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Poster 199: Radiculopathy Secondary to Diskal Cyst in the Adolescent Lumbar Spine: A Case Report
S90
usually occurring during contact sports. A wide range of clinical courses have been described, however, pain lasting longer than 24 hours is generally uncommon. The MSCSAC is a novel tool to predict chronic stinger syndrome. It is calculated by subtracting the sagittal diameter of the spinal cord from the disk level sagittal diameter of the spinal canal at the C3-6 levels and then averaging these values. A cutoff of ⬍4.3 mm has been shown to predict a greater than 13-fold increase in risk of developing chronic stinger syndrome. The MSCSAC score of 3.2 mm correlated with the patient’s history of multiple stingers. In discussing return to play, it was emphasized that he is at greater risk for future stinger injuries based on MSCSAC index. Conclusions: The MSCSAC is a novel, sensitive tool that may be used to predict chronic stinger syndrome.
Poster 197 Progressive Radiculopathy Due to Cervical Arteriovenous Fistula: A Case Report. Andrew Illig, DO (Rusk, New York, NY); Jeffrey M. Cohen, MD. Disclosures: A. Illig, None. Program Description: A 64-year-old woman was referred to rehabilitation clinic with a 2-year history of progressive left arm weakness without pain or sensory disturbances. Physical examination was significant for atrophy of the left deltoid, biceps, scapular, and parascapular muscles. Muscle strength testing was 0/5 in the deltoid and biceps, 3/5 in the triceps, and 4/5 in the wrist extensors, wrist flexors, and hand intrinsic muscles. Electrodiagnostic testing showed neuropathic changes in the distribution of the C5, C6, and C7 nerves and related paraspinal muscles. Radiological workup revealed an extradural vertebral artery arteriovenous (AV) plexus fistula at the level of C2-3 compressing the anterolateral cervical cord from the skull base extending down within the spinal canal through C6-7. The enlarged vessels also filled the C2-3 through C6-7 neural foramina causing root compression. The patient was referred to vascular surgery but declined surgical treatment and began a rehabilitation program designed to preserve function and learn compensatory strategies. Setting: Urban tertiary care center. Results: Multilevel cervical radiculopathy due to vertebral artery AV fistula. Discussion: Spinal AV fistulas are a rare cause of radiculopathy and myelopathy. This case reviews the radiologic and electrodiagnostic workup, the classification system, and the treatment options for spinal AV fistulas. Conclusions: Dural AV fistulas are the most common spinal cord vascular formation and can cause progressive or sudden neurologic deterioration due to mass effect or hemorrhage. An accurate diagnosis is important because AV fistulas can be a reversible cause of radiculopathy and myelopathy.
PRESENTATIONS
Poster 198 Puddle Slip Injury Resulting in a Complete Proximal Avulsion of the Semimembranosus Tendon in a Nonathlete: A Case Report. Christine M. Roque-Dang, DO (UMDNJ-New Jersey Medical School, Newark, NJ); Todd Stitik, MD. Disclosures: C. M. Roque-Dang, None. Patients or Programs: A 42-year-old female nursing assistant. Program Description: The patient complained of severe right hip region and lower limb pain after she slipped on a puddle of water. She stated that her right knee was flexed, her ankle was dorsiflexed, and she recalled hearing a “pop” while slipping. She complained of “burning” posterior and medial thigh pain with radiation to the posterior ankle and noted resolution of her initial right hip pain. On physical examination, she had an antalgic gait, ecchymoses were visualized over the posterior thigh, and she had decreased sensation to light touch in the distribution of the sciatic nerve. Setting: Outpatient private practice office. Results: Musculoskeletal ultrasound examination revealed architectural distortion of the biceps femoris and semimembranosus muscles with surrounding edema. A subsequent MRI showed complete avulsion tear of the semimembranosus tendon from the ischial tuberosity. At subsequent followups, the patient’s sciatica resolved as local edema subsided. An orthopedic surgery consult was obtained and, at 1-month postinjury, the patient underwent a right proximal hamstring tendon repair with good outcome. Discussion: Complete proximal origin avulsions of the hamstring tendons are rare and usually result from injuries with a flexed hip and extended knee. Most of these injuries occur in young athletes and several cases involve water skiers. In nonathletes, there is no consensus regarding conservative versus operative management. Few cases exist where concomitant temporary sciatica is described. Conclusions: Reported is an unusual case with an atypical presentation of a complete proximal hamstring tendon avulsion in a nonathlete and necessitating surgical repair for improved function.
