- Email: [email protected]
Poster 24 Brachial Plexopathy Caused by Pancoast Tumor From Recurrent Lung Cancer. A Case Report
PM&R
and EDX findings of new diffuse, patchy brachial plexopathy without myokymic discharges were consistent with PTS overlying chronic C7-C8 radiculopathy and argued against solely RFinduced symptoms. Improvement of C7 metastases on MRI favored a diagnosis of PTS over worsening cervical spine compression. Conclusions: A diagnosis of PTS may be complicated by the likeness in the clinical course with CR secondary to expansile metastases and RF brachial plexopathy. EDX was vital in distinguishing PTS from other potential underlying causes of acute weakness in this cancer patient. Poster 22 Thoracic Intrathecal Neurolysis for Intractable Metastatic Chest Wall Pain Refractory to High Doses of Opioids: A Case Report. Adrian Popescu, MD (Hospital of the University of Pennsylvania, Philadelphia, PA, United States); Kieran Slevin, MD. Disclosures: A. Popescu, none. Patients or Programs: A 51-year-old woman with a history of colon cancer and hypothyroidism presented with severe intractable right thoracic chest wall pain, poorly controlled on very high doses of opioid medication. Program Description: The patient was admitted and diagnosed with metastatic disease to the right lower lobe of the lung, right chest wall, and lumbar spine. A computed tomography of her chest showed evidence of metastatic disease, with a nondisplaced fracture that involved the posterior sixth rib, adjacent to a thoracic soft-wall mass, as well as focal areas of pleural thickening along the right posterior thorax. Her chest wall pain was the most significant limiting factor for her quality of life and precluded her participation in a cancer rehabilitation program. Furthermore, the high doses of opioids made the patient very drowsy and disoriented, and unable to interact with her family. Setting: A quaternary care academic hospital. Results: The patient was evaluated in the multidisciplinary pain clinic by the rehabilitation and pain specialists. It was decided that diagnostic right T4, T5, T6, and T7 intercostal nerve blocks followed by intrathecal neurolysis was to be performed. The patient received excellent relief after the diagnostic blocks. It was decided to proceed with the right-side thoracic interlaminar intrathecal neurolysis with 95% ethanol at T4, T5, T6, and T7 levels. The patient received excellent relief, and she was able to reduce by 75% the opioid dose requirement for pain control. She was able to further participate in physical therapy and family activities on a regular basis, and maintained her pain relief for more than 5 months after the procedure. Discussion: To our knowledge, this is a unique case of a patient with thoracic chest wall metastatic pain disease that benefited from an advanced targeted therapeutic procedure as a complementary alternative to failed opioid pain management, which allowed her to have an increased quality of life and participate in cancer rehabilitation. Conclusions: Comprehensive assessment and advanced therapeutic interventions can significantly impact the quality of life and functional outcomes of patients with metastatic disease with intractable chest wall pain resistant to high doses of opioid medication.
