Poster 223: Management of Man with Recurrent Intradural Extramedullary Metastasis from Breast Cancer Causing Progressive Lower Extremity Weakness and Paresthesias: A Case Report

Abstracts / PM R 9 (2017) S131-S290 presented for rehabilitation following prolonged hospital stay for respiratory failure. The patient required tracheostomy placement. Setting: Acute inpatient rehabilitation. Results: His stay was complicated by multiple episodes of tracheal dislodgment related to body habitus and sizing. Emergent transfers occurred in each instance. Characteristic morphologic differences in this patient with Klippel-Feil syndrome included craniofacial and spinal deformities with congenital absence of left nostril, scoliosis, and a short neck. These congenital deformities required consideration during episodes of respiratory compromise. He had multiple facial reconstruction surgeries as a child. The trach was replaced multiple times and placement maintained using a size 6.0 XLT distal flexible trach. Discussion: Klippel-Feil syndrome is characterized by congenital fusion of cervical vertebrae. This anomaly is associated with limited neck extension and rotation. Klippel-Feil syndrome has association with other phenotypic characteristics including scoliosis, short neck, low hairline, Sprengel’s deformity, cardiac abnormalities, and facial anomalies. Respiratory failure in these patients may be multifactorial. Anomalies may lead to the inefficacy of typical approaches during an event of respiratory compromise. Developmentally non-patent nares limit use of a nasal cannula for oxygen supplementation. Limited neck extension leads to difficult visualization of the larynx during traditional intubation. Conclusions: In the rehabilitation setting, Klippel-Feil syndrome presents a challenge to approaches relying on typical anatomy for positioning, therapy, and procedures. Vertebral anomalies with cervical fusion and limited rotation and extension are characteristic, however other patient specific and associated anomalies must be considered for proper management during acute events. Those with Klippel-Feil syndrome and respiratory failure are a unique group benefitting from a targeted approach to rehabilitation when scoliosis, obesity, and deconditioning are major factors contributing to functional decline. Level of Evidence: Level V Poster 222: A Rare Case of a Massive Bilateral Pulmonary Embolism After Routine Knee Arthroscopy: A Case Report Samuel S. Murala (Montefiore Medical Center/Albert Einstein, Bronx, NY, USA), Francis J. Lopez, MD Disclosures: Samuel Murala: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 53-year-old woman with no significant medical or surgical history underwent routine arthroscopic surgery to repair a meniscal tear in her left knee. A day after the procedure she developed severe shortness of breath and presented to the emergency department (ED). In the ED she was found to be tachycardic, hypoxic and hypotensive and subsequently diagnosed as having a massive pulmonary embolism (PE) and was admitted to Intensive Care Unit and ultimately underwent catheter directed thrombolysis. Once she was hemodynamically and medically stable, she was transferred to the acute inpatient rehabilitation unit for functional optimization with oral anti-coagulation. Setting: Acute Inpatient Rehabilitation Unit. Results: Lung spiral CT scan revealed large clot burden extending from the distal right and left main pulmonary arteries bilaterally to segmental and subsegmental branches, occlusive and nonocclusive along with elevated troponins. Her hypercoagulability workup was negative for all thrombophilic syndromes including antiphospholipid, anti-cardiolipin syndromes as well as lupus. Discussion: Pulmonary embolism following arthroscopic surgery is a very rare complication. One study placed the incidence of such events at just 2.8 cases per 10,000. However, there remains limited data describing the rarity this event. Conclusions: Though pulmonary embolism after arthroscopic surgery is an extremely rare event, it is extremely important for physiatrists and primary care practitioners to be cognizant of this serious and potentially fatal complication. Level of Evidence: Level V

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Poster 223: Management of Man with Recurrent Intradural Extramedullary Metastasis from Breast Cancer Causing Progressive Lower Extremity Weakness and Paresthesias: A Case Report Yodit Tefera (New York Presbyterian Hospital Columbia and Cornell), Akinpelumi Beckley, MD, Wade O. Johnson, DO Disclosures: Yodit Tefera: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 61-year-old man with Stage IV HER2/NEU breast cancer presented to a tertiary care facility with bilateral lower extremity weakness which began approximately 4 weeks prior with acute progression prompting presentation. He was initially diagnosed with breast cancer in 2004 and received treatment including chemotherapy, radiation, and Tamoxifen therapy. In June 2015, he developed weakness in his lower extremities and ambulatory difficulties. Found to have a metastatic lesion warranting T8 corpectomy and thoracic laminectomy to be followed by radiation and chemotherapy. The patient presented 15 months later with left lower limb weakness and paresthesia. He had a progressive loss of proprioception, sensation and ambulation over the course of 3 weeks. CT myelogram and MRI completed demonstrated a recurrence of his metastatic disease from T6-T10 and intradural lesions present at S1-S2. He underwent revision thoracic decompression and tumor resection. Post-surgery the patient continued to have lower extremity weakness, paresthesias, numbness, and incontinence necessitating acute rehabilitation and adjuvant therapy. Setting: Tertiary care hospital. Results: The neurological manifestations the patient presented with are characteristic of acute spinal cord compression. Neuropathic pain was a predominant complaint from the patient during hospital course. Discussion: Breast cancer in men is rare, representing 1% of total breast cancer cases worldwide. Spinal cord injury in the setting of breast cancer in males is even more rare and review of this case also brings attention to the natural progression and symptoms of thoracic myelopathy. Conclusions: It is important to recognize neurological changes in patients with history of malignancy in order to diagnose and treat metastatic disease. Rehabilitation is important in the management of these patients with acquired spinal cord injury. Level of Evidence: Level V Poster 224: An Unusual Case of Pulmonary Embolism in a Stroke Patient: A Case Report Ashley Simone Maybin, MD (Vanderbilt Univ Med Ctr) Disclosures: Ashley Simone Maybin: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 56-year-old African American man with a past medical history of hypertension and hyperlipidemia was admitted to inpatient rehabilitation for impaired mobility, self-care, and gait dysfunction status post-acute infarct in his left middle cerebral artery and posterior cerebral artery distribution. He was diagnosed with aphasia and right hemiparesis. He was progressing with his rehabilitation when suddenly he showed signs of abdominal discomfort. He was not able to communicate details but gestured. The patient had no nausea or emesis and vital signs were stable. Due to this acute change in pain, the patient was transferred for further evaluation. Setting: Inpatient Rehabilitation. Results: Patient was evaluated in the Emergency Department 1 hour after his initial symptoms. Focused physical examination was notable for upper abdominal pain radiating down toward his umbilical region. His exam was also positive for guarding. CT of his abdomen and pelvis revealed no evidence of acute intra-abdominal pathology, however there was an incidental finding of a pulmonary embolus in his right lower lobe. Radiology