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Poster 184 Bilateral Femoral Neuropathy Due to Prolonged Lithotomy Positioning During Surgery: A Case Report
PM&R
not performed. In this case, the SSEH resolved without the need for intervention. Conclusions: SSEH should be considered in healthy patients with pain and/or neurologic symptoms. Patients should be monitored for progression of symptoms or neurologic deterioration, which may indicate a need for surgical intervention, although SSEH can resolve spontaneously with conservative treatment.
Poster 182 Cheerleader With Nontraumatic Isolated Thoracic Transverse Process Fractures: A Case Report. Bryan Murtaugh, MD (Rehabilitation Institute of Chicago, Chicago, IL, United States); Ellen Casey, MD. Disclosures: B. Murtaugh, none. Patients or Programs: A 13-year-old girl with mid back pain. Program Description: The patient presented with more than 2 months of left-sided mid back pain, which started gradually during one cheerleading practice where she served as a base for multiple lifts. She had radiographs, passive modalities, and mobilizations for rib dysfunction at a chiropractor’s office for a several weeks without improvement. Her pain persisted despite stopping cheerleading for several weeks. Results of a physical examination was notable for tenderness to palpation of left-sided lower thoracic paraspinals. Pain was increased with thoracolumbar range of motion in all planes. Outside radiographs were reviewed and were negative for spondylolysis but notable for transitional anatomy and mild thoracolumbar scoliosis. Setting: Academic sports and spine practice. Results: The differential diagnosis of spondylolysis, ring apophysitis, and diskogenic pain, and imaging options were discussed with the patient and her mother. Based on her examination being somewhat atypical for spondylolysis and the family’s desire to avoid radiation exposure, we decided to obtain a magnetic resonance image and provided a warm and form brace for comfort. Magnetic resonance imaging showed mild T7 and moderate T8 transverse process edema. A single photon emission computed tomography study was ordered, which showed focal areas of increased uptake that corresponded to fractures of the left transverse processes of T7 and T8. Although the fractures were stable on imaging, she had persistent pain, so she was placed in a thoracolumbosacral orthosis, and a physical therapy program was initiated. Discussion: While traumatic transverse process fractures are common in high-energy injury, nontraumatic isolated transverse process fractures are rare, and, to our knowledge, this is the first reported case. Conclusions: Nontraumatic transverse process fractures can present with gradual onset of back pain, and require high index of suspicion with adequate imaging to confirm diagnosis.
Poster 183 Cryptococcal Abscess and Osteomyelitis of the Calcaneus: A Case Report. Elizabeth Nguyen, MD (New York Presbyterian Hospital – Columbia and Cornell, New York, NY, United States); Chi-Chang D. Lin, MD. Disclosures: E. Nguyen, none. Patients or Programs: A 56-year-old man with left calcaneal osteomyelitis.
Vol. 3, Iss. 10S1, 2011
S233
Program Description: This patient presented to a rehabilitation clinic with left heel pain for 1 month. He was initially diagnosed with tendinitis and prescribed a course of physical therapy. Because the heel pain persisted, a magnetic resonance imaging study of the left lower extremity was performed, which revealed osteomyelitis of the left calcaneus bone. He was admitted for an incision and drainage procedure. Bone cultures demonstrated a positive cryptococcal infection. He completed a 10-day course of intravenous aztreonam and vancomycin, and was started on fluconazole for 3 months. An immune deficiency workup was negative. Several weeks later, he noted continued discomfort in his left heel while ambulating. He denied fevers, chills, weight loss, or a history of trauma. A repeated magnetic resonance image demonstrated minimal improvement of osteomyelitis. He was readmitted for an incision and drainage procedure of the left calcaneus, and fluconazole was restarted. Surgical pathology returned with evidence of cryptococcal infection. He was recommended toe touch weight bearing until follow-up with his orthopedic surgeon. Setting: A tertiary care hospital. Results: The patient remained off work for 1 month and gradually advanced from toe touch weight bearing to weight bearing as tolerated. He completed a 12-month course of fluconazole. A follow-up magnetic resonance image showed improving osteomyelitis of the calcaneus. Discussion: Calcaneal osteomyelitis rarely affects immunocompetent hosts. Moreover, Cryptococcus neoformans typically manifests as pulmonary infections in immunocompromised individuals and is an uncommon cause of osteomyelitis. Few cases of isolated cryptococcal osteomyelitis have been reported, especially in an otherwise healthy individual with no history of human immunodeficiency virus. This condition is often difficult to treat and should be aggressively managed to prevent complications such as amputation. Conclusions: Although immunocompetent individuals rarely develop calcaneal osteomyelitis, especially from cryptococcal infections, this serious condition should be considered in a patient with persistent heel pain.