Vol. 3, Iss. 10S1, 2011
S183
Poster 23 Are There Adverse Effects to Rehabilitation in Cancer Patients With Thrombocytopenia? Samman Shahpar, MD (Rehabilitation Institute of Chicago, Chicago, IL, United States); Gail L. Gamble, MD, Christina M. Marciniak, MD, Gayle R. Spill, MD. Disclosures: S. Shahpar, none. Objective: To determine if cancer patients in acute inpatient rehabilitation (AIR) have an increased risk of bleeding complications associated with therapy services in the presence of thrombocytopenia. Design: A retrospective chart review. Setting: An AIR hospital. Participants: Cancer patients with thrombocytopenia who were admitted to AIR from December 2009 to April 2010. Interventions: The electronic medical records were reviewed, and patients with thrombocytopenia were identified, defined as ⱕ100,0000 platelets/L. These patients participated in the standard average of 3 hours of therapy per day. Main Outcome Measures: The primary outcome was bleeding events (including number, type, and severity), acute care transfers, and any potential precipitants of the event. Severity of the event was classified as mild (no change in status), moderate (transfusion given, therapy held), severe (transfer from AIR), or death. Results: 74 cancer patients who required AIR over the 5-month time frame were reviewed, and 18 patients with thrombocytopenia on at least 1 laboratory value during their stay were identified. Platelet levels were found to be as low as 4000 platelets/L and were ⱕ20,000 platelets/L on 35 separate occasions. Ten of the 18 cancer patients with thrombocytopenia had a total of 13 bleeding events. The types of bleeding events were varied and included epistaxis, with use of oxygen via nasal cannula; heme positive stool; self-limited episode of hematuria; subconjunctival hemorrhage; and bruising of the forearm after hemodialysis fistula access. Three of the events occurred when the patients were not thrombocytopenic, and no events were clearly attributable to activities performed in physical or occupational therapy. One patient required transfer to acute care due to a bleeding event, but this was 1 day after admission and before therapy initiation. Conclusions: In this sample, although bleeding events occurred in cancer patients with thrombocytopenic when in AIR, these events were not noted to be related to therapy interventions and rarely required interruption in rehabilitation services. Poster 24 Brachial Plexopathy Caused by Pancoast Tumor From Recurrent Lung Cancer. A Case Report. Anupam Sinha, DO (Rothman Institute, Philadelphia, PA, United States); William A. Anderson, MD, Madhuri Dholakia, MD. Disclosures: A. Sinha, none. Patients or Programs: A 69-year-old man. Program Description: A 69-year-old, right-hand dominant man with a medical history of prostate and lung cancer (in remission) presented with a 3-week history of acute right upper extremity pain, weakness, and paresthesia. Symptoms were radiating down the shoulder, biceps, radial distribution of the forearm, thumb, and index finger. The patient reported mild neck stiffness. He denied any bowel or bladder disturbance. Physical examination revealed
S184
significant weakness in the right shoulder and biceps, and 4/5 muscle strength in the right first dorsal interosseous and abductor pollicis brevis. Hoffmann sign was positive bilaterally. Lower extremity examination was unremarkable. Setting: An outpatient spine practice. Results: Prior magnetic resonance imaging (MRI) of the cervical spine revealed right paracentral disk herniation at C3-4, with mild disk bulging at C4-5 and C5-6. Prior MRI of brain was unremarkable. Prior computed tomography of the chest also was unremarkable. MRI of the shoulder was ordered, which was unremarkable. An electromyogram of the right upper extremity was performed, which showed a diffuse right brachial plexus injury that primarily affected the upper trunk. Dedicated MRI of the right brachial plexus was ordered and showed a 4-cm mass at the apex of the right lung, which distorted the brachial plexus and subclavian vessels. The patient was referred back to oncology for further evaluation. Discussion: Pancoast tumors can cause Horner syndrome in severe cases: miosis (constriction of the pupils), anhidrosis (lack of