Poster 199 Radiculopathy Secondary to Diskal Cyst in the Adolescent Lumbar Spine: A Case Report. Arun T. Gupta, MD (Hospital for Special Surgery, New York, NY); David Hoffman; Christopher Lutz; Gregory E. Lutz, MD. Disclosures: A. T. Gupta, None. Patients or Programs: A 16-year-old athletic man. Program Description: This patient originally presented to our clinic with a 3-week history of progressive right posterolateral lower extremity pain with radiation into the hip and proximal lateral thigh pain. Multiple physicians,
PM&R
including a pediatric orthopedist, who offered the patient explorative hip surgery, reviewed and treated him unsuccessfully. Given the family’s frustration and fear of an unnecessary operation they explored a fourth opinion at our hospital with a spine surgeon. A lumbar spine magnetic resonance imaging (MRI) study was organized and the patient was subsequently referred to our clinic. After a careful neurologic examination a radicular pattern of pain and weakness after the L5 distribution was discovered. The MRI demonstrated a large cyst extending posteriorly from the L4-5 disk. At first, it was difficult to ascertain the origin of the cyst, but with the assistance of a radiology consultation the cyst was confirmed to extend from the disk itself. Setting: Outpatient interventional physiatry clinic. Results: The L5 radicular symptoms were treated successfully with a transforaminal epidural corticosteroid injection. The patient was able to return to sport and is currently being followed up with serial MRI studies to determine the rate and extent of disk resorption in the adolescent spine. Discussion: To our knowledge, there are only a handful of case reports with radicular symptoms secondary to diskal cyst. Furthermore, none of these have been described in the adolescent population. It is important to consider lumbar etiology for hip and lower extremity pain in young patients. This etiology can be easily missed leading to inappropriate therapies and interventions, which can be time consuming, costly, and detrimental. Conclusions: Diskal cysts are rare, particularly in the adolescent population. They can contribute to extensive radicular symptoms. It is important to consider an appropriate trial of conservative management, especially in the young population.
Poster 200 Recalcitrant Peroneal Tenosynovitis Treated With Ultrasound-Guided Injection: A Case Report. Moshe Ben-Roohi, MD (LAGS Spine & Sportscare, Santa Maria, CA); Sawey A. Harhash, MD; Francis P. Lagattuta, PhD; Phillip J. Smith; Vincenzo Vitto, DO. Disclosures: M. Ben-Roohi, None. Patients or Programs: A 46-year-old woman with a 6-year history of lateral foot pain. Program Description: The patient could not relate her symptoms to a specific injury but reported progression of symptoms and increased pain with activity. Magnetic resonance imaging (MRI) showed swelling of the peroneal tendon sheath. She was treated with orthotics and physical therapy without success. She was later referred to the physical medicine clinic. On examination she had moderate retro-malleolar tenderness to palpation and pain with passive inversion and resisted eversion without swelling or erythema. An ultrasound evaluation showed extensive swelling in the peroneal
Vol. 2, Iss. 9S, 2010
S91
tendon sheath without tendon tear or subluxation. She was treated with an ultrasound-guided injection of methylprednisolone with 0.25% preservative-free bupivacaine. Immediately after the injection she felt 90% pain relief. After 3 months’ follow-up she continues to have 80% pain relief with improved functional ability. Setting: Outpatient musculoskeletal clinic. Results: The patient had peroneal tenosynovitis, which was not responsive to conservative care. After ultrasound examination and guided injection the patient experienced immediate and lasting relief. Discussion: Peroneal tenosynovitis may be caused by acute ankle inversion or overuse injuries. Treatment involves a spectrum of rest from aggravating activities, anti-inflammatory medication, correction of predisposing biomechanical factors and progressive physical therapy. Injections can be considered in unresponsive cases. In severe cases surgery may be required. In this case ultrasound examination allowed rapid diagnosis, exclusion of tendon subluxation, and visualization of correct needle placement. Conclusions: Musculoskeletal ultrasound allows rapid diagnosis as well treatment options; it is an inexpensive, portable and increasingly invaluable diagnostic and treatment tool.