Poster 184 Bilateral Femoral Neuropathy Due to Prolonged Lithotomy Positioning During Surgery: A Case Report. Elizabeth Nguyen, MD (New York Presbyterian Hospital – Columbia and Cornell, New York, NY, United States); Chi-Chang D. Lin, MD. Disclosures: E. Nguyen, none. Patients or Programs: A 51-year-old woman with bilateral femoral neuropathy. Program Description: The patient underwent a suprapubic pubovaginal sling procedure, pelvic floor repair, and cystoscopy for stress incontinence, in addition to dilatation and curettage for endometrial polyps with the patient under epidural anesthesia. She remained in the lithotomy position for 3 hours during these procedures. On postoperative day 1, she noted lower extremity weakness and numbness bilaterally. On examination, hip flexion was 3⫹/5 on the right and 3–/5 on the left, knee extension was 1/5 bilaterally, and patellar tendon reflexes were absent bilaterally. Sensation was decreased along the anterior thigh and medial leg bilaterally. Imaging studies of the lumbar spine and pelvis were negative for hematoma or abscess. Physical therapy was initiated for lower extremity
S234
strengthening and gait training. On postoperative day 3, she was admitted to acute inpatient rehabilitation. She demonstrated decreased balance with gait secondary to quadriceps weakness. After 10 days of therapy, she achieved modified independence with transfers and ambulation by using a rolling walker. Setting: A tertiary care hospital. Results: At 6 weeks after surgery, electromyography and nerve conduction studies revealed axonal injury to the femoral nerves bilaterally. At 12 weeks after surgery, the patient noted significant improvement in her lower extremity strength. Hip flexion was 4⫹/5 bilaterally, right knee extension was 4⫹/5, and left knee extension was 4/5. She progressed to ambulation by using a cane in the community. Discussion: Lithotomy positioning can lead to bilateral femoral neuropathy due to prolonged hip flexion, extreme hip abduction, and external rotation. This position may not only compress the femoral nerve but also stretch it beneath the inguinal ligament, which results in demyelinating or axonal nerve injuries. This complication may be prevented by modifying posture and decreasing operating time. Conclusions: Bilateral femoral neuropathy is a rare complication of prolonged surgery in the lithotomy position. Clinicians should timely recognize this condition and promptly initiate a comprehensive rehabilitation program to address the significant functional impairments and associated psychological stress.
Poster 185 Miller Fisher Variant of Guillain-Barré Syndrome With an Unusual Presentation: A Case Report. Lisa R. Kroopf, MD (Loma Linda University Medical Center, Loma Linda, CA, United States); Murray Brandstater, MD, Menandro Cunanan, MD. Disclosures: L. R. Kroopf, none. Patients or Programs: A 64-year-old man with hypertension and diabetes mellitus. Program Description: The patient presented with blurred vision, bilateral hand numbness, unsteady gait, dysarthria, and dysphagia for several days. He was unable to stand up unassisted. The initial diagnosis was a small brainstem stroke although brain magnetic resonance imaging was normal. The patient was transferred to the acute rehabilitation unit for stroke rehabilitation 8 days after initial presentation. The physical examination was notable for slight dysarthria, nystagmus, diplopia, ptosis of the right eye, and ataxia. There was no motor weakness, and deep tendon reflexes were symmetric and normal. The patient progressed poorly. He had severe truncal ataxia. On the fourth day of admission, he fell from his wheelchair and sustained a head injury. He was transferred to the acute medical ward for further workup. Setting: Veterans Affairs inpatient rehabilitation center. Results: Three weeks later, the patient was readmitted to the acute rehabilitation unit. He had undergone a full neurologic workup and was now diagnosed with Miller Fisher variant of Guillain-Barré syndrome. Ganglioside GQ1b auto antibody test was positive, and cerebrospinal fluid showed high protein levels without white cells, features indicative of Guillain-Barré syndrome. A nerve conduction test was nondiagnostic, with mild abnormalities. Intravenous immunoglobulins were not administered. Discussion: Miller Fisher syndrome is a rare clinical variant of Guillain-Barré syndrome, an acute inflammatory polyneuropathy,
PRESENTATIONS
and a diagnosis of this variant may be difficult. It typically presents with ataxia, ophthalmoplegia, and areflexia, and there may be oropharyngeal weakness. Anti-GQ1b antiganglioside antibodies are present in 90% of cases. Conclusions: Patients usually show significant improvement in neurologic function within several weeks after diagnosis and full neurologic recovery in approximately 10 weeks. It is important to confirm the diagnosis because of the expected good recovery and because this gives therapists the opportunity to create a customized rehabilitation program to address the patient’s specific deficits.
