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Poster 232 Severe Sciatic Nerve Palsy from a Gluteal Hematoma after Scoliosis Surgery: A Case Report
Abstracts / PM R 7 (2015) S83-S222 for patients with chronic spinal cord injury patients who develop cancer. Poster 230 Paraneoplastic Cranial Nerve Palsies as the Initial Presentation of Sarcomatoid Carcinoma of the Lung: A Case Report Tracy J. Eicher, MD, Sean A. Lacey (Lake Erie College of Osteopathic Medicine - Bradenton Campus, Louisville, KY, United States) Disclosures: S. A. Lacey: I Have No Relevant Financial Relationships To Disclose. Case Description: A 79-year-old man consulted his doctor because of dysarthria, dysphagia, blurred vision, pain in the left eye, and pruritus accompanying shooting pains in the left V2 dermatome distribution. After admission to the hospital, the patient’s symptoms worsened to include bilateral lateral gaze palsy and ptosis. Non-contrast CT scan of the head, CT angiography of the head and neck, CT scan of the abdomen and pelvis, autoimmune panels, lumbar puncture, and infectious disease titers were all negative. There was a persistent absolute neutrophilia, polypharmacy resistant hypertension revealed to be caused by renal artery stenosis, an M-spike on SPEP determined to be MGUS, and a 6mm noncalcified pulmonary nodule on the posterior aspect of the right upper lobe accompanied by a 2.6cm carinal mass, which was then attributed to lymphadenopathy. The patient underwent seven rounds of plasmapheresis, which led to complete resolution of his cranial nerve symptoms by hospital day 24. 45 days later, the patient noticed the onset of similar progression of cranial nerve involvement, and was admitted again after presenting to the ED with the complaint of severe nausea and vomiting. Two weeks into his second hospital stay, he was treated with an additional five rounds of plasmapheresis, without considerable improvement. He was then transferred to a different hospital, where a PET scan was performed, revealing hypermetabolic right subcarinal lymphadenopathy and a hypermetabolic right upper lobe nodule. The nodule was biopsied and revealed to be sarcomatoid carcinoma. Setting: In-patient neurology wards. Results or Clinical Course: At 2 weeks post diagnosis, the patient had initiated treatment with chemotherapy at a nearby cancer hospital. Additional developments will be discussed. Discussion: To our knowledge, this is the first reported case of sarcomatoid cancer presenting with immune mediated paraneoplastic cranial nerve palsies. Small cell carcinoma has been described as affecting the peripheral nerves as a paraneoplastic syndrome, but this is the first documented case of sarcomatoid lung cancer having such a paraneoplastic syndrome. Conclusion: A mononeuritis multiplex appearing clinical presentation may be the initial symptomatology of an occult malignancy. Poster 231 Paraneoplastic Syndrome Presenting As Gait Abnormality and Sensory Polyneuropathy: A Case Report Yana Abayev, DO (Saint Charles Rehabilitation Center, Port Jefferson, NY, United States), Jennifer M. Gray, DO, Jessica Engle, DO, Jun Zhang, MD Disclosures: Y. Abayev: I Have No Relevant Financial Relationships To Disclose. Case Description: A 63-year-old man with history of testicular cancer and presumed Guillain Barre Syndrome (GBS) 3 months prior presented with worsening numbness, weakness and paresthesias on his right side associated with loss of coordination and unsteady gait. He received IVIG for treatment of presumed GBS without improvement. A right-sided hilar mass was identified on chest x-ray. He underwent right thoracotomy with right middle and lower lobectomies.
