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Poster 164 A Sciatic Neuropathy by Focal Venous Engorgement: A Case Report
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Setting: Academic medical center. Results or Clinical Course: On examination, the patient had weakness of his right gluteus medius, tibialis anterior, tibialis posterior, peronei and extensor hallucis longus muscles. There was reduced sensation to pinprick over his dorsolateral right foot. Magnetic resonance imaging of his lumbar spine was unremarkable for neural compression. Electrodiagnostic studies revealed changes that localized either to the right sciatic nerve or sacral plexus. He was diagnosed with right lower limb weakness due to herpes zoster infection. Following physical therapy, he regained some functional strength of the right foot and was able to ambulate with an anklefoot-orthosis and cane. Discussion: Herpes zoster infection occurs due to reactivation of the varicella zoster virus. Over 90% of the reported cases are in immunocompetent individuals and the greatest risk factor is increased age. Zoster-associated limb weakness is an uncommon complication and has been reported in 3% of individuals with herpes zoster infections. The pathophysiology of zoster-associated limb weakness is hypothesized to be viral-mediated injury to the anterior horn cell or dysmyelination of the peripheral nerve. Conclusions: Zoster-associated limb weakness is a rare complication of herpes zoster infection, but should be included in the differential diagnosis of acute limb weakness.
Poster 164 A Sciatic Neuropathy by Focal Venous Engorgement: A Case Report. Young-Ah Choi (Seoul National University Hospital, Seoul, Korea, Republic of); Keewon Kim, MD, MS. Disclosures: Y. Choi, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: We report a case in which sciatic neuropathy developed associated with engorged vessels after disseminated deep vein thrombosis (DVT). A 69-year-old woman who had been admitted in intensive care unit (ICU) for uroseptic shock with multiple organ dysfunction syndrome and following DVT involving both lower extremities and right subclavian vein complained of sustained severe weakness and pain of the left lower extremity after ICU admission. The motor power of ankle dorsiflexor and plantar flexor were grade 2 on the MRC scale and she could not raise her leg against gravity. Electrodiagnostic study revealed a left sciatic neuropathy and magnetic resonance image of the pelvis showed prominent perineural and intraneural venous structures in adjacent sciatic nerve, suspected as a vascular malformation or varix. Based on the electrodiagnostic results and imaging studies, a sciatic neuropathy was diagnosed, presumably due to vascular engorgement. Setting: A tertiary hospital. Results or Clinical Course: After consultation with a vascular surgeon, conservative management was determined including anticoagulation therapy, a direct, selective, reversible factor Xa inhibitor (Rivaroxaban) and rehabilitation therapy. At three months later at outpatient clinic, the motor power of ankle dorsiflexor was grade 4 and plantar flexor was grade 3 on the MRC scale. Also follow-up computed tomography angiography showed improved focal enlargement and enhancement at and around the sciatic nerve without DVT in the lower extremities.
PRESENTATIONS
Discussion: The vascular cause of the sciatic neuropathy, focal venous engorgement in association with systemic illness such as DVT, is a very rare cause but treatable neurologic disorder with conservative therapy. Conclusions: If sustained weakness is observed among patients in poor general medical condition with high risk of DVT, electromyography could give critical clue for differential diagnosis and DVT is worthy of consideration as the vascular cause of sciatic neuropathy. Poster 165 Insensate but Ambulatory: Unique Solutions for Thoracic Wound Care After Complex Spinal Surgery. Katherine N. Nanos, MD (Mayo Clinic, Rochester, MN, United States); Casandra J. Rosenberg, MD; Darcy Erickson, OT; Mark Christopherson, MD. Disclosures: K. N. Nanos, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: The patient underwent tumor resection with extensive reconstruction and instrumentation of her spine from C7-T12. Her postoperative course was complicated by thoracic spine numbness and surgical site infection. She then developed wound dehiscence of her thoracic wound, causing concern for hardware breakthrough. The area of dehiscence overlaid the most prominent point in her spine curvature; a suspected pressure point when seated and lying back, causing concern for further breakdown. Occupational therapy was consulted for pressure mapping, which indeed revealed increased pressure along the area of concern. The initial thought was to create a cushion to be placed behind her back when seated. This option was trialed, however was not feasible for the patient and her husband, especially on a long term basis as the cushion required constant adjustment. Adjustments were not able to be made accurately by the patient, as her sensory deficits impaired her ability to assess its proper placement, putting her at risk for pressure or shear in the area. A thoracolumbar sacral orthosis with custom contouring was made to offload the affected area. This seemed ideal as a long term solution for a person in her position; insensate and ambulatory. She was molded with focus on increased support at bilateral PSIS joints to help maintain neutral pelvis as well as fit and flair around the torso to offload the thoracic spine. Setting: Outpatient Rehabilitation. Results or Clinical Course: A custom posterior back with sheepskin liner and an Aspen contour front was created. Repeat pressure mapping within the brace showed pressure along the low back and sides, removing pressure from the thoracic wound, with the exception of 20 mmHg in the semi-reclined position (recliner chair). Patient Specific Functional Scale demonstrated improvement of score from 6/10 to 9/10, specifically stating improvement in her ability to change her body position and move freely without concern. Discussion: The gold standard for treatment and prevention of pressure sores is offloading. Achieving this can be complicated by certain patient conditions, including impaired sensation. Conclusions: A custom made orthosis was an effective long term strategy in preventing catastrophic outcomes in this patient, and its portability and comfort offered her quality of life.