Poster 201 Rehabilitation and Osteopathic Manipulative Medicine for a Patient With Dysphagia Secondary to a Hyoid Somatic Dysfunction: A Case Report. Gilbert Siu, DO, PhD (Temple University Hospital/ MossRehab, Philadelphia, PA); Anjuli Desai, MD; Barkha B. Manne, MD; David Mason, DO; Michael M. Weinik, DO. Disclosures: G. Siu, None. Patients or Programs: A 25-year-old healthy woman. Program Description: The patient sustained a cervical acceleration-deceleration injury (whiplash) from rear end motor vehicle collision. After the whiplash injury, she presented with neck pain, headaches, and dysphagia. After physical therapy to neck and pain management, the patient continued to complain of persistent dysphagia. Magnetic resonance imaging and computed tomography of the head and neck were normal. Subsequently, she underwent upper endoscopy and electrodiagnostic studies, where the results were normal. Setting: Neuromusculoskeletal and rehabilitation clinic. Results: The patient was examined with an osteopathic palpatory diagnosis documenting specific somatic dysfunctions by finding palpable tissue texture changes, asymmetry to motion, range of motion deficits and areas of tenderness at the neck. She presented with a left hyoid asymmetry with decreased range of motion and left digastric and hyoid muscle tenderness and tightness. The left sternocleidomastoid
usually occurring during contact sports. A wide range of clinical courses have been described, however, pain lasting longer than 24 hours is generally uncommon. The MSCSAC is a novel tool to predict chronic stinger syndrome. It is calculated by subtracting the sagittal diameter of the spinal cord from the disk level sagittal diameter of the spinal canal at the C3-6 levels and then averaging these values. A cutoff of ⬍4.3 mm has been shown to predict a greater than 13-fold increase in risk of developing chronic stinger syndrome. The MSCSAC score of 3.2 mm correlated with the patient’s history of multiple stingers. In discussing return to play, it was emphasized that he is at greater risk for future stinger injuries based on MSCSAC index. Conclusions: The MSCSAC is a novel, sensitive tool that may be used to predict chronic stinger syndrome.
Poster 197 Progressive Radiculopathy Due to Cervical Arteriovenous Fistula: A Case Report. Andrew Illig, DO (Rusk, New York, NY); Jeffrey M. Cohen, MD. Disclosures: A. Illig, None. Program Description: A 64-year-old woman was referred to rehabilitation clinic with a 2-year history of progressive left arm weakness without pain or sensory disturbances. Physical examination was significant for atrophy of the left deltoid, biceps, scapular, and parascapular muscles. Muscle strength testing was 0/5 in the deltoid and biceps, 3/5 in the triceps, and 4/5 in the wrist extensors, wrist flexors, and hand intrinsic muscles. Electrodiagnostic testing showed neuropathic changes in the distribution of the C5, C6, and C7 nerves and related paraspinal muscles. Radiological workup revealed an extradural vertebral artery arteriovenous (AV) plexus fistula at the level of C2-3 compressing the anterolateral cervical cord from the skull base extending down within the spinal canal through C6-7. The enlarged vessels also filled the C2-3 through C6-7 neural foramina causing root compression. The patient was referred to vascular surgery but declined surgical treatment and began a rehabilitation program designed to preserve function and learn compensatory strategies. Setting: Urban tertiary care center. Results: Multilevel cervical radiculopathy due to vertebral artery AV fistula. Discussion: Spinal AV fistulas are a rare cause of radiculopathy and myelopathy. This case reviews the radiologic and electrodiagnostic workup, the classification system, and the treatment options for spinal AV fistulas. Conclusions: Dural AV fistulas are the most common spinal cord vascular formation and can cause progressive or sudden neurologic deterioration due to mass effect or hemorrhage. An accurate diagnosis is important because AV fistulas can be a reversible cause of radiculopathy and myelopathy.
