male patient. Case Description: The patient, who had a medical history of osteoarthritis of the knees and hips bilaterally, left total hip replacement, and right total knee replacement, was seen in the outpatient department for inability to evert and dorsiflex the right foot and decreased sensation on the lateral aspect of the right leg which started after removal of heterotopic ossification (HO) from the right hip. Assessment/Results: On physical examination, right ankle dorsiflexion and eversion was 2/5. There was decreased sensation to touch and pain on the lateral aspect of the right lower leg. The patient was ambulating with right a ankle foot orthosis and single-axis cane. Postoperatively, the patient was put on Indomethacin for 3 months. Preoperatively, radiographs showed HO in bilateral hips and knees. An electrodiagnostic study was suggestive of peroneal
Arch Phys Med Rehabil Vol 86, September 2005
component (L5) involvement. Discussion: Peroneal nerve deficits especially after hip surgery should be assessed with physical examination and electromyographic studies to diagnose and assess severity and prognosis of lesions. Conclusions: Hip surgery may result in sensory or motor symptoms in nerves or branches or nerves crossing hip joint and should be addressed earlier in the course and electrodiagnostic studies should be instituted earlier. Key Words: Heterotopic ossification; Peroneal nerve injury; Rehabilitation.
Poster 119 Epidural Loculations After Multiple Spinal Surgeries. Sami E. Moufawad, MD (Cleveland Clinic Foundation, Cleveland, OH), e-mail: [email protected]. Disclosure: None. Setting: Outpatient clinic. Patient: A 67-year-old gentleman with back pain. Case Description: The patient had a history of 4 lumbar surgeries for decompression with instrumentation with 3 thoracic kyphoplasties. The patient had an implanted intrathecal delivery system 2 years earlier, which was controlling his back pain until August 2004. After multiple solutions adjustments, the catheter was revised in October 2004. The persistence of pain raised the possibility of central pain, and an epidural differential block was proposed. The placement of the epidural catheter, at L1-2 interspace, with fluoroscopic guidance was uneventful. Immediately after injecting the test dose, the patient started to report severe pain in the lower back area with radiation to the knees. No incontinence was reported; a neurologic exam remained intact. Due to the severity of the pain, the patient was admitted for pain control. Magnetic resonance imaging (MRI) was obtained and showed a collection at L1 level compressing the conus. Because of the lack of signs of myelopathy, the surgical team did not recommend surgery. Another MRI was performed 2 days later and showed the same findings. 7 days later, the symptoms started to improve; the patient was discharged home. The pain returned to baseline several weeks later. Assessment/Results: The immediate appearance of pain following the injection was in favor of collection of the solution injected in a loculated area of the epidural space. Discussion: The possibility of an epidural hematoma was not completely eliminated; however, the course of a hematoma is more insidious. Conclusions: The presence of loculations in the epidural space especially after surgical interventions could potentially lead to serious complications if the solution is entrapped in these loculations. Key Words: Conus; Compression; Epidural; Loculations; Rehabilitation.
Poster 120 Spontaneous Epidural Hematoma Presenting as Paraplegia: A Case Report. Sanjeev Agarwal, MD (NUMC, East Meadow, NY); Joshua Levy, DO; Ernesto Capulong, MD; Lyn D. Weiss, MD, e-mail: [email protected]. Disclosure: None. Setting: Inpatient rehabilitation unit. Patient: An 81-year-old woman. Case Description: The patient with medical history of atrial fibrillation and coronary artery disease on Coumadin developed sudden, severe back pain around T6 with gradual onset of bilateral leg numbness and weakness followed by rapid complete paraplegia and sensory loss associated with loss of bladder and bowel sensations. Assessment/Results: The patient was anesthetic below T6 bilaterally with loss of reflexes, motor power (0/5), and perianal and perivaginal sensations. Urgent magnetic resonance imaging (MRI) revealed posterior epidural mass at T6-7 compressing the cord and consistent with subacute hematoma. The patient was managed conservatively with intravenous steroids, FFP, and supportive care in consultation with neurosurgery and neurology with no improvement in clinical picture so far. Discussion: Spontaneous spinal epidural hematoma (EDH) is a rare spinal emergency, with a frequency of less than 1% of spinal space-occupying lesions. Patients typically present with acute onset of severe back pain and rapidly develop signs of compression of cord or cauda equina. Spinal EDH occurring spontaneously or after minimal trauma has been attributed most often to a venous source. Predisposing factors include coagulopathy, anticoagulation (25%–70% of cases), vascular anamoly, disk herniation, Paget’s disease, or the Valsalva maneuver. Our case, like many of the reported cases, was anticoagulated in therapeutic range. MRI scan is considered to be the technique of choice and can differentiate acute from subacute hematoma. Outcome after surgery is variable with favorable prognosis if surgery is performed before blood supply to cord is compromised. The neurologic recovery after surgery varies with the severity of the preoperative impairment and the time between presentation and operation. Conclusions: Spontaneous spinal epidural hematoma should be suspected in any patient receiving anticoagulant agents who complains of local or referred spinal pain associated with limb weakness, sensory deficits, or urinary retention. Key Words: Anticoagulation; Spontaneous epidural hematoma; Rehabilitation.
