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Poster 156 Botulinum Toxin Therapy for Severe Raynaud’s Syndrome and Digital Ulcerations in a Patient with Limited Scleroderma: A Case Report
Abstracts / PM R 7 (2015) S83-S222 Discussion: The thoracic spine is not typically responsible for isolated, nondermatomal abdominal pain. More common etiologies must be ruled out. It is reasonable to consider atypical etiologies of pain in resistant cases that had extensive workup and treatment without adequate explanation of the presenting symptom. Thoracic neuritis may be responsible for resistant cases of abdominal pain for which no obvious etiology may be identified. Conclusion: Thoracic neuritis should be considered in the differential diagnosis of isolated abdominal pain without apparent explanation. In such cases TTFESIs may serve both a diagnostic and therapeutic role.
Poster 156 Botulinum Toxin Therapy for Severe Raynaud’s Syndrome and Digital Ulcerations in a Patient with Limited Scleroderma: A Case Report Radhika Sood, DO (VA Greater Los Angeles Healthcare System/UCLA, Los Angeles, CA, United States), Chirag Vora, DO, Sanjog Pangarkar, MD Disclosures: R. Sood: I Have No Relevant Financial Relationships To Disclose. Case Description: A 55-year-old woman with history of scleroderma presenting with chronic digital ulcerations of the hands secondary to severe Raynaud’s syndrome. She demonstrated poor hand dexterity and severe pain limiting function. The patient’s symptoms were refractory to conservative treatments including occupational therapy and oral medications including Tadalafil and Amlodipine. She was consequently referred for trial of IncobutulinumtoxinA (Xeomin) injections to the bilateral hands. Setting: Outpatient clinic. Results or Clinical Course: Three weeks post-injections, the patient reported improved pain, range of motion of the fingers, dexterity, skin color, and healing of the digital ulcerations. No complications were reported. Discussion: Rheumatologic conditions, such as scleroderma, pose a particular challenge for patient and provider alike. DMARDs can help slow disease progression but may not provide symptomatic relief for the vasospastic changes that lead to ischemic ulcers, pain, and loss of function. We present a patient with significant symptomatic relief in both hands three weeks after botulinum toxin injection. We speculate that botulinum toxin improves circulation through modulation of sympathetic tone, though further studies are needed to confirm this effect. Conclusion: We present a case of scleroderma induced Raynauld’s syndrome, digital ulceration, and poor hand function successfully treated with botulinum toxin.
Poster 157 Non-Inferiority of Cooled Versus Traditional Radiofrequency Ablation of the Lumbar Medial Branch Nerves in the Treatment of Axial Low Back Pain Jonathan Napolitano, MD (Loyola University, Maywood, IL, United States), Adam Hintz, BS, Henry Legaspi, DO, Abhishek K. Das, MD, Prempreet S. Bajaj, DO Disclosures: J. Napolitano: I Have No Relevant Financial Relationships To Disclose. Objective: To determine non-inferiority of cooled radiofrequency ablation (RFA) to traditional RFA in providing pain relief, time to repeat procedure, and radiation exposure. Design: Retrospective chart review. Setting: Single provider PM&R pain clinic at an academic medical center. Participants: Thirty-nine patients undergoing a total of sixty lumbar medial nerve branch radiofrequency ablations (36 traditional and 24 cooled).
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Main Outcome Measures: Follow-up post-procedure pain score, percent improvement, days to repeat RFA, and fluoroscopy time of procedure. Results or Clinical Course: When comparing 60 radiofrequency ablations, there was no significant difference in BMI (29.33 vs. 31.60 kg/ m2, P¼.19) or sex (29% vs. 42% male, P¼.42) between cooled or traditional groups. Patients who underwent cooled RFA had an older average age (68.48 vs. 51.80 years, P<.001). The pre-procedure pain scores were not significantly different between groups (6.08 vs. 6.28, P¼.78). Post-procedure pain scores for patients who followed up between 30 and 90 days post RFA were lower in the cooled group (4.28 vs. 6.26, P¼.008), while patient perceived percent improvement in their axial low back pain was greater in traditional group (81.67% vs. 40.0%, P¼.006). The time to repeat ablation was longer in the traditional group than in the cooled group, however the difference was not statistically significant (359.3 vs. 288.7 days, P¼.45). Finally, traditional RFA procedure of six or more levels exposed patients to longer fluoroscopy time than cooled RFA at the same levels (196.2 vs 141.4 seconds, P¼.02). Conclusion: The process of cooled radiofrequency ablation has been adopted by the interventional pain management community, with a more direct approach to the lumbar medial branch nerve, as a means to create a larger burn. This retrospective study demonstrates non-inferiority of cooled radiofrequency ablation compared to traditional RF in improvement of pain and time to repeat ablation. Cooled RF exhibits additional clinical benefits noted in our study. The older average age of the cooled RF group demonstrates an opportunity to treat more degenerative spines that previously were not candidates for traditional RF due to the complex anatomy. Additionally, with a more direct approach patients and providers are exposed to less fluoroscopy time and possibly increased efficiency.
