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Poster 318 Transient Neuropathic Pain After the Insertion of Spinal Cord Stimulator Leads: A Case Report
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and 0.8 mcg/dL, respectively), and a positive synthetic urine corticoid screen for triamcinolone acetonide (1.1 mcg/dL) several weeks after the final injection. Setting: Outpatient sports and spine clinic. Results: The patient was diagnosed with iatrogenic Cushing syndrome 7 months after initial symptom presentation. She discontinued use of ritonavir for 2 weeks and was treated with an extended hydrocortisone taper. Over the course of several months, she had marked improvement in facial fullness, became euglycemic, and her adrenal function normalized. Discussion: In patients infected with HIV, ritonavir is frequently used to enhance plasma concentrations of coadministered protease inhibitors. Although this has translated into improved virologic outcomes, there have been a growing number of reports over the last decade that suggest the need for increased surveillance when administering medications that share this common metabolic pathway. Steroids are particularly problematic because of similarities between the symptoms of iatrogenic Cushing and the more prevalent antiretroviral-associated lipodystrophy, which can lead to a delayed diagnosis with severe manifestations. Conclusions: Physicians performing epidural steroid injection should be aware of potential drug interactions to avoid important adverse effects in patients who receive epidural corticosteroids.
Poster 316 Multiple Epidural Cysts: A Case Report. Jane Wang, MD (Napa Pain Institute, Napa, CA, United States); Lizu Xiao, MD, Harvey Yee, MD. Disclosures: J. Wang, none. Patients or Programs: The patient is a 36-year-old woman with sudden onset of lower extremities weakness. Program Description: The patient, with no significant history of back pain, presented with sudden onset of back pain and weakness of both lower extremities on awakening. In less than 4 hours, she was unable to walk. Pain was localized, aggravated by Valsalva maneuvers and forward flexion. By evening, she began to feel numbness of the left great toe. There were no bowel or bladder symptoms. No history of trauma or infection. On examination, the patient was supine, unable to sit up or roll side to side, more because of weakness rather than pain. There was tenderness to palpation in the lumbosacral region. There was a small hyperpigmented area in the midline of the back, of which the patient had no knowledge. Proximally, hip flexors were 2/5, knee extensors were 3/5, ankle dorsiflexor on the right was 4/5, on the left was 5/5, and plantar flexors were 5/5. Sensory examination showed decreased pinprick in the left L5 distribution with hesitancy on joint sense. The right ankle reflex was unobtainable, whereas the left was 1⫹. The Faber test caused pain in the back. Straight leg raising test was negative. Magnetic resonance imaging showed multiple cysts in the sacral cavity, computed tomographic myelogram showed communicating cysts on the right, with no filling in the cysts on the left. Setting: Inpatient pain department. Results: She was started on diclofenac sodium intravenous 16 mg for 5 days, with improvements, so that by day 10 she had normal gait with full range of motion of the lumbosacral area and intact sensation in both lower extremities. Prophylactic removal of cysts by minimally invasive techniques was offered, but the patient declined because she thought that she was back to normal. Discussion: Review of the literature showed that epidural cysts
PRESENTATIONS
are surgically removed. This is the first case, to our knowledge, in which the compression effects of epidural cysts resolved with nonsteroidal anti-inflammatory drugs and rest. We anticipate that there will be a recurrence, and the patient will return for treatment. Conclusions: This is a rare case of multiple epidural cysts that caused acute compression with sudden onset of pain, weakness, sensory loss, and reflex changes that cleared with nonsteroidal anti-inflammatory drugs.
Poster 317 Variant for Transforaminal Injection: Retrodiskal Approach for Paracentral Disk Herniation Case Series. Sebastian Tobon, MD (Jackson Memorial/UM, Miami, FL, United States); Jose Mena, MD, Jose Ramil O. Santos, MD, Andrew L. Sherman, MD. Disclosures: S. Tobon, none. Patients or Programs: A 34-year-old man, 42-year-old woman, 45-year-old woman, 52-year-old man, 47-year-old man, and 58year-old woman. Program Description: This case series reports on 6 patients who presented with radicular pain symptoms. Initial medical-rehabilitative treatment failed to alleviate their symptoms. In all cases, magnetic resonance Imaging revealed a unilateral lumbar paracentral disk herniation that caused ipsilateral radicular symptoms consistent with the level the herniation. All the patients then underwent a single ipsilateral retrodiskal transforaminal epidural steroid injection. Setting: Academic medical center outpatient interdisciplinary spine center. Results: No patient had immediate complications. During their 2-week follow-up appointments, all patients reported marked improvement in their symptomatology that continued at their 6-week follow-up. Discussion: The retrodiskal approach was used in this series of 6 patients as an alternative to the 2 classic approaches of performing epidural steroid injections. The retrodiskal approach consists of approaching the site of pathology as one would for a diskogram in the inferior aspect of the neural foramen. The anterior advancement of the needle is monitored by fluoroscopy in multiple planes so as to not puncture the annulus. This approach has been reported only sporadically in the literature but has been found to be safe in all cases. An advantage of this approach is fewer intravascular injections and bringing the medication even closer to the site of the herniation. Conclusions: In these cases of paracentral disk herniation and retrodiskal transforaminal epidural injection, the technique proved a safe and effective technique to deliver medication closer to the site of pathology. Future studies that compare the 2 traditional injection techniques with the retrodiskal approach should be considered.
