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Poster 252 Longitudinal Approach for Ultrasound-Guided Hydrodissection for Carpal Tunnel Syndrome: A Case Report
PM&R
PM&R and rheumatology MUS faculty, performing diagnostic and interventional MUS under direct supervision. Main Outcome Measures: Five-point Likert scale-formatted questionnaire to assess resident-perceived value of the curriculum. Results or Clinical Course: Response rate was 87% (20/23). Self-reported MUS knowledge was compared pre- and postcurriculum implementation resulting in significant improvement (p¼.001). Peer teaching was highly valued, with 70% of residents rating it “very” or “extremely” beneficial (4.0 1.0). Selfguided learning, by supplemental scanning and reading, was rated “beneficial” or “very beneficial” by 80% of residents (3.1 0.7). Overall, curriculum rating was “good” to “excellent” for 70% of residents (4.0 0.8). Training by rheumatology faculty was found to be “very” or “extremely” beneficial by 83% of residents. Conclusions: Our structured collaborative MUS program was beneficial in the education of PM&R residents. Our pilot program can serve as a teaching model for other PM&R residency programs introducing required MUS teaching. Poster 252 Longitudinal Approach for Ultrasound-Guided Hydrodissection for Carpal Tunnel Syndrome: A Case Report. Rui Zhang, MD (Deptment of Physical Medicine and Rehabilitation, Rutgers-NJMS/Kessler Institute for Rehabilitation, West Orange, NJ, United States); Boqing Chen, MD, PhD; Todd P. Stitik, MD; Patrick M. Foye, MD. Disclosures: R. Zhang, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: The patient presented with 5 months of pain, severe numbness and tingling in the bilateral fingers of median nerve distribution. Physical examination revealed diminished sensation in bilateral 1st-3rd fingers. Carpal compression test reproduced finger paresthesias. Bilateral carpal tunnel syndrome (CTS) was diagnosed and confirmed by a subsequent electrodiagnostic study. After failure to respond to high dose oral corticosteroids, duloxetine, and amitriptyline, an ultrasound-guided carpal tunnel hydrodissection was performed. A 25-gauge 2-inch spinal needle was inserted at the wrist, in-plane to the ultrasound transducer which was oriented long-axis to the median nerve. The needle was advanced between the transverse carpal ligament and the epineurium of the median nerve. Ten milliliter of 0.5% lidocaine was injected, and observed to create a longitudinal fluid dissection plane, lifting the entire length of the overlying transverse carpal ligament from the median nerve. Program Description: A 37-year-old woman with systemic lupus erythematosus presents with bilateral hand CTS. Setting: An outpatient clinic. Results or Clinical Course: Patient reported 80% and 50% CTS symptom improvement at 6-weeks and 23-weeks follow-up, respectively. Discussion: This is the first case report on the successful treatment of CTS symptoms with ultrasound-guided hydrodissection using a longitudinal/in-plane approach. Conclusions: Ultrasound-guided hydrodissection using a longitudinal/in-plane approach may be an effective treatment for CTS.
Vol. 6, Iss. 9S, 2014
S273
Poster 253 Validity of a Positive Lag Test with Diagnostic Ultrasound in Articular Supraspintaus Tear: A Case Report. Prathap Jayaram, MD (Baylor, Houston, TX, United States); Judy Thomas. Disclosures: P. Jayaram, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: A 63-year-old woman was admitted to acute stroke service team for management of an ischemic stroke involving the left basal ganglia. The patient had a notable history for a prior left MCA lesion in January 2012 with residual aphasic deficits. Patient’s right shoulder pain was present prior to the recent stroke, however right shoulder pain had increased in intensity. A focused physical examination revealed positive impingement maneuvers, acromioclavicular joint arthopathy signs, with most provocative maneuver being an external lag test: shoulder was placed in 90 elbow flexion with 20 abduction and was unable to maintain full external rotation position. A 12 point diagnostic shoulder ultrasound evaluation revealed a partial thickness articular surface tear, biceps tendon effusion and dynamic evidence of right supraspinatus impingement with possible type III acromion architecture. Setting: Inpatient Stroke Center. Results or Clinical Course: Patient then underwent right shoulder MRI to further evaluate clinical and diagnostic ultrasound findings. MRI without contrast showed a 50 % partial thickness tear of the supraspinatus, without evidence of capsule thickening or adhesive capsulitis and confirmed a type III acromion with signal evidence of impingement. Prior to MRI the patient underwent a right posterior interarticular injection to address possible adhesive capsulitis and glenohumeral joint stiffness. Discussion: To our knowledge no studies have evaluated the sensitivities or specificities of a positive external lag test in conjunction with a diagnostic ultrasound evaluation of the shoulder for articular surface supraspinatus tears. Diagnostic shoulder ultrasound has become more routine in evaluating rotator cuff tears (RCTs), and holds a sensitivity of 93% and specificity of 94% for partial thickness tears. The specificity can further be increased with a true positive external lag test which holds a 94% specificity for evaluating full thickness tears. This raises awareness that the external lag test should be incorporated into the physical examination and 12 point shoulder examination when considering FTRCT and PTRCTs. Conclusions: External lag test is a good predictor for evaluating both partial and full thickness supraspinatus tears and should be incorporated into a 12 point diagnostic ultrasound evaluation of the shoulder. Poster 254 Ultrasound Diagnosis of Calcium Pyrophosphate Dihydrate Deposition Disease in a Patient with Hemochromatosis: A Case Report. Angelie Mascarinas, MD (Spaulding Rehabilitation Hospital/Harvard Medical School, Boston, MA, United States); Anne H. Johnson, MD; Minna Kohler, MD. Disclosures: A. Mascarinas, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: A 27-year-old woman with well-controlled hemochromatosis with left foot pain and swelling. Patient routinely