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Post-operatively, patient experienced respiratory insufficiency, lower extremity weakness and sensory polyneuropathy was found on EMG. Examination revealed reduced strength and severe sensory loss in bilateral lower extremities, loss of coordination, loss of proprioception, dysmetria and unsteady gait. He had 5/5 strength in both upper extremities and 2+/4 reflexes throughout. Setting: Acute care community hospital Results or Clinical Course: Biopsy of the hilar mass revealed neuroendocrine B-cell cancer, and he tested positive for anti-neuronal and anti-Hu antibodies. Throughout his rehabilitation course, he made functional gains including independence in ambulation, grooming, bathing and transfers with a FIM gain of 33. Treatment with excision, chemotherapy, and radiation for small cell lung cancer led to improvement in functional status without improvement in sensory deficits. Discussion: Paraneoplastic disorders can be confused with GBS and other neurological syndromes. They are triggered by an altered immune system response to malignancy. Signs and symptoms develop over days to weeks. Antibodies such as anti-Hu, CV2, Ma2, and amphiphysin can be detected. Scant data is available regarding rehabilitation outcomes in such patients. There is a trend to suggest that treatment of the underlying malignancy is successful at halting progression of the sensory polyneuropathy and is associated with improvement in functional status. Conclusion: Paraneoplastic syndrome secondary to anti-Hu antibodies is seen in association with sensory polyneuropathy. Prompt recognition of paraneoplastic syndrome is essential to initiate effective treatment of the underlying malignancy and facilitate return of function.
Poster 232 Severe Sciatic Nerve Palsy from a Gluteal Hematoma after Scoliosis Surgery: A Case Report Kaila A. Holtz, MD, MSc (University of British Columbia, Vancouver, Canada), Raphaele Charest, MD FRCSI, FRCSC, Charles Fisher, MD, MHSc (Epi), FRCSC, John T. Street, MD, PhD, FRCS Disclosures: K. A. Holtz: I Have No Relevant Financial Relationships To Disclose. Case Description: A 59-year-old woman underwent elective posterior spinal fusion, T2 to ilium with bilateral skeletal femoral traction, for progressive scoliosis. There was significant intra-operative blood loss. Peri-operative neurophysiologic monitoring and post-operative neurological examination were normal. On post op day 1, she had persisting anemia with back pain and pain to her right thigh and buttock. A retropertoneal hematoma was suspected. CT scan revealed a large (11cm 6.4 cm 4 cm) hematoma within the right gluteus medius muscle. On post-op day 2 she developed a complete right-sided sciatic nerve palsy. Angiography did not reveal a target for embolization and so the hematoma was emergently surgically evacuated. An actively bleeding artery, at the level of the greater trochanter, was identified and ligated. The sciatic nerve was found severely compressed. Program Description: Orthopaedic Spine Surgery & Physical Medicine and Rehabilitation. Setting: Quaternary academic teaching hospital. Results or Clinical Course: Post-operatively she was transferred to inpatient rehabilitation. At 10 weeks post-op, electrodiagnostic studies, demonstrated active denervation with no voluntary recruitment of tibialis anterior, peroneus longus, medial gastrocnemius and long head of biceps femoris. Gluteus medius (superior gluteal nerve) was also involved. Patient was fitted with an ankle-foot orthosis (AFO) for foot drop. She had neuropathic pain and was showing early signs of chronic regional pain syndrome (CRPS). Discussion: This is the first report of sciatic nerve palsy due to a compressive gluteal hematoma following scoliosis spine surgery. The etiology for this complication is unclear. Conclusion: Gluteal hematoma should be considered in the differential diagnosis of delayed unilateral neurological deficit, particularly in