Poster 186 Avulsion of the Adductor Muscle at the Symphysis Pubis Diagnosed With Ultrasound: A Case Report. David J. Chen, MD (University of Pennsylvania, Philadelphia, PA, United States); Franklin E. Caldera, DO, MBA, Woojin Kim, MD. Disclosures: D. J. Chen, none. Patients or Programs: A 58-year-old woman with obstructive sleep apnea and hyperlipidemia, presented to the clinic with left hip and left groin pain for 1 month, which began after taking a misstep. Program Description: We describe the use of ultrasound in diagnosing an avulsion tear at the insertion of the adductor muscles at the symphysis pubis, predominantly involving the adductor longus and brevis muscles. Setting: Tertiary care academic teaching hospital. Results: The patient ultimately was treated conservatively with nonsteroidal anti-inflammatory drugs for pain control, and physical therapy for muscle strengthening and balance improvement, and subsequently did well on follow-up. Discussion: The long adductor, short adductor, and gracilis muscles insert into the symphysis pubis and inferior pubic ramus. Avulsion injuries have previously been described at the symphysis pubis, with patients experiencing pain localizing to the groin. It is most common in adolescent athletes, and commonly mistaken for muscle or tendon injuries. The differential diagnosis of such chronic avulsion injury also includes infection or sarcomas. The standard treatment includes conservative measures, with rest and limited weight-bearing status for several weeks. The accepted method of diagnosis includes reviewing the history; physical examination; and radiologic imaging, such as the use of bone scans (which will demonstrate increased linear uptake) and the use of magnetic resonance (can have findings of bone marrow edema with enhancing periostitis). Conclusions: The use of ultrasound can be helpful in the diagnosis of avulsion tear at the insertion of the adductor muscles, as well as adductor insertion avulsion syndrome at the symphysis pubis. Sonography is becoming an increasingly used imaging modality in evaluating the musculoskeletal system because of its portability, absence of ionizing radiation, and relatively low cost compared with other cross-sectional imaging modalities.
Poster 187 Groin Pain Can Be Quite Painful With the Wrong Diagnosis: A Case Report. Sebastian Klisiewicz, DO (MCW, Wauwatosa, WI, United States); Thomas Kotsonis, MD. Disclosures: S. Klisiewicz, none.
not performed. In this case, the SSEH resolved without the need for intervention. Conclusions: SSEH should be considered in healthy patients with pain and/or neurologic symptoms. Patients should be monitored for progression of symptoms or neurologic deterioration, which may indicate a need for surgical intervention, although SSEH can resolve spontaneously with conservative treatment.
Poster 182 Cheerleader With Nontraumatic Isolated Thoracic Transverse Process Fractures: A Case Report. Bryan Murtaugh, MD (Rehabilitation Institute of Chicago, Chicago, IL, United States); Ellen Casey, MD. Disclosures: B. Murtaugh, none. Patients or Programs: A 13-year-old girl with mid back pain. Program Description: The patient presented with more than 2 months of left-sided mid back pain, which started gradually during one cheerleading practice where she served as a base for multiple lifts. She had radiographs, passive modalities, and mobilizations for rib dysfunction at a chiropractor’s office for a several weeks without improvement. Her pain persisted despite stopping cheerleading for several weeks. Results of a physical examination was notable for tenderness to palpation of left-sided lower thoracic paraspinals. Pain was increased with thoracolumbar range of motion in all planes. Outside radiographs were reviewed and were negative for spondylolysis but notable for transitional anatomy and mild thoracolumbar scoliosis. Setting: Academic sports and spine practice. Results: The differential diagnosis of spondylolysis, ring apophysitis, and diskogenic pain, and imaging options were discussed with the patient and her mother. Based on her examination being somewhat atypical for spondylolysis and the family’s desire to avoid radiation exposure, we decided to obtain a magnetic resonance image and provided a warm and form brace for comfort. Magnetic resonance imaging showed mild T7 and moderate T8 transverse process edema. A single photon emission computed tomography study was ordered, which showed focal areas of increased uptake that corresponded to fractures of the left transverse processes of T7 and T8. Although the fractures were stable on imaging, she had persistent pain, so she was placed in a thoracolumbosacral orthosis, and a physical therapy program was initiated. Discussion: While traumatic transverse process fractures are common in high-energy injury, nontraumatic isolated transverse process fractures are rare, and, to our knowledge, this is the first reported case. Conclusions: Nontraumatic transverse process fractures can present with gradual onset of back pain, and require high index of suspicion with adequate imaging to confirm diagnosis.