sweating), ptosis (drooping of the eyelid), and enophthalmos (sunken eyeball). In progressive cases, the brachial plexus is also affected, which causes pain and weakness in the muscles of the arm and hand. The tumor also can compress the right recurrent laryngeal nerve, which produces a hoarse voice and cough. Treatment may involve radiation, chemotherapy, and/or surgical resection. Conclusions: We present a case of right brachial plexopathy as a result of Pancoast tumor. The patient had a history of lung cancer in remission, which did return. Clinicians should order dedicated MRI of the brachial plexus rather than relying on computed tomography of the chest, in patients who present with these symptoms. Poster 25 Barriers to the Acute Rehabilitation of Patients With Cerebellopontine Angle Syndrome: A Case Series. Alexander J. Martinez, MD (New York Presbyterian Hospital – Columbia University Medical Center, New York, NY, United States); Kenny Chantasi, DO, David Cheng, MD. Disclosures: A. J. Martinez, none. Patients or Programs: A 66-year-old man and a 60-year-old woman with left cerebellopontine angle (CPA) meningiomas. Program Description: Two patients presented to their primary care physicians with progressively worsening gait ataxia. Brain magnetic resonance imaging revealed a large extra-axial mass that occupied the left CPA of each patient, consistent with meningiomas. The lesions measured 5.2 ⫻ 2.2 cm and 6.0 ⫻ 3.5 cm. Each patient underwent suboccipital craniectomy and tumor resection. After surgery, they developed ipsilateral facial nerve palsy, sensorineural hearing loss, limb dysmetria, and persistent balance deficits that impaired ambulation. One patient also presented with unintelligible speech and dysphagia after the surgery due to vocal cord paralysis. Setting: An acute inpatient rehabilitation unit of a tertiary care center. Results: On admission to acute rehabilitation, an initial evaluation demonstrated an ambulation subscale of the Functional Independence Measure score of 2, which required maximum assistance for ambulation in each case. Speech and swallow evaluation revealed dysphasia. As a consequence of left facial nerve palsy and subsequent orbicularis oculi weakness, they developed left ocular pain that required tarsorrhaphy by ophthalmology. After 3 weeks of
PRESENTATIONS
acute rehabilitation, ambulation subscale of the Functional Independence Measure for the patients improved to 4 and 6. They were discharged home with modified independence; one patient required a wheelchair for mobility. The left vocal cord paralysis improved significantly, with a return of near-normal speech on discharge. Discussion: CPA syndrome can be seen with any mass that occupies the CPA; vestibular schwannomas, meningiomas, and epidermoids account for the vast majority (99%) of tumors. Regardless of the etiology, signs and symptoms are similar due to displacement of the same neural structures. The most common manifestations include trigeminal, glossopharyngeal, and facial nerve dysfunction as well as cerebellar ataxia. Conclusions: Early identification of CPA syndrome and complications after tumor resection may yield improved functional outcomes and shorter hospitalizations in acute inpatient rehabilitation. Poster 26 Femoral Mononeuropathy and Lumbar Radiculopathy in the Setting of Radiation Fibrosis: A Case Report. Annemarie E. Gallagher, MD (Columbia and Cornell Universities: New York Presbyterian Hospital, New York, NY, United States); Michael D. Stubblefield, MD, Gaurav Telhan, MD. Disclosures: A. E. Gallagher, none. Patients or Programs: A 58-year-old man with a history of prostate cancer after radical prostatectomy and image-guided radiation therapy (IGRT) with 2600 cGy for metastases to the right acetabulum and ischium, presented with right leg numbness. Program Description: 1 year after IGRT, the patient developed right lower extremity paresthesias, which radiated to the medial thigh and calf, and hip flexor weakness. He also had pain that radiated down the posterior aspect of his leg, but there was no incontinence of bowel or bladder. Oral neuropathic pain agents provided no relief of symptoms. Setting: An urban tertiary care center. Results: The patient underwent electrodiagnostic testing. There was no response