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the context of persistent postoperative anemia. A sciatic nerve injury of this nature may result in significant disability. Poster 233 Median and Radial Neuropathy Following Vesicant Chemotherapy Extravasation: A Case Report Isaac P. Syrop (New York Presbyterian Columbia/Cornell, New York, NY, United States), Katherine V. Yao, MD, Christian M. Custodio, MD Disclosures: I. P. Syrop: I Have No Relevant Financial Relationships To Disclose. Case Description: For the treatment of recurrent well-differentiated liposarcoma of the abdomen, a 65-year-old man was treated with a course of intravenous (IV) gemcitabine/docetaxel. Following infusion of docetaxel via a left antecubital IV catheter, the patient noticed redness surrounding the IV insertion site. Erythema worsened over the next week, associated with pain and weakness in the left hand, specifically in the first and second digits. Over the next month, the erythema improved while the weakness worsened. At four weeks post extravasation, the patient presented to an outpatient rehabilitation center. Physical examination was pertinent for LUE strength of 4/5 in wrist extension/flexion, 4-/5 in extension/flexion of digits 1, 2, 3 and near normal strength of digits 4 and 5. Sensation was decreased in both the palmar and dorsal aspects of the left hand, most noticeably in digits 1 and 2. The patient was prescribed OT for strengthening and ROM of the LUE and referred for electrodiagnostic studies. Setting: Academic outpatient rehabilitation center. Results or Clinical Course: At 6 weeks post extravasation, the patient had electrodiagnostic studies performed. Findings were consistent with chronic, incomplete, left median and radial mononeuropathies at the elbow, with the median more affected compared to the radial nerve. These findings were superimposed over a mild, more generalized, sensorimotor polyneuropathy. Discussion: This is the first reported case, to our knowledge, of a median and radial neuropathy secondary to docetaxel extravasation. Compressive peripheral neuropathy has been shown to occur with IV extravasation, however there is sparse literature describing neuropathy resulting from chemically noxious injuries from extravasation of chemotherapeutic agents. This case adds to the overall literature of vesicant chemotherapy complications. Conclusion: Median and radial neuropathies are a potential side effect secondary to extravasation of docetaxel when infused using antecubital IV access. Poster 234 Vaginal Numbness and Sexual Dysfunction as Presenting Symptoms of a Grade III L6-S1 Spondylolisthesis: A Case Report Reina Nakamura, DO (Rutgers New Jersey Medical School, Upper Montclair, NJ, United States), Jeffrey L. Cole, MD Disclosures: R. Nakamura: I Have No Relevant Financial Relationships To Disclose. Case Description: A 46-year-old woman was referred for electrodiagnostic evaluation for complaint of progressive vaginal numbness and sexual dysfunction for 2-3 years. Past medical history was significant for mild rectocele. MRI showed severe degenerative changes at the lumbosacral junction, sharp angulation of the coccyx, and scarring around bilateral pudendal nerves at Alcock’s canal. The patient did not initially recall history of trauma, however upon further questioning, remembered a remote accident in which she fell down a flight of stairs. Physical examination was significant for virtually no movement at L5/S1 junction, decreased vaginal sensation, and positive Tinel’s sign at Alcock’s canal with radiation towards the spine rather than the vagina. Sensation to S2-3 dermatomes was normal. Electrodiagnosis showed evidence of bilateral L5 radiculopathy, bilateral collateral sprouting of the paraspinals at S1, bilateral partial denervation
potentials of S2-4, and normal bilateral pudendal nerve terminal motor latencies. Given these findings, a more proximal process was suspected. Lumbar spine x-rays were obtained, revealing a spina bifida occulta, and grade III spondylolisthesis at L6-S1. Setting: Outpatient physiatry office. Results or Clinical Course: The patient underwent L6-S1 decompression, partial reduction of spondylolisthesis, and spinal fusion. She fully recovered vaginal sensation 3 months later. Discussion: To our knowledge, this is the first case of a L5-S4 radiculopathy manifesting as vaginal numbness without additional neurological signs or symptoms. Conclusion: Vaginal numbness and sexual dysfunction may be the only presenting symptom of a lumbosacral radiculopathy.