Poster 183 Cryptococcal Abscess and Osteomyelitis of the Calcaneus: A Case Report. Elizabeth Nguyen, MD (New York Presbyterian Hospital – Columbia and Cornell, New York, NY, United States); Chi-Chang D. Lin, MD. Disclosures: E. Nguyen, none. Patients or Programs: A 56-year-old man with left calcaneal osteomyelitis.
Vol. 3, Iss. 10S1, 2011
S233
Program Description: This patient presented to a rehabilitation clinic with left heel pain for 1 month. He was initially diagnosed with tendinitis and prescribed a course of physical therapy. Because the heel pain persisted, a magnetic resonance imaging study of the left lower extremity was performed, which revealed osteomyelitis of the left calcaneus bone. He was admitted for an incision and drainage procedure. Bone cultures demonstrated a positive cryptococcal infection. He completed a 10-day course of intravenous aztreonam and vancomycin, and was started on fluconazole for 3 months. An immune deficiency workup was negative. Several weeks later, he noted continued discomfort in his left heel while ambulating. He denied fevers, chills, weight loss, or a history of trauma. A repeated magnetic resonance image demonstrated minimal improvement of osteomyelitis. He was readmitted for an incision and drainage procedure of the left calcaneus, and fluconazole was restarted. Surgical pathology returned with evidence of cryptococcal infection. He was recommended toe touch weight bearing until follow-up with his orthopedic surgeon. Setting: A tertiary care hospital. Results: The patient remained off work for 1 month and gradually advanced from toe touch weight bearing to weight bearing as tolerated. He completed a 12-month course of fluconazole. A follow-up magnetic resonance image showed improving osteomyelitis of the calcaneus. Discussion: Calcaneal osteomyelitis rarely affects immunocompetent hosts. Moreover, Cryptococcus neoformans typically manifests as pulmonary infections in immunocompromised individuals and is an uncommon cause of osteomyelitis. Few cases of isolated cryptococcal osteomyelitis have been reported, especially in an otherwise healthy individual with no history of human immunodeficiency virus. This condition is often difficult to treat and should be aggressively managed to prevent complications such as amputation. Conclusions: Although immunocompetent individuals rarely develop calcaneal osteomyelitis, especially from cryptococcal infections, this serious condition should be considered in a patient with persistent heel pain.
Poster 184 Bilateral Femoral Neuropathy Due to Prolonged Lithotomy Positioning During Surgery: A Case Report. Elizabeth Nguyen, MD (New York Presbyterian Hospital – Columbia and Cornell, New York, NY, United States); Chi-Chang D. Lin, MD. Disclosures: E. Nguyen, none. Patients or Programs: A 51-year-old woman with bilateral femoral neuropathy. Program Description: The patient underwent a suprapubic pubovaginal sling procedure, pelvic floor repair, and cystoscopy for stress incontinence, in addition to dilatation and curettage for endometrial polyps with the patient under epidural anesthesia. She remained in the lithotomy position for 3 hours during these procedures. On postoperative day 1, she noted lower extremity weakness and numbness bilaterally. On examination, hip flexion was 3⫹/5 on the right and 3–/5 on the left, knee extension was 1/5 bilaterally, and patellar tendon reflexes were absent bilaterally. Sensation was decreased along the anterior thigh and medial leg bilaterally. Imaging studies of the lumbar spine and pelvis were negative for hematoma or abscess. Physical therapy was initiated for lower extremity
S234
strengthening and gait training. On postoperative day 3, she was admitted to acute inpatient rehabilitation. She demonstrated decreased balance with gait secondary to quadriceps weakness. After 10 days of therapy, she achieved modified independence with transfers and ambulation by using a rolling walker. Setting: A tertiary care hospital. Results: At 6 weeks after surgery, electromyography and nerve conduction studies revealed axonal injury to the femoral nerves bilaterally. At 12 weeks after surgery, the patient noted significant improvement in her lower extremity strength. Hip flexion was 4⫹/5 bilaterally, right knee extension was 4⫹/5, and left knee extension was 4/5. She progressed to ambulation by using a cane in the community. Discussion: Lithotomy positioning can lead to bilateral femoral neuropathy due to prolonged hip flexion, extreme hip abduction, and external rotation. This position may not only compress the femoral nerve but also stretch it beneath the inguinal ligament, which results in demyelinating or axonal nerve injuries. This complication may be prevented by modifying posture and decreasing operating time. Conclusions: Bilateral femoral neuropathy is a rare complication of prolonged surgery in the lithotomy position. Clinicians should timely recognize this condition and promptly initiate a comprehensive rehabilitation program to address the significant functional impairments and associated psychological stress.