PM&R and rheumatology MUS faculty, performing diagnostic and interventional MUS under direct supervision. Main Outcome Measures: Five-point Likert scale-formatted questionnaire to assess resident-perceived value of the curriculum. Results or Clinical Course: Response rate was 87% (20/23). Self-reported MUS knowledge was compared pre- and postcurriculum implementation resulting in significant improvement (p¼.001). Peer teaching was highly valued, with 70% of residents rating it “very” or “extremely” beneficial (4.0 1.0). Selfguided learning, by supplemental scanning and reading, was rated “beneficial” or “very beneficial” by 80% of residents (3.1 0.7). Overall, curriculum rating was “good” to “excellent” for 70% of residents (4.0 0.8). Training by rheumatology faculty was found to be “very” or “extremely” beneficial by 83% of residents. Conclusions: Our structured collaborative MUS program was beneficial in the education of PM&R residents. Our pilot program can serve as a teaching model for other PM&R residency programs introducing required MUS teaching. Poster 252 Longitudinal Approach for Ultrasound-Guided Hydrodissection for Carpal Tunnel Syndrome: A Case Report. Rui Zhang, MD (Deptment of Physical Medicine and Rehabilitation, Rutgers-NJMS/Kessler Institute for Rehabilitation, West Orange, NJ, United States); Boqing Chen, MD, PhD; Todd P. Stitik, MD; Patrick M. Foye, MD. Disclosures: R. Zhang, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: The patient presented with 5 months of pain, severe numbness and tingling in the bilateral fingers of median nerve distribution. Physical examination revealed diminished sensation in bilateral 1st-3rd fingers. Carpal compression test reproduced finger paresthesias. Bilateral carpal tunnel syndrome (CTS) was diagnosed and confirmed by a subsequent electrodiagnostic study. After failure to respond to high dose oral corticosteroids, duloxetine, and amitriptyline, an ultrasound-guided carpal tunnel hydrodissection was performed. A 25-gauge 2-inch spinal needle was inserted at the wrist, in-plane to the ultrasound transducer which was oriented long-axis to the median nerve. The needle was advanced between the transverse carpal ligament and the epineurium of the median nerve. Ten milliliter of 0.5% lidocaine was injected, and observed to create a longitudinal fluid dissection plane, lifting the entire length of the overlying transverse carpal ligament from the median nerve. Program Description: A 37-year-old woman with systemic lupus erythematosus presents with bilateral hand CTS. Setting: An outpatient clinic. Results or Clinical Course: Patient reported 80% and 50% CTS symptom improvement at 6-weeks and 23-weeks follow-up, respectively. Discussion: This is the first case report on the successful treatment of CTS symptoms with ultrasound-guided hydrodissection using a longitudinal/in-plane approach. Conclusions: Ultrasound-guided hydrodissection using a longitudinal/in-plane approach may be an effective treatment for CTS.
Vol. 6, Iss. 9S, 2014
S273
Poster 253 Validity of a Positive Lag Test with Diagnostic Ultrasound in Articular Supraspintaus Tear: A Case Report. Prathap Jayaram, MD (Baylor, Houston, TX, United States); Judy Thomas. Disclosures: P. Jayaram, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: A 63-year-old woman was admitted to acute stroke service team for management of an ischemic stroke involving the left basal ganglia. The patient had a notable history for a prior left MCA lesion in January 2012 with residual aphasic deficits. Patient’s right shoulder pain was present prior to the recent stroke, however right shoulder pain had increased in intensity. A focused physical examination revealed positive impingement maneuvers, acromioclavicular joint arthopathy signs, with most provocative maneuver being an external lag test: shoulder was placed in 90 elbow flexion with 20 abduction and was unable to maintain full external rotation position. A 12 point diagnostic shoulder ultrasound evaluation revealed a partial thickness articular surface tear, biceps tendon effusion and dynamic evidence of right supraspinatus impingement with possible type III acromion architecture. Setting: Inpatient Stroke Center. Results or Clinical Course: Patient then underwent right shoulder MRI to further evaluate clinical and diagnostic ultrasound findings. MRI without contrast showed a 50 % partial thickness tear of the supraspinatus, without evidence of capsule thickening or adhesive capsulitis and confirmed a type III acromion with signal evidence of impingement. Prior to MRI the patient underwent a right posterior interarticular injection to address possible adhesive capsulitis and glenohumeral joint stiffness. Discussion: To our knowledge no studies have evaluated the sensitivities or specificities of a positive external lag test in conjunction with a diagnostic ultrasound evaluation of the shoulder for articular surface supraspinatus tears. Diagnostic shoulder ultrasound has become more routine in evaluating rotator cuff tears (RCTs), and holds a sensitivity of 93% and specificity of 94% for partial thickness tears. The specificity can further be increased with a true positive external lag test which holds a 94% specificity for evaluating full thickness tears. This raises awareness that the external lag test should be incorporated into the physical examination and 12 point shoulder examination when considering FTRCT and PTRCTs. Conclusions: External lag test is a good predictor for evaluating both partial and full thickness supraspinatus tears and should be incorporated into a 12 point diagnostic ultrasound evaluation of the shoulder. Poster 254 Ultrasound Diagnosis of Calcium Pyrophosphate Dihydrate Deposition Disease in a Patient with Hemochromatosis: A Case Report. Angelie Mascarinas, MD (Spaulding Rehabilitation Hospital/Harvard Medical School, Boston, MA, United States); Anne H. Johnson, MD; Minna Kohler, MD. Disclosures: A. Mascarinas, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: A 27-year-old woman with well-controlled hemochromatosis with left foot pain and swelling. Patient routinely