with right peroneal motor testing. Electromyography needle evaluation of the right anterior tibialis showed increased insertional activity, whereas the right medial gastrocnemius showed both increased insertional and spontaneous activity. The right vastus medialis and rectus femoris showed increased motor unit amplitude potentials, increased motor unit duration, increased polyphasic potentials, and reduced recruitment, whereas the right vastus lateralis showed increased motor unit amplitude potentials, decreased motor unit duration, increased polyphasic potentials, and reduced recruitment. Discussion: Radiation therapy may result in late-onset complications as a result of insidious tissue fibrosis and subsequent damage to vasculature, nerve, muscle, and other tissues. The resulting clinical manifestations are known as the radiation fibrosis syndrome. This patient’s history, physical examination and electrodiagnostic findings are consistent with a chronic right femoral mononeuropathy. Myopathic and neuropathic changes observed in the right iliopsoas muscle are consistent with the history of IGRT to
and EDX findings of new diffuse, patchy brachial plexopathy without myokymic discharges were consistent with PTS overlying chronic C7-C8 radiculopathy and argued against solely RFinduced symptoms. Improvement of C7 metastases on MRI favored a diagnosis of PTS over worsening cervical spine compression. Conclusions: A diagnosis of PTS may be complicated by the likeness in the clinical course with CR secondary to expansile metastases and RF brachial plexopathy. EDX was vital in distinguishing PTS from other potential underlying causes of acute weakness in this cancer patient. Poster 22 Thoracic Intrathecal Neurolysis for Intractable Metastatic Chest Wall Pain Refractory to High Doses of Opioids: A Case Report. Adrian Popescu, MD (Hospital of the University of Pennsylvania, Philadelphia, PA, United States); Kieran Slevin, MD. Disclosures: A. Popescu, none. Patients or Programs: A 51-year-old woman with a history of colon cancer and hypothyroidism presented with severe intractable right thoracic chest wall pain, poorly controlled on very high doses of opioid medication. Program Description: The patient was admitted and diagnosed with metastatic disease to the right lower lobe of the lung, right chest wall, and lumbar spine. A computed tomography of her chest showed evidence of metastatic disease, with a nondisplaced fracture that involved the posterior sixth rib, adjacent to a thoracic soft-wall mass, as well as focal areas of pleural thickening along the right posterior thorax. Her chest wall pain was the most significant limiting factor for her quality of life and precluded her participation in a cancer rehabilitation program. Furthermore, the high doses of opioids made the patient very drowsy and disoriented, and unable to interact with her family. Setting: A quaternary care academic hospital. Results: The patient was evaluated in the multidisciplinary pain clinic by the rehabilitation and pain specialists. It was decided that diagnostic right T4, T5, T6, and T7 intercostal nerve blocks followed by intrathecal neurolysis was to be performed. The patient received excellent relief after the diagnostic blocks. It was decided to proceed with the right-side thoracic interlaminar intrathecal neurolysis with 95% ethanol at T4, T5, T6, and T7 levels. The patient received excellent relief, and she was able to reduce by 75% the opioid dose requirement for pain control. She was able to further participate in physical therapy and family activities on a regular basis, and maintained her pain relief for more than 5 months after the procedure. Discussion: To our knowledge, this is a unique case of a patient with thoracic chest wall metastatic pain disease that benefited from an advanced targeted therapeutic procedure as a complementary alternative to failed opioid pain management, which allowed her to have an increased quality of life and participate in cancer rehabilitation. Conclusions: Comprehensive assessment and advanced therapeutic interventions can significantly impact the quality of life and functional outcomes of patients with metastatic disease with intractable chest wall pain resistant to high doses of opioid medication.