Poster 318 Transient Neuropathic Pain After the Insertion of Spinal Cord Stimulator Leads: A Case Report. Jason D. Berk, MD (Thomas Jefferson University Hospital, Philadelphia, PA, United States); Linqiu Zhou, MD. Disclosures: J. D. Berk, none. Patients or Programs: Four patients who experienced new
PM&R
neuropathic pain in a lower extremity immediately after spinal cord stimulator (SCS) lead insertion. Program Description: A retrospective chart review from May 2005 to May 2010 was conducted and identified: 165 patients having undergone a total of 285 SCS procedures (trial, 160; implantation, 125). Four of these patients were noted to have experienced new pain in their lower extremity immediately after lead insertions. Each of them underwent lumbar SCS lead insertion; 2 after trial, 1 after implantation, and 1 after both trial and implantation. Their symptoms were pain localized to a small area of 1 lower extremity: 3 at the dorsum of the first metatarsophalangeal joint, 1 at the median knee, and 1 localized to the dorsal foot. A thorough clinical examination was notable for heightened sensitivity to light touch and pinprick (allodynia) at the painful area, but no sensory or motor deficits were noted. All 4 patients were treated with oral steroids for 7 days (Medrol Dosepack taper) and followed closely until symptom resolution. Setting: Private practice outpatient clinic. Results: Within 5 to 10 days of oral steroid treatment, all the patients experienced complete resolution of this pain symptomology without residual neurologic complications. None of the patients required removal of their SCS leads secondary to this pain issue. Discussion: Transient neuropathic pain after SCS lead insertion is an uncommon complication. Based on data collected, the incidence is 1.40% (4/285). The clinical presentation is focal pain and allodynia without other neurologic deficits. The etiology of these symptoms is unclear, however, irritation to a single or small group of nerve fibers caused by the spinal needle or SCS lead insertion may provide an explanation. Conclusions: Spinal cord stimulation therapy has been adopted as a standard modality for neuropathic pain. Although the development of new neuropathic pain symptoms is an uncommon complication of this procedure, it can be transient if well managed with oral steroids, patient reassurance, and close follow-up.
Poster 319 Retrospective Prevalence of Myofascial Tender and Trigger Points in Patients Presenting With Cervicothoracic and Lumbosacral Spine–related Pain. Akshay Garg (The George Washington University School of Medicine and Health Sciences, Washington, DC, United States); Mehul Desai, Puneet Sayal. Disclosures: A. Garg, none. Objective: To retrospectively report the prevalence of tender points and trigger points at The George Washington University Spine and Pain Center in patients presenting with cervicothoracic and lumbosacral spine pain, differentiating each based on referral patterns. To organize the data according to specific diagnoses and correlate the specific innervations of the associated tender point and trigger point muscles. Design: Retrospective. Setting: Tertiary spine and pain center. Participants: 11 subjects with cervicothoracic spine–related pain, and 13 subjects with lumbosacral spine–related pain. Interventions: We tested for the presence or absence of cervical and/or lumbar tender and/or trigger points and the minimum pain pressure threshold reading of those points by using a digital algometer.
Vol. 3, Iss. 10S1, 2011
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Main Outcome Measures: The presence or absence of tender and trigger points, minimum pain pressure threshold. Results: Of patients with cervical spine–related pain, 82% were found to have tender and/or trigger points in specific muscles. Patients with lesions in C3-C4 presented more commonly with both tender and trigger points located in the middle trapezius; C5-C6 lesions with tender points in biceps brachii, brachioradialis, pectoralis major; C5-C6 lesions with trigger points in pectoralis major; and C6-C7 lesions with tender points in latissimus dorsi and triceps brachii. Of patients with lumbar spine–related pain, 62% were found to have tender and/or trigger points in specific muscles. Patients with lesions in L2-L3 and L3-L4 presented more commonly with both tender and trigger points located in adductor longus; and L5-S1 lesions with both tender and trigger points in tibialis anterior, soleus, and biceps femoris. The majority of diagnoses made in these patients with cervical and lumbar spine pain included spondylosis, disk bulging, and spinal stenosis. No adverse effects were noted from pressure algometer usage. Conclusions: Tender and trigger points appear more likely to occur in specific muscles in the presence of spinal pathology.