Poster 235 Exertional Rhabdomyolysis as the Presenting Symptom of Metabolic Myopathy, an Opportunity for Interdisciplinary Care: A Case Report James Liadis, MD (Medstar National Rehabilitation Hospital, Washington, DC, United States), Caroline Sizer, MD Disclosures: J. Liadis: I Have No Relevant Financial Relationships To Disclose. Case Description: A healthy 24-year-old woman performed a short series of squats and developed muscle soreness. The soreness worsened throughout the following day and was accompanied by dark urine, prompting medical evaluation. She was diagnosed with exertional rhabdomyolysis, requiring ICU care. Further history revealed subclinical proximal weakness for years, prompting EMG and muscle biopsy, which pointed towards a metabolic myopathy. Genetic testing is pending. The patient presented to physical medicine and rehabilitation clinic for recommendations regarding safe activity resumption and optimization of function. Setting: Acute inpatient rehabilitation hospital. Results or Clinical Course: Appreciating the risk for recurrent exercise induced rhabdomyolysis, the patient was instructed on submaximal, brief physical activity with adequate rest and appropriate nutritional support. She was educated on activity precautions to prevent further loss of function. Through collaboration with a neuromuscular physical therapist, the patient began a program for energy conservation and initiation of aerobic exercise. Coordination with her neurologists allowed the interdisciplinary team to maximize her function and allow her to return to college to complete her studies. Discussion: Rhabdomyolysis, which recurs or occurs with minimal exertion, should raise suspicion of underlying metabolic myopathy. Such patients should be queried on risk factors and previous symptoms, and should receive further diagnostic evaluation. The risk of recurrence and potential complications including acute renal failure, require cautious and structured return to physical activity. The ideal management is via a multispecialty approach which pairs treatment with activity resumption to maximize functional outcome. Conclusion: Metabolic myopathies predispose patients to exertional rhabdomyolysis. This condition highlights the importance of the interdisciplinary rehabilitation team’s role in maximizing functional outcomes while minimizing risk of complications.
Poster 236 Neoplastic Upper Trunk Brachial Plexus Lesion with Normal Sensory Nerve Conduction Studies: A Case Report Lisa Williams, MD (Stanford University, Stanford, CA, United States), Joshua H. Levin, MD Disclosures: L. Williams: I Have No Relevant Financial Relationships To Disclose.
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Post-operatively, patient experienced respiratory insufficiency, lower extremity weakness and sensory polyneuropathy was found on EMG. Examination revealed reduced strength and severe sensory loss in bilateral lower extremities, loss of coordination, loss of proprioception, dysmetria and unsteady gait. He had 5/5 strength in both upper extremities and 2+/4 reflexes throughout. Setting: Acute care community hospital Results or Clinical Course: Biopsy of the hilar mass revealed neuroendocrine B-cell cancer, and he tested positive for anti-neuronal and anti-Hu antibodies. Throughout his rehabilitation course, he made functional gains including independence in ambulation, grooming, bathing and transfers with a FIM gain of 33. Treatment with excision, chemotherapy, and radiation for small cell lung cancer led to improvement in functional status without improvement in sensory deficits. Discussion: Paraneoplastic disorders can be confused with GBS and other neurological syndromes. They are triggered by an altered immune system response to malignancy. Signs and symptoms develop over days to weeks. Antibodies such as anti-Hu, CV2, Ma2, and amphiphysin can be detected. Scant data is available regarding rehabilitation outcomes in such patients. There is a trend to suggest that treatment of the underlying malignancy is successful at halting progression of the sensory polyneuropathy and is associated with improvement in functional status. Conclusion: Paraneoplastic syndrome secondary to anti-Hu antibodies is seen in association with sensory polyneuropathy. Prompt recognition of paraneoplastic syndrome is essential to initiate effective treatment of the underlying malignancy and facilitate return of function.