Poster 158 Excruciating Bilateral Toe Pain in a Patient with a Substantial Smoking History: A Case Report Roman Zolotoy (Tufts Medical Center, Boston, MA, United States) Disclosures: R. Zolotoy: I Have No Relevant Financial Relationships To Disclose. Case Description: A 64-year-old woman presented to a hospital complaining of long-standing, excruciating bilateral toe pain. While multiple diagnoses were considered in the past, including peripheral neuropathy and gout, standard treatments for both were unsuccessful. Accidental foot trauma also caused permanent purple discoloration to multiple toes leading to her presentation to the hospital. At the time, all of the toes were extremely painful. Sensation description varied from severe burning to “electrical shock.” During initial interview she also revealed a 140-pack-year smoking history. Patient was admitted and seen by vascular surgery, rheumatology and infectious disease services. Given her presentation and tobacco history, the collaborating services established a working diagnosis of Buerger’s Disease (BD). Setting: Acute care hospital. Results or Clinical Course: Patient was treated conservatively with pain medication, instructed to quit tobacco immediately and discharged home. Unfortunately, she was unable to quit smoking and returned two weeks later with worsening pain. Multiple treatments were considered but given progression of her disease, she underwent a right transmetatarsal amputation and a month later a left transmetatarsal amputation. Discussion: BD is a non-atherosclerotic, thrombotic, occlusive disease which affects small to medium-sized vessels. Most common presentation is digit ischemia affecting toes, fingers or both. BD is predominantly a clinical diagnosis but tests specific for other conditions can be used to diagnose BD via exclusion of respective diseases. Main role of management in BD is to prevent tissue loss and
Poster 156 Botulinum Toxin Therapy for Severe Raynaud’s Syndrome and Digital Ulcerations in a Patient with Limited Scleroderma: A Case Report Radhika Sood, DO (VA Greater Los Angeles Healthcare System/UCLA, Los Angeles, CA, United States), Chirag Vora, DO, Sanjog Pangarkar, MD Disclosures: R. Sood: I Have No Relevant Financial Relationships To Disclose. Case Description: A 55-year-old woman with history of scleroderma presenting with chronic digital ulcerations of the hands secondary to severe Raynaud’s syndrome. She demonstrated poor hand dexterity and severe pain limiting function. The patient’s symptoms were refractory to conservative treatments including occupational therapy and oral medications including Tadalafil and Amlodipine. She was consequently referred for trial of IncobutulinumtoxinA (Xeomin) injections to the bilateral hands. Setting: Outpatient clinic. Results or Clinical Course: Three weeks post-injections, the patient reported improved pain, range of motion of the fingers, dexterity, skin color, and healing of the digital ulcerations. No complications were reported. Discussion: Rheumatologic conditions, such as scleroderma, pose a particular challenge for patient and provider alike. DMARDs can help slow disease progression but may not provide symptomatic relief for the vasospastic changes that lead to ischemic ulcers, pain, and loss of function. We present a patient with significant symptomatic relief in both hands three weeks after botulinum toxin injection. We speculate that botulinum toxin improves circulation through modulation of sympathetic tone, though further studies are needed to confirm this effect. Conclusion: We present a case of scleroderma induced Raynauld’s syndrome, digital ulceration, and poor hand function successfully treated with botulinum toxin.