Poster 121 Giant Cell Tumor of Proximal Fibula Presents With Abnormal Neural Tension Sign: A Case Report. Wesley L. Smeal, MD (Rehabilitation Institute of Chicago, Chicago, IL); Paul H. Lento, MD, e-mail: [email protected]. Disclosure: None. Setting: Outpatient physical medicine and rehabilitation clinic. Patient: A 32-year-old woman with left lateral knee pain. Case Description: The patient presented with a 2-month history of left lateral knee pain. Her pain, which was progressively getting worse, was described as achy with a sensation of tightness. The pain was also occurring at night. She denied any antecedent trauma except for a mild left ankle sprain several months before the onset of symptoms. Following a fall approximately 1 year prior, she had normal left knee radiographs. On physical examination, she had tenderness along the left proximal fibula. Muscle strength, sensation, and reflexes were normal. Adverse neural tension signs were positive, including a slump sit. Assessment/Results: Radiographs of the left knee showed a 3⫻3cm expansile, ill-defined geographic osteolysis in the proximal left fibula. Differential diagnosis included aneurysmal bone cyst, osteosarcoma, and primary bone tumor, including giant cell type. Magnetic resonance imaging showed abnormal T1- and T2-signal intensity in the proximal left fibula and homogenous enhancement with contrast. An orthopedic bone
2005 ACADEMY ANNUAL ASSEMBLY ABSTRACTS
diagnose secondary to apparent strong psychological components especially in early stages wherein patients are often categorized as malingering thereby delaying effective treatment. Electromyography is reported to be of some value. Definitive diagnosis may be made by anti-GAD autoantibody titer. Conclusions: In patients with generalized whole-body spasms, SMS should be in the differential diagnosis. Anti-GAD autoantibody titer is a better diagnostic tool than electromyographic examination. Pertinent literature will be discussed. Key Words: Muscle spasticity; Rehabilitation; Stiff-Man syndrome.
Poster 116 Cervical Dystonia After Head Trauma: A Case Report. Joy D. McIver, MD (University of Minnesota, Minneapolis, MN); Dennis D. Dykstra, MD, PhD, e-mail: [email protected]. Disclosure: Dykstra, Research grant from Allergan, Allergan Speakers Bureau; Other authors: None. Setting: Physical medicine and rehabilitation clinic. Patient: A 42-year-old man with painful neck. Case Description: The patient was injured at work when his head hit a stationary auger. He was stunned but did not lose consciousness. Immediately after the injury, he had difficulty turning his head to the right. A few weeks after the accident, this limitation in range of motion progressed until he was essentially fixed in a left turning position with left tilt. A neurologist obtained a cervical magnetic resonance imaging (MRI) reported as normal. 2 months after the injury, a second neurologist ordered a cervical radiograph read as minimal C1-2 subluxation. The brain, thoracic, and lumbar MRI were read as normal. A cervical MRI did not visualize C1-2. There was no evidence of radiculopathy on electromyography. 11 months postinjury, he was referred to a third neurologist who questioned the “organicity of his presentation” and referred him to a fourth neurologist. 13 months after the original accident the fourth neurologist recommended dynamic cervical computed tomography (CT), to evaluate “a structural abnormality versus a conversion disorder” and referred him to our clinic for botulinum toxin. On presentation to our clinic (15mo after injury), the physiatrist ordered a dynamic CT, which revealed approximately 50° of C1-2 rotatory subluxation. Subsequently, the patient underwent posterior C1-3 fusion, botulinum toxin injections, and physical therapy. Assessment/Results: He continues to receive botulinum toxin type A injections with 40% improvement in pain and 50% decrease in neck pulling to date. Discussion: When assessing potential for botulinum toxin, atlantoaxial subluxation should be considered in the differential diagnosis of posttraumatic cervical dystonia. Conclusions: Caution should be used when developing a plan of intervention in the patient with posttraumatic cervical dystonia to assure evaluation has excluded rotatory subluxation. Key Words: Atlantoaxial subluxation; Cervical dystonia; Rehabilitation.