PRESENTATIONS
Poster 198 Puddle Slip Injury Resulting in a Complete Proximal Avulsion of the Semimembranosus Tendon in a Nonathlete: A Case Report. Christine M. Roque-Dang, DO (UMDNJ-New Jersey Medical School, Newark, NJ); Todd Stitik, MD. Disclosures: C. M. Roque-Dang, None. Patients or Programs: A 42-year-old female nursing assistant. Program Description: The patient complained of severe right hip region and lower limb pain after she slipped on a puddle of water. She stated that her right knee was flexed, her ankle was dorsiflexed, and she recalled hearing a “pop” while slipping. She complained of “burning” posterior and medial thigh pain with radiation to the posterior ankle and noted resolution of her initial right hip pain. On physical examination, she had an antalgic gait, ecchymoses were visualized over the posterior thigh, and she had decreased sensation to light touch in the distribution of the sciatic nerve. Setting: Outpatient private practice office. Results: Musculoskeletal ultrasound examination revealed architectural distortion of the biceps femoris and semimembranosus muscles with surrounding edema. A subsequent MRI showed complete avulsion tear of the semimembranosus tendon from the ischial tuberosity. At subsequent followups, the patient’s sciatica resolved as local edema subsided. An orthopedic surgery consult was obtained and, at 1-month postinjury, the patient underwent a right proximal hamstring tendon repair with good outcome. Discussion: Complete proximal origin avulsions of the hamstring tendons are rare and usually result from injuries with a flexed hip and extended knee. Most of these injuries occur in young athletes and several cases involve water skiers. In nonathletes, there is no consensus regarding conservative versus operative management. Few cases exist where concomitant temporary sciatica is described. Conclusions: Reported is an unusual case with an atypical presentation of a complete proximal hamstring tendon avulsion in a nonathlete and necessitating surgical repair for improved function.
Poster 199 Radiculopathy Secondary to Diskal Cyst in the Adolescent Lumbar Spine: A Case Report. Arun T. Gupta, MD (Hospital for Special Surgery, New York, NY); David Hoffman; Christopher Lutz; Gregory E. Lutz, MD. Disclosures: A. T. Gupta, None. Patients or Programs: A 16-year-old athletic man. Program Description: This patient originally presented to our clinic with a 3-week history of progressive right posterolateral lower extremity pain with radiation into the hip and proximal lateral thigh pain. Multiple physicians,
PM&R
including a pediatric orthopedist, who offered the patient explorative hip surgery, reviewed and treated him unsuccessfully. Given the family’s frustration and fear of an unnecessary operation they explored a fourth opinion at our hospital with a spine surgeon. A lumbar spine magnetic resonance imaging (MRI) study was organized and the patient was subsequently referred to our clinic. After a careful neurologic examination a radicular pattern of pain and weakness after the L5 distribution was discovered. The MRI demonstrated a large cyst extending posteriorly from the L4-5 disk. At first, it was difficult to ascertain the origin of the cyst, but with the assistance of a radiology consultation the cyst was confirmed to extend from the disk itself. Setting: Outpatient interventional physiatry clinic. Results: The L5 radicular symptoms were treated successfully with a transforaminal epidural corticosteroid injection. The patient was able to return to sport and is currently being followed up with serial MRI studies to determine the rate and extent of disk resorption in the adolescent spine. Discussion: To our knowledge, there are only a handful of case reports with radicular symptoms secondary to diskal cyst. Furthermore, none of these have been described in the adolescent population. It is important to consider lumbar etiology for hip and lower extremity pain in young patients. This etiology can be easily missed leading to inappropriate therapies and interventions, which can be time consuming, costly, and detrimental. Conclusions: Diskal cysts are rare, particularly in the adolescent population. They can contribute to extensive radicular symptoms. It is important to consider an appropriate trial of conservative management, especially in the young population.