Poster 157 Non-Inferiority of Cooled Versus Traditional Radiofrequency Ablation of the Lumbar Medial Branch Nerves in the Treatment of Axial Low Back Pain Jonathan Napolitano, MD (Loyola University, Maywood, IL, United States), Adam Hintz, BS, Henry Legaspi, DO, Abhishek K. Das, MD, Prempreet S. Bajaj, DO Disclosures: J. Napolitano: I Have No Relevant Financial Relationships To Disclose. Objective: To determine non-inferiority of cooled radiofrequency ablation (RFA) to traditional RFA in providing pain relief, time to repeat procedure, and radiation exposure. Design: Retrospective chart review. Setting: Single provider PM&R pain clinic at an academic medical center. Participants: Thirty-nine patients undergoing a total of sixty lumbar medial nerve branch radiofrequency ablations (36 traditional and 24 cooled).
S143
Main Outcome Measures: Follow-up post-procedure pain score, percent improvement, days to repeat RFA, and fluoroscopy time of procedure. Results or Clinical Course: When comparing 60 radiofrequency ablations, there was no significant difference in BMI (29.33 vs. 31.60 kg/ m2, P¼.19) or sex (29% vs. 42% male, P¼.42) between cooled or traditional groups. Patients who underwent cooled RFA had an older average age (68.48 vs. 51.80 years, P<.001). The pre-procedure pain scores were not significantly different between groups (6.08 vs. 6.28, P¼.78). Post-procedure pain scores for patients who followed up between 30 and 90 days post RFA were lower in the cooled group (4.28 vs. 6.26, P¼.008), while patient perceived percent improvement in their axial low back pain was greater in traditional group (81.67% vs. 40.0%, P¼.006). The time to repeat ablation was longer in the traditional group than in the cooled group, however the difference was not statistically significant (359.3 vs. 288.7 days, P¼.45). Finally, traditional RFA procedure of six or more levels exposed patients to longer fluoroscopy time than cooled RFA at the same levels (196.2 vs 141.4 seconds, P¼.02). Conclusion: The process of cooled radiofrequency ablation has been adopted by the interventional pain management community, with a more direct approach to the lumbar medial branch nerve, as a means to create a larger burn. This retrospective study demonstrates non-inferiority of cooled radiofrequency ablation compared to traditional RF in improvement of pain and time to repeat ablation. Cooled RF exhibits additional clinical benefits noted in our study. The older average age of the cooled RF group demonstrates an opportunity to treat more degenerative spines that previously were not candidates for traditional RF due to the complex anatomy. Additionally, with a more direct approach patients and providers are exposed to less fluoroscopy time and possibly increased efficiency.
Poster 158 Excruciating Bilateral Toe Pain in a Patient with a Substantial Smoking History: A Case Report Roman Zolotoy (Tufts Medical Center, Boston, MA, United States) Disclosures: R. Zolotoy: I Have No Relevant Financial Relationships To Disclose. Case Description: A 64-year-old woman presented to a hospital complaining of long-standing, excruciating bilateral toe pain. While multiple diagnoses were considered in the past, including peripheral neuropathy and gout, standard treatments for both were unsuccessful. Accidental foot trauma also caused permanent purple discoloration to multiple toes leading to her presentation to the hospital. At the time, all of the toes were extremely painful. Sensation description varied from severe burning to “electrical shock.” During initial interview she also revealed a 140-pack-year smoking history. Patient was admitted and seen by vascular surgery, rheumatology and infectious disease services. Given her presentation and tobacco history, the collaborating services established a working diagnosis of Buerger’s Disease (BD). Setting: Acute care hospital. Results or Clinical Course: Patient was treated conservatively with pain medication, instructed to quit tobacco immediately and discharged home. Unfortunately, she was unable to quit smoking and returned two weeks later with worsening pain. Multiple treatments were considered but given progression of her disease, she underwent a right transmetatarsal amputation and a month later a left transmetatarsal amputation. Discussion: BD is a non-atherosclerotic, thrombotic, occlusive disease which affects small to medium-sized vessels. Most common presentation is digit ischemia affecting toes, fingers or both. BD is predominantly a clinical diagnosis but tests specific for other conditions can be used to diagnose BD via exclusion of respective diseases. Main role of management in BD is to prevent tissue loss and