Poster 232 Severe Sciatic Nerve Palsy from a Gluteal Hematoma after Scoliosis Surgery: A Case Report Kaila A. Holtz, MD, MSc (University of British Columbia, Vancouver, Canada), Raphaele Charest, MD FRCSI, FRCSC, Charles Fisher, MD, MHSc (Epi), FRCSC, John T. Street, MD, PhD, FRCS Disclosures: K. A. Holtz: I Have No Relevant Financial Relationships To Disclose. Case Description: A 59-year-old woman underwent elective posterior spinal fusion, T2 to ilium with bilateral skeletal femoral traction, for progressive scoliosis. There was significant intra-operative blood loss. Peri-operative neurophysiologic monitoring and post-operative neurological examination were normal. On post op day 1, she had persisting anemia with back pain and pain to her right thigh and buttock. A retropertoneal hematoma was suspected. CT scan revealed a large (11cm 6.4 cm 4 cm) hematoma within the right gluteus medius muscle. On post-op day 2 she developed a complete right-sided sciatic nerve palsy. Angiography did not reveal a target for embolization and so the hematoma was emergently surgically evacuated. An actively bleeding artery, at the level of the greater trochanter, was identified and ligated. The sciatic nerve was found severely compressed. Program Description: Orthopaedic Spine Surgery & Physical Medicine and Rehabilitation. Setting: Quaternary academic teaching hospital. Results or Clinical Course: Post-operatively she was transferred to inpatient rehabilitation. At 10 weeks post-op, electrodiagnostic studies, demonstrated active denervation with no voluntary recruitment of tibialis anterior, peroneus longus, medial gastrocnemius and long head of biceps femoris. Gluteus medius (superior gluteal nerve) was also involved. Patient was fitted with an ankle-foot orthosis (AFO) for foot drop. She had neuropathic pain and was showing early signs of chronic regional pain syndrome (CRPS). Discussion: This is the first report of sciatic nerve palsy due to a compressive gluteal hematoma following scoliosis spine surgery. The etiology for this complication is unclear. Conclusion: Gluteal hematoma should be considered in the differential diagnosis of delayed unilateral neurological deficit, particularly in
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the context of persistent postoperative anemia. A sciatic nerve injury of this nature may result in significant disability. Poster 233 Median and Radial Neuropathy Following Vesicant Chemotherapy Extravasation: A Case Report Isaac P. Syrop (New York Presbyterian Columbia/Cornell, New York, NY, United States), Katherine V. Yao, MD, Christian M. Custodio, MD Disclosures: I. P. Syrop: I Have No Relevant Financial Relationships To Disclose. Case Description: For the treatment of recurrent well-differentiated liposarcoma of the abdomen, a 65-year-old man was treated with a course of intravenous (IV) gemcitabine/docetaxel. Following infusion of docetaxel via a left antecubital IV catheter, the patient noticed redness surrounding the IV insertion site. Erythema worsened over the next week, associated with pain and weakness in the left hand, specifically in the first and second digits. Over the next month, the erythema improved while the weakness worsened. At four weeks post extravasation, the patient presented to an outpatient rehabilitation center. Physical examination was pertinent for LUE strength of 4/5 in wrist extension/flexion, 4-/5 in extension/flexion of digits 1, 2, 3 and near normal strength of digits 4 and 5. Sensation was decreased in both the palmar and dorsal aspects of the left hand, most noticeably in digits 1 and 2. The patient was prescribed OT for strengthening and ROM of the LUE and referred for electrodiagnostic studies. Setting: Academic outpatient rehabilitation center. Results or Clinical Course: At 6 weeks post extravasation, the patient had electrodiagnostic studies performed. Findings were consistent with chronic, incomplete, left median and radial mononeuropathies at the elbow, with the median more affected compared to the radial nerve. These findings were superimposed over a mild, more generalized, sensorimotor polyneuropathy. Discussion: This is the first reported case, to our knowledge, of a median and radial neuropathy secondary to docetaxel extravasation. Compressive peripheral neuropathy has been shown to occur with IV extravasation, however there is sparse literature describing neuropathy resulting from chemically noxious injuries from extravasation of chemotherapeutic agents. This case adds to the overall literature of vesicant chemotherapy complications. Conclusion: Median and radial neuropathies are a potential side effect secondary to extravasation of docetaxel when infused using