Poster 117 Botulinum Toxin Type A for Nonsurgical Lateral Release in Patellofemoral Pain Syndrome: A Case Report. Andrew Hou, MD (Medical College of Virginia/Virginia Commonwealth University, Richmond, VA); David F. Drake, MD; Peter Pidcoe, PT, PHD; Jeff Ericksen, MD; Ralph Brutus, MD, e-mail: [email protected]. Disclosure: None. Setting: Outpatient rehabilitation clinic. Patient: A 37-year-old physically active man with patellofemoral pain syndrome (PFPS). Case Description: The patient presented with bilateral anterior knee pain that is worse on the left, exacerbated when climbing stairs, sitting with knees bent for a prolonged period, and when running. He had no focal deficits on examination except for lateral tracking patellae bilaterally with crepitus in the left knee worse than the right. We injected 150U of botulinum toxin type A into his left vastus lateralis. He was placed on a 12-week home exercise program performed 3 times per week consisting of strengthening exercises targeting the vastus medialis with short arc squats and wall sits with the feet externally rotated, and stretching of the iliotibial band, quadriceps, hip adductors, hamstrings, and gluteal muscles. Assessment/Results: visual analog scale decreased from 70 on a 150-mm scale to 0, from initial until 8 weeks postinjection. Functional Index Questionnaire increased from 11 to 16 over the same period. Knee torque and surface electromyographic findings showed increased activity of the vastus medialis during knee extension. Discussion: Improper tracking of the patella in the femoral groove due to muscle imbalance between the opposing forces of the vastus medialis and vastus lateralis is thought to be one of the causes of PFPS. We have attempted to weaken the vastus lateralis to allow focused strengthening of the vastus medialis, thus increasing the medial force on the patella, to improve patellar mechanics and decrease patellar pain. Conclusions: Strengthening of the quadriceps particularly the vastus medialis has been shown in the literature to reduce symptoms of PFPS. Botulinum injection in conjunction with vastus medialis strengthening may provide more effective treatment of PFPS. Further study is needed to explore this novel treatment of PFPS. Key Words: Botulinum toxin type A; Patellofemoral pain syndrome; Rehabilitation.
Poster 118 Right Peroneal Nerve Injury After Resection of Heterotopic Ossification From Right Hip: A Case Report. Ali I. Khawaja, MD (Nassau University Medical Center, East Meadow, NY); Glorisel Rodriguez-Villegas, MD; Martin Ferrillo, DO; A. Sohal, MD; Lyn D. Weiss, MD, e-mail: [email protected]. Disclosure: None. Setting: Outpatient rehabilitation unit. Patient: A 51-year-old male patient. Case Description: The patient, who had a medical history of osteoarthritis of the knees and hips bilaterally, left total hip replacement, and right total knee replacement, was seen in the outpatient department for inability to evert and dorsiflex the right foot and decreased sensation on the lateral aspect of the right leg which started after removal of heterotopic ossification (HO) from the right hip. Assessment/Results: On physical examination, right ankle dorsiflexion and eversion was 2/5. There was decreased sensation to touch and pain on the lateral aspect of the right lower leg. The patient was ambulating with right a ankle foot orthosis and single-axis cane. Postoperatively, the patient was put on Indomethacin for 3 months. Preoperatively, radiographs showed HO in bilateral hips and knees. An electrodiagnostic study was suggestive of peroneal
Arch Phys Med Rehabil Vol 86, September 2005
component (L5) involvement. Discussion: Peroneal nerve deficits especially after hip surgery should be assessed with physical examination and electromyographic studies to diagnose and assess severity and prognosis of lesions. Conclusions: Hip surgery may result in sensory or motor symptoms in nerves or branches or nerves crossing hip joint and should be addressed earlier in the course and electrodiagnostic studies should be instituted earlier. Key Words: Heterotopic ossification; Peroneal nerve injury; Rehabilitation.