Poster 320 Efficacy of an Interdisciplinary Pain Management Program: Patient Perception. James Huang, MD (Northwestern, Chicago, IL, United States); Sara D. Barrett, PhD, Christine M. Gagnon, PhD, Steven P. Stanos, DO. Disclosures: J. Huang, none. Objective: To assess patients’ perception of change beyond traditional functional restoration program goals of improved function and decreased pain by using a new questionnaire that consisted of additional patient-centered outcomes. Design: Retrospective chart review. Setting: Academic pain center. Participants: Sixty-six consecutive chronic pain patients participating in a pain management program. Interventions: Patients with intractable chronic pain were assessed by a physician, psychologist, and a vocational counselor (if worker’s compensation related). The patients participated in either an intensive (5 days per week, for up to 4 weeks) or a modified (1-2 half days per week for up to 5 weeks) outpatient program, depending upon identified needs during the initial assessment. Treatment programs included individual and group appointments with pain psychology, physical, and occupational therapy, biofeedback and/or relaxation training, and medical management. The patients also participated in group nursing lectures, vocational lectures, and movement-based classes, including Feldenkrais. Main Outcome Measures: Adaptation to the Patient’s Global Impression of Change. Domains assessed included the following: overall status, overall pain, overall sleep, overall mood, overall physical functioning, overall ability to cope with pain, overall ability to manage pain flare-ups, and the overall efficacy of medication. Each domain could be rated from 1 (very much improved) to 7 (very much worse). Results: Mean ratings showed that patients considered the program effective. Domains perceived to be most improved were “overall status” and “overall ability to cope with pain” (M⫽1.91, SD⫽0.89; M⫽1.95, SD⫽0.94, respectively). Domains perceived as
and 0.8 mcg/dL, respectively), and a positive synthetic urine corticoid screen for triamcinolone acetonide (1.1 mcg/dL) several weeks after the final injection. Setting: Outpatient sports and spine clinic. Results: The patient was diagnosed with iatrogenic Cushing syndrome 7 months after initial symptom presentation. She discontinued use of ritonavir for 2 weeks and was treated with an extended hydrocortisone taper. Over the course of several months, she had marked improvement in facial fullness, became euglycemic, and her adrenal function normalized. Discussion: In patients infected with HIV, ritonavir is frequently used to enhance plasma concentrations of coadministered protease inhibitors. Although this has translated into improved virologic outcomes, there have been a growing number of reports over the last decade that suggest the need for increased surveillance when administering medications that share this common metabolic pathway. Steroids are particularly problematic because of similarities between the symptoms of iatrogenic Cushing and the more prevalent antiretroviral-associated lipodystrophy, which can lead to a delayed diagnosis with severe manifestations. Conclusions: Physicians performing epidural steroid injection should be aware of potential drug interactions to avoid important adverse effects in patients who receive epidural corticosteroids.
Poster 316 Multiple Epidural Cysts: A Case Report. Jane Wang, MD (Napa Pain Institute, Napa, CA, United States); Lizu Xiao, MD, Harvey Yee, MD. Disclosures: J. Wang, none. Patients or Programs: The patient is a 36-year-old woman with sudden onset of lower extremities weakness. Program Description: The patient, with no significant history of back pain, presented with sudden onset of back pain and weakness of both lower extremities on awakening. In less than 4 hours, she was unable to walk. Pain was localized, aggravated by Valsalva maneuvers and forward flexion. By evening, she began to feel numbness of the left great toe. There were no bowel or bladder symptoms. No history of trauma or infection. On examination, the patient was supine, unable to sit up or roll side to side, more because of weakness rather than pain. There was tenderness to palpation in the lumbosacral region. There was a small hyperpigmented area in the midline of the back, of which the patient had no knowledge. Proximally, hip flexors were 2/5, knee extensors were 3/5, ankle dorsiflexor on the right was 4/5, on the left was 5/5, and plantar flexors were 5/5. Sensory examination showed decreased pinprick in the left L5 distribution with hesitancy on joint sense. The right ankle reflex was unobtainable, whereas the left was 1⫹. The Faber test caused pain in the back. Straight leg raising test was negative. Magnetic resonance imaging showed multiple cysts in the sacral cavity, computed tomographic myelogram showed communicating cysts on the right, with no filling in the cysts on the left. Setting: Inpatient pain department. Results: She was started on diclofenac sodium intravenous 16 mg for 5 days, with improvements, so that by day 10 she had normal gait with full range of motion of the lumbosacral area and intact sensation in both lower extremities. Prophylactic removal of cysts by minimally invasive techniques was offered, but the patient declined because she thought that she was back to normal. Discussion: Review of the literature showed that epidural cysts
PRESENTATIONS
are surgically removed. This is the first case, to our knowledge, in which the compression effects of epidural cysts resolved with nonsteroidal anti-inflammatory drugs and rest. We anticipate that there will be a recurrence, and the patient will return for treatment. Conclusions: This is a rare case of multiple epidural cysts that caused acute compression with sudden onset of pain, weakness, sensory loss, and reflex changes that cleared with nonsteroidal anti-inflammatory drugs.