Vol. 3, Iss. 10S1, 2011
S183
Poster 23 Are There Adverse Effects to Rehabilitation in Cancer Patients With Thrombocytopenia? Samman Shahpar, MD (Rehabilitation Institute of Chicago, Chicago, IL, United States); Gail L. Gamble, MD, Christina M. Marciniak, MD, Gayle R. Spill, MD. Disclosures: S. Shahpar, none. Objective: To determine if cancer patients in acute inpatient rehabilitation (AIR) have an increased risk of bleeding complications associated with therapy services in the presence of thrombocytopenia. Design: A retrospective chart review. Setting: An AIR hospital. Participants: Cancer patients with thrombocytopenia who were admitted to AIR from December 2009 to April 2010. Interventions: The electronic medical records were reviewed, and patients with thrombocytopenia were identified, defined as ⱕ100,0000 platelets/L. These patients participated in the standard average of 3 hours of therapy per day. Main Outcome Measures: The primary outcome was bleeding events (including number, type, and severity), acute care transfers, and any potential precipitants of the event. Severity of the event was classified as mild (no change in status), moderate (transfusion given, therapy held), severe (transfer from AIR), or death. Results: 74 cancer patients who required AIR over the 5-month time frame were reviewed, and 18 patients with thrombocytopenia on at least 1 laboratory value during their stay were identified. Platelet levels were found to be as low as 4000 platelets/L and were ⱕ20,000 platelets/L on 35 separate occasions. Ten of the 18 cancer patients with thrombocytopenia had a total of 13 bleeding events. The types of bleeding events were varied and included epistaxis, with use of oxygen via nasal cannula; heme positive stool; self-limited episode of hematuria; subconjunctival hemorrhage; and bruising of the forearm after hemodialysis fistula access. Three of the events occurred when the patients were not thrombocytopenic, and no events were clearly attributable to activities performed in physical or occupational therapy. One patient required transfer to acute care due to a bleeding event, but this was 1 day after admission and before therapy initiation. Conclusions: In this sample, although bleeding events occurred in cancer patients with thrombocytopenic when in AIR, these events were not noted to be related to therapy interventions and rarely required interruption in rehabilitation services. Poster 24 Brachial Plexopathy Caused by Pancoast Tumor From Recurrent Lung Cancer. A Case Report. Anupam Sinha, DO (Rothman Institute, Philadelphia, PA, United States); William A. Anderson, MD, Madhuri Dholakia, MD. Disclosures: A. Sinha, none. Patients or Programs: A 69-year-old man. Program Description: A 69-year-old, right-hand dominant man with a medical history of prostate and lung cancer (in remission) presented with a 3-week history of acute right upper extremity pain, weakness, and paresthesia. Symptoms were radiating down the shoulder, biceps, radial distribution of the forearm, thumb, and index finger. The patient reported mild neck stiffness. He denied any bowel or bladder disturbance. Physical examination revealed
S184
significant weakness in the right shoulder and biceps, and 4/5 muscle strength in the right first dorsal interosseous and abductor pollicis brevis. Hoffmann sign was positive bilaterally. Lower extremity examination was unremarkable. Setting: An outpatient spine practice. Results: Prior magnetic resonance imaging (MRI) of the cervical spine revealed right paracentral disk herniation at C3-4, with mild disk bulging at C4-5 and C5-6. Prior MRI of brain was unremarkable. Prior computed tomography of the chest also was unremarkable. MRI of the shoulder was ordered, which was unremarkable. An electromyogram of the right upper extremity was performed, which showed a diffuse right brachial plexus injury that primarily affected the upper trunk. Dedicated MRI of the right brachial plexus was ordered and showed a 4-cm mass at the apex of the right lung, which distorted the brachial plexus and subclavian vessels. The patient was referred back to oncology for further evaluation. Discussion: Pancoast tumors can cause Horner syndrome in severe cases: miosis (constriction of the pupils), anhidrosis (lack of sweating), ptosis (drooping of the eyelid), and enophthalmos (sunken eyeball). In progressive cases, the brachial plexus is also affected, which causes pain and weakness in the muscles of the arm and hand. The tumor also can compress the right recurrent laryngeal nerve, which produces a hoarse voice and cough. Treatment may involve radiation, chemotherapy, and/or surgical resection. Conclusions: We present a case of right brachial plexopathy as a result of Pancoast tumor. The patient had a history of lung cancer in remission, which did return. Clinicians