Poster 200 Recalcitrant Peroneal Tenosynovitis Treated With Ultrasound-Guided Injection: A Case Report. Moshe Ben-Roohi, MD (LAGS Spine & Sportscare, Santa Maria, CA); Sawey A. Harhash, MD; Francis P. Lagattuta, PhD; Phillip J. Smith; Vincenzo Vitto, DO. Disclosures: M. Ben-Roohi, None. Patients or Programs: A 46-year-old woman with a 6-year history of lateral foot pain. Program Description: The patient could not relate her symptoms to a specific injury but reported progression of symptoms and increased pain with activity. Magnetic resonance imaging (MRI) showed swelling of the peroneal tendon sheath. She was treated with orthotics and physical therapy without success. She was later referred to the physical medicine clinic. On examination she had moderate retro-malleolar tenderness to palpation and pain with passive inversion and resisted eversion without swelling or erythema. An ultrasound evaluation showed extensive swelling in the peroneal
Vol. 2, Iss. 9S, 2010
S91
tendon sheath without tendon tear or subluxation. She was treated with an ultrasound-guided injection of methylprednisolone with 0.25% preservative-free bupivacaine. Immediately after the injection she felt 90% pain relief. After 3 months’ follow-up she continues to have 80% pain relief with improved functional ability. Setting: Outpatient musculoskeletal clinic. Results: The patient had peroneal tenosynovitis, which was not responsive to conservative care. After ultrasound examination and guided injection the patient experienced immediate and lasting relief. Discussion: Peroneal tenosynovitis may be caused by acute ankle inversion or overuse injuries. Treatment involves a spectrum of rest from aggravating activities, anti-inflammatory medication, correction of predisposing biomechanical factors and progressive physical therapy. Injections can be considered in unresponsive cases. In severe cases surgery may be required. In this case ultrasound examination allowed rapid diagnosis, exclusion of tendon subluxation, and visualization of correct needle placement. Conclusions: Musculoskeletal ultrasound allows rapid diagnosis as well treatment options; it is an inexpensive, portable and increasingly invaluable diagnostic and treatment tool.
Poster 201 Rehabilitation and Osteopathic Manipulative Medicine for a Patient With Dysphagia Secondary to a Hyoid Somatic Dysfunction: A Case Report. Gilbert Siu, DO, PhD (Temple University Hospital/ MossRehab, Philadelphia, PA); Anjuli Desai, MD; Barkha B. Manne, MD; David Mason, DO; Michael M. Weinik, DO. Disclosures: G. Siu, None. Patients or Programs: A 25-year-old healthy woman. Program Description: The patient sustained a cervical acceleration-deceleration injury (whiplash) from rear end motor vehicle collision. After the whiplash injury, she presented with neck pain, headaches, and dysphagia. After physical therapy to neck and pain management, the patient continued to complain of persistent dysphagia. Magnetic resonance imaging and computed tomography of the head and neck were normal. Subsequently, she underwent upper endoscopy and electrodiagnostic studies, where the results were normal. Setting: Neuromusculoskeletal and rehabilitation clinic. Results: The patient was examined with an osteopathic palpatory diagnosis documenting specific somatic dysfunctions by finding palpable tissue texture changes, asymmetry to motion, range of motion deficits and areas of tenderness at the neck. She presented with a left hyoid asymmetry with decreased range of motion and left digastric and hyoid muscle tenderness and tightness. The left sternocleidomastoid