Setting: Academic medical center. Results or Clinical Course: On examination, the patient had weakness of his right gluteus medius, tibialis anterior, tibialis posterior, peronei and extensor hallucis longus muscles. There was reduced sensation to pinprick over his dorsolateral right foot. Magnetic resonance imaging of his lumbar spine was unremarkable for neural compression. Electrodiagnostic studies revealed changes that localized either to the right sciatic nerve or sacral plexus. He was diagnosed with right lower limb weakness due to herpes zoster infection. Following physical therapy, he regained some functional strength of the right foot and was able to ambulate with an anklefoot-orthosis and cane. Discussion: Herpes zoster infection occurs due to reactivation of the varicella zoster virus. Over 90% of the reported cases are in immunocompetent individuals and the greatest risk factor is increased age. Zoster-associated limb weakness is an uncommon complication and has been reported in 3% of individuals with herpes zoster infections. The pathophysiology of zoster-associated limb weakness is hypothesized to be viral-mediated injury to the anterior horn cell or dysmyelination of the peripheral nerve. Conclusions: Zoster-associated limb weakness is a rare complication of herpes zoster infection, but should be included in the differential diagnosis of acute limb weakness.
Poster 164 A Sciatic Neuropathy by Focal Venous Engorgement: A Case Report. Young-Ah Choi (Seoul National University Hospital, Seoul, Korea, Republic of); Keewon Kim, MD, MS. Disclosures: Y. Choi, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: We report a case in which sciatic neuropathy developed associated with engorged vessels after disseminated deep vein thrombosis (DVT). A 69-year-old woman who had been admitted in intensive care unit (ICU) for uroseptic shock with multiple organ dysfunction syndrome and following DVT involving both lower extremities and right subclavian vein complained of sustained severe weakness and pain of the left lower extremity after ICU admission. The motor power of ankle dorsiflexor and plantar flexor were grade 2 on the MRC scale and she could not raise her leg against gravity. Electrodiagnostic study revealed a left sciatic neuropathy and magnetic resonance image of the pelvis showed prominent perineural and intraneural venous structures in adjacent sciatic nerve, suspected as a vascular malformation or varix. Based on the electrodiagnostic results and imaging studies, a sciatic neuropathy was diagnosed, presumably due to vascular engorgement. Setting: A tertiary hospital. Results or Clinical Course: After consultation with a vascular surgeon, conservative management was determined including anticoagulation therapy, a direct, selective, reversible factor Xa inhibitor (Rivaroxaban) and rehabilitation therapy. At three months later at outpatient clinic, the motor power of ankle dorsiflexor was grade 4 and plantar flexor was grade 3 on the MRC scale. Also follow-up computed tomography angiography showed improved focal enlargement and enhancement at and around the sciatic nerve without DVT in the lower extremities.
PRESENTATIONS
Discussion: The vascular cause of the sciatic neuropathy, focal venous engorgement in association with systemic illness such as DVT, is a very rare cause but treatable neurologic disorder with conservative therapy. Conclusions: If sustained weakness is observed among patients in poor general medical condition with high risk of DVT, electromyography could give critical clue for differential diagnosis and DVT is worthy of consideration as the vascular cause of sciatic neuropathy. Poster 165 Insensate but Ambulatory: Unique Solutions for Thoracic Wound Care After Complex Spinal Surgery. Katherine N. Nanos, MD (Mayo Clinic, Rochester, MN, United States); Casandra J. Rosenberg, MD; Darcy Erickson, OT; Mark Christopherson, MD. Disclosures: K. N. Nanos, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: The patient underwent tumor resection with extensive reconstruction and instrumentation of her spine from C7-T12. Her postoperative course was complicated by thoracic spine numbness and surgical site infection. She then developed wound dehiscence of her thoracic wound, causing concern for hardware breakthrough. The area of dehiscence overlaid the most prominent point in her spine curvature; a suspected pressure point when seated and lying back, causing concern for further breakdown. Occupational therapy was consulted for pressure mapping, which indeed revealed increased pressure along the area of concern. The initial thought was to create a cushion to be placed behind her back when seated. This option was trialed, however was not feasible for the patient and her husband, especially on a long term basis as the cushion required constant adjustment. Adjustments were not able to be made accurately by the patient, as her sensory deficits impaired her ability to assess its proper placement, putting her at risk for pressure or shear in the area. A thoracolumbar sacral orthosis with custom contouring was made to offload the affected area. This seemed ideal as a long term solution for a person in her position; insensate and ambulatory. She was molded with focus on increased support at bilateral PSIS joints to help maintain neutral pelvis as well as fit and flair around the torso to offload the thoracic spine. Setting: Outpatient Rehabilitation. Results or Clinical Course: A custom posterior back with sheepskin liner and an Aspen contour front was created. Repeat pressure mapping within the brace showed pressure along the low back and sides, removing pressure from the thoracic wound, with the exception of 20 mmHg in the semi-reclined position (recliner chair). Patient Specific Functional Scale demonstrated improvement of score from 6/10 to 9/10, specifically stating improvement in her ability to change her body position and move freely without concern. Discussion: The gold standard for treatment and prevention of pressure sores is offloading. Achieving this can be complicated by certain patient conditions, including impaired sensation. Conclusions: A custom made orthosis was an effective long term strategy in preventing catastrophic outcomes in this patient, and its portability and comfort offered her quality of life.