should order dedicated MRI of the brachial plexus rather than relying on computed tomography of the chest, in patients who present with these symptoms. Poster 25 Barriers to the Acute Rehabilitation of Patients With Cerebellopontine Angle Syndrome: A Case Series. Alexander J. Martinez, MD (New York Presbyterian Hospital – Columbia University Medical Center, New York, NY, United States); Kenny Chantasi, DO, David Cheng, MD. Disclosures: A. J. Martinez, none. Patients or Programs: A 66-year-old man and a 60-year-old woman with left cerebellopontine angle (CPA) meningiomas. Program Description: Two patients presented to their primary care physicians with progressively worsening gait ataxia. Brain magnetic resonance imaging revealed a large extra-axial mass that occupied the left CPA of each patient, consistent with meningiomas. The lesions measured 5.2 ⫻ 2.2 cm and 6.0 ⫻ 3.5 cm. Each patient underwent suboccipital craniectomy and tumor resection. After surgery, they developed ipsilateral facial nerve palsy, sensorineural hearing loss, limb dysmetria, and persistent balance deficits that impaired ambulation. One patient also presented with unintelligible speech and dysphagia after the surgery due to vocal cord paralysis. Setting: An acute inpatient rehabilitation unit of a tertiary care center. Results: On admission to acute rehabilitation, an initial evaluation demonstrated an ambulation subscale of the Functional Independence Measure score of 2, which required maximum assistance for ambulation in each case. Speech and swallow evaluation revealed dysphasia. As a consequence of left facial nerve palsy and subsequent orbicularis oculi weakness, they developed left ocular pain that required tarsorrhaphy by ophthalmology. After 3 weeks of
PRESENTATIONS
acute rehabilitation, ambulation subscale of the Functional Independence Measure for the patients improved to 4 and 6. They were discharged home with modified independence; one patient required a wheelchair for mobility. The left vocal cord paralysis improved significantly, with a return of near-normal speech on discharge. Discussion: CPA syndrome can be seen with any mass that occupies the CPA; vestibular schwannomas, meningiomas, and epidermoids account for the vast majority (99%) of tumors. Regardless of the etiology, signs and symptoms are similar due to displacement of the same neural structures. The most common manifestations include trigeminal, glossopharyngeal, and facial nerve dysfunction as well as cerebellar ataxia. Conclusions: Early identification of CPA syndrome and complications after tumor resection may yield improved functional outcomes and shorter hospitalizations in acute inpatient rehabilitation. Poster 26 Femoral Mononeuropathy and Lumbar Radiculopathy in the Setting of Radiation Fibrosis: A Case Report. Annemarie E. Gallagher, MD (Columbia and Cornell Universities: New York Presbyterian Hospital, New York, NY, United States); Michael D. Stubblefield, MD, Gaurav Telhan, MD. Disclosures: A. E. Gallagher, none. Patients or Programs: A 58-year-old man with a history of prostate cancer after radical prostatectomy and image-guided radiation therapy (IGRT) with 2600 cGy for metastases to the right acetabulum and ischium, presented with right leg numbness. Program Description: 1 year after IGRT, the patient developed right lower extremity paresthesias, which radiated to the medial thigh and calf, and hip flexor weakness. He also had pain that radiated down the posterior aspect of his leg, but there was no incontinence of bowel or bladder. Oral neuropathic pain agents provided no relief of symptoms. Setting: An urban tertiary care center. Results: The patient underwent electrodiagnostic testing. There was no response with right peroneal motor testing. Electromyography needle evaluation of the right anterior tibialis showed increased insertional activity, whereas the right medial gastrocnemius showed both increased insertional and spontaneous activity. The right vastus medialis and rectus femoris showed increased motor unit amplitude potentials, increased motor unit duration, increased polyphasic potentials, and reduced recruitment, whereas the right vastus lateralis showed increased motor unit amplitude potentials, decreased motor unit duration, increased polyphasic potentials, and reduced recruitment. Discussion: Radiation therapy may result in late-onset complications as a result of insidious tissue fibrosis and subsequent damage to vasculature, nerve, muscle, and other tissues. The resulting clinical manifestations are known as the radiation fibrosis syndrome. This patient’s history, physical examination and electrodiagnostic findings are consistent with a chronic right femoral mononeuropathy. Myopathic and neuropathic changes observed in the right iliopsoas muscle are consistent with the history of IGRT to