antecubital IV access. Poster 234 Vaginal Numbness and Sexual Dysfunction as Presenting Symptoms of a Grade III L6-S1 Spondylolisthesis: A Case Report Reina Nakamura, DO (Rutgers New Jersey Medical School, Upper Montclair, NJ, United States), Jeffrey L. Cole, MD Disclosures: R. Nakamura: I Have No Relevant Financial Relationships To Disclose. Case Description: A 46-year-old woman was referred for electrodiagnostic evaluation for complaint of progressive vaginal numbness and sexual dysfunction for 2-3 years. Past medical history was significant for mild rectocele. MRI showed severe degenerative changes at the lumbosacral junction, sharp angulation of the coccyx, and scarring around bilateral pudendal nerves at Alcock’s canal. The patient did not initially recall history of trauma, however upon further questioning, remembered a remote accident in which she fell down a flight of stairs. Physical examination was significant for virtually no movement at L5/S1 junction, decreased vaginal sensation, and positive Tinel’s sign at Alcock’s canal with radiation towards the spine rather than the vagina. Sensation to S2-3 dermatomes was normal. Electrodiagnosis showed evidence of bilateral L5 radiculopathy, bilateral collateral sprouting of the paraspinals at S1, bilateral partial denervation
potentials of S2-4, and normal bilateral pudendal nerve terminal motor latencies. Given these findings, a more proximal process was suspected. Lumbar spine x-rays were obtained, revealing a spina bifida occulta, and grade III spondylolisthesis at L6-S1. Setting: Outpatient physiatry office. Results or Clinical Course: The patient underwent L6-S1 decompression, partial reduction of spondylolisthesis, and spinal fusion. She fully recovered vaginal sensation 3 months later. Discussion: To our knowledge, this is the first case of a L5-S4 radiculopathy manifesting as vaginal numbness without additional neurological signs or symptoms. Conclusion: Vaginal numbness and sexual dysfunction may be the only presenting symptom of a lumbosacral radiculopathy.
Poster 235 Exertional Rhabdomyolysis as the Presenting Symptom of Metabolic Myopathy, an Opportunity for Interdisciplinary Care: A Case Report James Liadis, MD (Medstar National Rehabilitation Hospital, Washington, DC, United States), Caroline Sizer, MD Disclosures: J. Liadis: I Have No Relevant Financial Relationships To Disclose. Case Description: A healthy 24-year-old woman performed a short series of squats and developed muscle soreness. The soreness worsened throughout the following day and was accompanied by dark urine, prompting medical evaluation. She was diagnosed with exertional rhabdomyolysis, requiring ICU care. Further history revealed subclinical proximal weakness for years, prompting EMG and muscle biopsy, which pointed towards a metabolic myopathy. Genetic testing is pending. The patient presented to physical medicine and rehabilitation clinic for recommendations regarding safe activity resumption and optimization of function. Setting: Acute inpatient rehabilitation hospital. Results or Clinical Course: Appreciating the risk for recurrent exercise induced rhabdomyolysis, the patient was instructed on submaximal, brief physical activity with adequate rest and appropriate nutritional support. She was educated on activity precautions to prevent further loss of function. Through collaboration with a neuromuscular physical therapist, the patient began a program for energy conservation and initiation of aerobic exercise. Coordination with her neurologists allowed the interdisciplinary team to maximize her function and allow her to return to college to complete her studies. Discussion: Rhabdomyolysis, which recurs or occurs with minimal exertion, should raise suspicion of underlying metabolic myopathy. Such patients should be queried on risk factors and previous symptoms, and should receive further diagnostic evaluation. The risk of recurrence and potential complications including acute renal failure, require cautious and structured return to physical activity. The ideal management is via a multispecialty approach which pairs treatment with activity resumption to maximize functional outcome. Conclusion: Metabolic myopathies predispose patients to exertional rhabdomyolysis. This condition highlights the importance of the interdisciplinary rehabilitation team’s role in maximizing functional outcomes while minimizing risk of complications.
Poster 236 Neoplastic Upper Trunk Brachial Plexus Lesion with Normal Sensory Nerve Conduction Studies: A Case Report Lisa Williams, MD (Stanford University, Stanford, CA, United States), Joshua H. Levin, MD Disclosures: L. Williams: I Have No Relevant Financial Relationships To Disclose.