Poster 269: Acute Onset Patchy Upper Extremity Weakness: A Case Report

Abstracts / PM R 9 (2017) S131-S290 upper extremities consistent with neuralgic amyotrophy also known as Parsonage-Turner syndrome. Setting: Tertiary care hospital outpatient clinic. Results: At 4 months after the onset of symptoms the patient regained significant amount of strength and function in bilateral upper extremities. He has continued with his prescribed physical therapy and home exercise program. Discussion: Neuralgic amyotrophy is a rare condition presenting usually unilaterally. It is thought to be caused by immune-mediated processes but exact cause is unknown. As per previous studies, the recovery usually takes few years and is associated with residual weakness. This is the first reported case, to my knowledge, of significant recovery in bilateral neuralgic amyotrophy before 6 months after the onset of disease. Conclusions: Recovery of strength and function in bilateral neuralgic amyotrophy may occur earlier in the course of the disease than previously thought. Level of Evidence: Level V Poster 268: Metastatic and Radiation Brachial Plexopathy Masquerading as Carpal Tunnel Syndrome: A Case Report Yue-Shan L. Yang (WA Hosp Cntr/Georgetown Univ), Joseph Connor, MD, Eric Wisotzky, MD Disclosures: Yue-Shan Yang: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 70-year-old woman with a past medical history of right breast adenocarcinoma status-post lumpectomy, radiation, mastectomy, and lymph node dissection 24 years ago presented with complaints of persistent right hand burning and stinging for 2 years. This was associated with progressive weakness and increasing right arm edema. Prior to presentation in our clinic, she was diagnosed with carpal tunnel syndrome (CTS) of the right wrist and had a carpal tunnel release without relief. This was complicated by scar tissue resulting in a 2nd release. Physical examination was significant for weakness of the right triceps, wrist extensors, and finger abductors with decreased sensation over antebrachial, median, and ulnar dermatomes. Prior electromyography (EMG) demonstrated right median neuropathy and possible ulnar and radial neuropathy with absent sensory responses. Setting: Outpatient academic rehabilitation center. Results: Brachial plexopathy was suspected after our evaluation and magnetic resonance imaging (MRI) was ordered. MRI revealed an 8 by 3 cm fibrotic mass encompassing the brachial plexus, suspicious for radiation fibrosis. Upon surgical dissection of the mass, a nodule was discovered in the right lateral pectoralis muscle. It was excised and pathology was conclusive for metastatic breast adenocarcinoma. Discussion: This is an example of a serious life threatening medical condition (recurrent breast cancer) that was mistaken for a common medical condition (CTS). The patient’s radiation and metastatic plexopathy presented resembling aspects of CTS, with hand dysesthesias and weakness. Multiple surgical procedures for CTS were performed, resulting in no clinical benefit. Therefore, in the presence of findings suggesting other etiologies, a clinician should rethink the diagnosis of CTS after failed therapies. Conclusions: In this case, the above physical examination and EMG findings should alarm a clinician that a more complex diagnosis than CTS was involved. When treatment fails, other diagnoses should be considered. Level of Evidence: Level V Poster 269: Acute Onset Patchy Upper Extremity Weakness: A Case Report Eric S. Larsen (Philadelphia Col of Osteo Med), Ziva Petrin, MD, Jeffery Gehret, DO Disclosures: Eric Larsen: I Have No Relevant Financial Relationships To Disclose

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Case/Program Description: A healthy left handed male police officer presented with acute painless weakness in his left shoulder and arm. Four week prior to evaluation, he woke up with weakness, unable to strap on his gun holster. There was no preceding trauma, illness, surgery, or associated sensory changes. Upon extensive questioning, the only pain preceding the event occurred 1 week prior to the weakness in the trapezius region, was mild and resolved after a few hours with massage. There was no family history of weakness or episodic shoulder girdle pain consistent with myopathy or hereditary neuralgic amyotrophy. Setting: Outpatient musculoskeletal clinic. Results: Exam revealed preserved muscle bulk with 4/5 weakness of the left external rotators, deltoid and biceps, with normal sensation and reflexes. Electrodiagnostic studies 6 weeks after onset of symptoms showed normal conductions except borderline reduced lateral antebrachial cutaneous amplitude with normal distal latency, and fibrillation potentials in the left deltoid, biceps, supraspinatus, infraspinatus and paraspinals, suggestive of an acute C5 radiculopathy. MRI of the cervical spine showed an acute left sided foraminal disk herniation at C4-C5. He was referred for surgery but opted for conservative treatment with physical therapy. His weakness had fully resolved by follow up 7 weeks post EMG. Discussion: The patient was initially suspected to have an atypical case of neuralgic amyotrophy, based on history of acute asymmetric painless shoulder weakness. Cervical MRI and EMG confirmed acute C5 radiculopathy secondary to a large foraminal herniation. Interestingly, the patient had no pain or sensory changes typical for radiculopathy. Conclusions: This case describes acute foraminal cervical herniation presenting with acute onset of weakness without other symptoms. Further research involving MRI findings of painless lesions would help delineate why this large herniation presented with weakness only, without any pain or sensation changes compared to typical presentation of radiculopathy. Level of Evidence: Level V Poster 270: Manual Medicine as Effective Treatment for PostLaminectomy Syndrome Chronic Low Back Pain: A Case Report Michael D. Smith, OMS-III (Nova Southeastern University College of Osteopathic Medicine, Orlando, FL, United States), Yasmin Qureshi, DPT, MHS (osteo) Disclosures: Michael Smith: I Have No Relevant Financial Relationships To Disclose Case/Program Description: The patient is a 35-year-old man presenting with chronic low back pain (LBP), first appearing at age 15 when he sustained a weight lifting injury. Shortly after he underwent a lumbar laminectomy, physical therapy, and pharmacologic treatment. His pain persisted and has significantly worsening over the last 2 years. Physical exam revealed normal muscle strength, sensation, and deep tendon reflexes bilaterally. Taught lumbar paraspinals, quadratus lumborum, and gluteus medius musculature was appreciated with positive left sided straight leg raise. Lumbar X-ray showed no pathologic findings. A specific manual medicine protocol was performed a total of 5 times over an 8-week period consisting of techniques to increase range of motion, loosen musculature and align boney structures. Prior to each treatment and 2 months after final treatment, pain and functional disability was measured using the Visual Analog Pain Scale (VAS) and Oswestry Disability Index (ODI), respectively. Setting: Outpatient medical clinic. Results: On first visit, the patient reported a VAS of 8/10 and an ODI score of 32%. By the 5th visit, the patient reported a VAS of 2/10 and an ODI score of 16%. Two months after the final treatment, VAS and ODI were measured to evaluate if treatments had lasting results. VAS was a 0/10 and ODI score of 12% 2-month post-treatment. Discussion: Many patients who undergo surgical laminectomy experience ongoing pain symptoms. Etiology of pain may not be corrected by