Poster 185 Miller Fisher Variant of Guillain-Barré Syndrome With an Unusual Presentation: A Case Report. Lisa R. Kroopf, MD (Loma Linda University Medical Center, Loma Linda, CA, United States); Murray Brandstater, MD, Menandro Cunanan, MD. Disclosures: L. R. Kroopf, none. Patients or Programs: A 64-year-old man with hypertension and diabetes mellitus. Program Description: The patient presented with blurred vision, bilateral hand numbness, unsteady gait, dysarthria, and dysphagia for several days. He was unable to stand up unassisted. The initial diagnosis was a small brainstem stroke although brain magnetic resonance imaging was normal. The patient was transferred to the acute rehabilitation unit for stroke rehabilitation 8 days after initial presentation. The physical examination was notable for slight dysarthria, nystagmus, diplopia, ptosis of the right eye, and ataxia. There was no motor weakness, and deep tendon reflexes were symmetric and normal. The patient progressed poorly. He had severe truncal ataxia. On the fourth day of admission, he fell from his wheelchair and sustained a head injury. He was transferred to the acute medical ward for further workup. Setting: Veterans Affairs inpatient rehabilitation center. Results: Three weeks later, the patient was readmitted to the acute rehabilitation unit. He had undergone a full neurologic workup and was now diagnosed with Miller Fisher variant of Guillain-Barré syndrome. Ganglioside GQ1b auto antibody test was positive, and cerebrospinal fluid showed high protein levels without white cells, features indicative of Guillain-Barré syndrome. A nerve conduction test was nondiagnostic, with mild abnormalities. Intravenous immunoglobulins were not administered. Discussion: Miller Fisher syndrome is a rare clinical variant of Guillain-Barré syndrome, an acute inflammatory polyneuropathy,
PRESENTATIONS
and a diagnosis of this variant may be difficult. It typically presents with ataxia, ophthalmoplegia, and areflexia, and there may be oropharyngeal weakness. Anti-GQ1b antiganglioside antibodies are present in 90% of cases. Conclusions: Patients usually show significant improvement in neurologic function within several weeks after diagnosis and full neurologic recovery in approximately 10 weeks. It is important to confirm the diagnosis because of the expected good recovery and because this gives therapists the opportunity to create a customized rehabilitation program to address the patient’s specific deficits.
Poster 186 Avulsion of the Adductor Muscle at the Symphysis Pubis Diagnosed With Ultrasound: A Case Report. David J. Chen, MD (University of Pennsylvania, Philadelphia, PA, United States); Franklin E. Caldera, DO, MBA, Woojin Kim, MD. Disclosures: D. J. Chen, none. Patients or Programs: A 58-year-old woman with obstructive sleep apnea and hyperlipidemia, presented to the clinic with left hip and left groin pain for 1 month, which began after taking a misstep. Program Description: We describe the use of ultrasound in diagnosing an avulsion tear at the insertion of the adductor muscles at the symphysis pubis, predominantly involving the adductor longus and brevis muscles. Setting: Tertiary care academic teaching hospital. Results: The patient ultimately was treated conservatively with nonsteroidal anti-inflammatory drugs for pain control, and physical therapy for muscle strengthening and balance improvement, and subsequently did well on follow-up. Discussion: The long adductor, short adductor, and gracilis muscles insert into the symphysis pubis and inferior pubic ramus. Avulsion injuries have previously been described at the symphysis pubis, with patients experiencing pain localizing to the groin. It is most common in adolescent athletes, and commonly mistaken for muscle or tendon injuries. The differential diagnosis of such chronic avulsion injury also includes infection or sarcomas. The standard treatment includes conservative measures, with rest and limited weight-bearing status for several weeks. The accepted method of diagnosis includes reviewing the history; physical examination; and radiologic imaging, such as the use of bone scans (which will demonstrate increased linear uptake) and the use of magnetic resonance (can have findings of bone marrow edema with enhancing periostitis). Conclusions: The use of ultrasound can be helpful in the diagnosis of avulsion tear at the insertion of the adductor muscles, as well as adductor insertion avulsion syndrome at the symphysis pubis. Sonography is becoming an increasingly used imaging modality in evaluating the musculoskeletal system because of its portability, absence of ionizing radiation, and relatively low cost compared with other cross-sectional imaging modalities.
Poster 187 Groin Pain Can Be Quite Painful With the Wrong Diagnosis: A Case Report. Sebastian Klisiewicz, DO (MCW, Wauwatosa, WI, United States); Thomas Kotsonis, MD. Disclosures: S. Klisiewicz, none.