Poster 119 Epidural Loculations After Multiple Spinal Surgeries. Sami E. Moufawad, MD (Cleveland Clinic Foundation, Cleveland, OH), e-mail: [email protected]. Disclosure: None. Setting: Outpatient clinic. Patient: A 67-year-old gentleman with back pain. Case Description: The patient had a history of 4 lumbar surgeries for decompression with instrumentation with 3 thoracic kyphoplasties. The patient had an implanted intrathecal delivery system 2 years earlier, which was controlling his back pain until August 2004. After multiple solutions adjustments, the catheter was revised in October 2004. The persistence of pain raised the possibility of central pain, and an epidural differential block was proposed. The placement of the epidural catheter, at L1-2 interspace, with fluoroscopic guidance was uneventful. Immediately after injecting the test dose, the patient started to report severe pain in the lower back area with radiation to the knees. No incontinence was reported; a neurologic exam remained intact. Due to the severity of the pain, the patient was admitted for pain control. Magnetic resonance imaging (MRI) was obtained and showed a collection at L1 level compressing the conus. Because of the lack of signs of myelopathy, the surgical team did not recommend surgery. Another MRI was performed 2 days later and showed the same findings. 7 days later, the symptoms started to improve; the patient was discharged home. The pain returned to baseline several weeks later. Assessment/Results: The immediate appearance of pain following the injection was in favor of collection of the solution injected in a loculated area of the epidural space. Discussion: The possibility of an epidural hematoma was not completely eliminated; however, the course of a hematoma is more insidious. Conclusions: The presence of loculations in the epidural space especially after surgical interventions could potentially lead to serious complications if the solution is entrapped in these loculations. Key Words: Conus; Compression; Epidural; Loculations; Rehabilitation.
Poster 120 Spontaneous Epidural Hematoma Presenting as Paraplegia: A Case Report. Sanjeev Agarwal, MD (NUMC, East Meadow, NY); Joshua Levy, DO; Ernesto Capulong, MD; Lyn D. Weiss, MD, e-mail: [email protected]. Disclosure: None. Setting: Inpatient rehabilitation unit. Patient: An 81-year-old woman. Case Description: The patient with medical history of atrial fibrillation and coronary artery disease on Coumadin developed sudden, severe back pain around T6 with gradual onset of bilateral leg numbness and weakness followed by rapid complete paraplegia and sensory loss associated with loss of bladder and bowel sensations. Assessment/Results: The patient was anesthetic below T6 bilaterally with loss of reflexes, motor power (0/5), and perianal and perivaginal sensations. Urgent magnetic resonance imaging (MRI) revealed posterior epidural mass at T6-7 compressing the cord and consistent with subacute hematoma. The patient was managed conservatively with intravenous steroids, FFP, and supportive care in consultation with neurosurgery and neurology with no improvement in clinical picture so far. Discussion: Spontaneous spinal epidural hematoma (EDH) is a rare spinal emergency, with a frequency of less than 1% of spinal space-occupying lesions. Patients typically present with acute onset of severe back pain and rapidly develop signs of compression of cord or cauda equina. Spinal EDH occurring spontaneously or after minimal trauma has been attributed most often to a venous source. Predisposing factors include coagulopathy, anticoagulation (25%–70% of cases), vascular anamoly, disk herniation, Paget’s disease, or the Valsalva maneuver. Our case, like many of the reported cases, was anticoagulated in therapeutic range. MRI scan is considered to be the technique of choice and can differentiate acute from subacute hematoma. Outcome after surgery is variable with favorable prognosis if surgery is performed before blood supply to cord is compromised. The neurologic recovery after surgery varies with the severity of the preoperative impairment and the time between presentation and operation. Conclusions: Spontaneous spinal epidural hematoma should be suspected in any patient receiving anticoagulant agents who complains of local or referred spinal pain associated with limb weakness, sensory deficits, or urinary retention. Key Words: Anticoagulation; Spontaneous epidural hematoma; Rehabilitation.
Poster 121 Giant Cell Tumor of Proximal Fibula Presents With Abnormal Neural Tension Sign: A Case Report. Wesley L. Smeal, MD (Rehabilitation Institute of Chicago, Chicago, IL); Paul H. Lento, MD, e-mail: [email protected]. Disclosure: None. Setting: Outpatient physical medicine and rehabilitation clinic. Patient: A 32-year-old woman with left lateral knee pain. Case Description: The patient presented with a 2-month history of left lateral knee pain. Her pain, which was progressively getting worse, was described as achy with a sensation of tightness. The pain was also occurring at night. She denied any antecedent trauma except for a mild left ankle sprain several months before the onset of symptoms. Following a fall approximately 1 year prior, she had normal left knee radiographs. On physical examination, she had tenderness along the left proximal fibula. Muscle strength, sensation, and reflexes were normal. Adverse neural tension signs were positive, including a slump sit. Assessment/Results: Radiographs of the left knee showed a 3⫻3cm expansile, ill-defined geographic osteolysis in the proximal left fibula. Differential diagnosis included aneurysmal bone cyst, osteosarcoma, and primary bone tumor, including giant cell type. Magnetic resonance imaging showed abnormal T1- and T2-signal intensity in the proximal left fibula and homogenous enhancement with contrast. An orthopedic bone