Poster 317 Variant for Transforaminal Injection: Retrodiskal Approach for Paracentral Disk Herniation Case Series. Sebastian Tobon, MD (Jackson Memorial/UM, Miami, FL, United States); Jose Mena, MD, Jose Ramil O. Santos, MD, Andrew L. Sherman, MD. Disclosures: S. Tobon, none. Patients or Programs: A 34-year-old man, 42-year-old woman, 45-year-old woman, 52-year-old man, 47-year-old man, and 58year-old woman. Program Description: This case series reports on 6 patients who presented with radicular pain symptoms. Initial medical-rehabilitative treatment failed to alleviate their symptoms. In all cases, magnetic resonance Imaging revealed a unilateral lumbar paracentral disk herniation that caused ipsilateral radicular symptoms consistent with the level the herniation. All the patients then underwent a single ipsilateral retrodiskal transforaminal epidural steroid injection. Setting: Academic medical center outpatient interdisciplinary spine center. Results: No patient had immediate complications. During their 2-week follow-up appointments, all patients reported marked improvement in their symptomatology that continued at their 6-week follow-up. Discussion: The retrodiskal approach was used in this series of 6 patients as an alternative to the 2 classic approaches of performing epidural steroid injections. The retrodiskal approach consists of approaching the site of pathology as one would for a diskogram in the inferior aspect of the neural foramen. The anterior advancement of the needle is monitored by fluoroscopy in multiple planes so as to not puncture the annulus. This approach has been reported only sporadically in the literature but has been found to be safe in all cases. An advantage of this approach is fewer intravascular injections and bringing the medication even closer to the site of the herniation. Conclusions: In these cases of paracentral disk herniation and retrodiskal transforaminal epidural injection, the technique proved a safe and effective technique to deliver medication closer to the site of pathology. Future studies that compare the 2 traditional injection techniques with the retrodiskal approach should be considered.
Poster 318 Transient Neuropathic Pain After the Insertion of Spinal Cord Stimulator Leads: A Case Report. Jason D. Berk, MD (Thomas Jefferson University Hospital, Philadelphia, PA, United States); Linqiu Zhou, MD. Disclosures: J. D. Berk, none. Patients or Programs: Four patients who experienced new
PM&R
neuropathic pain in a lower extremity immediately after spinal cord stimulator (SCS) lead insertion. Program Description: A retrospective chart review from May 2005 to May 2010 was conducted and identified: 165 patients having undergone a total of 285 SCS procedures (trial, 160; implantation, 125). Four of these patients were noted to have experienced new pain in their lower extremity immediately after lead insertions. Each of them underwent lumbar SCS lead insertion; 2 after trial, 1 after implantation, and 1 after both trial and implantation. Their symptoms were pain localized to a small area of 1 lower extremity: 3 at the dorsum of the first metatarsophalangeal joint, 1 at the median knee, and 1 localized to the dorsal foot. A thorough clinical examination was notable for heightened sensitivity to light touch and pinprick (allodynia) at the painful area, but no sensory or motor deficits were noted. All 4 patients were treated with oral steroids for 7 days (Medrol Dosepack taper) and followed closely until symptom resolution. Setting: Private practice outpatient clinic. Results: Within 5 to 10 days of oral steroid treatment, all the patients experienced complete resolution of this pain symptomology without residual neurologic complications. None of the patients required removal of their SCS leads secondary to this pain issue. Discussion: Transient neuropathic pain after SCS lead insertion is an uncommon complication. Based on data collected, the incidence is 1.40% (4/285). The clinical presentation is focal pain and allodynia without other neurologic deficits. The etiology of these symptoms is unclear, however, irritation to a single or small group of nerve fibers caused by the spinal needle or SCS lead insertion may provide an explanation. Conclusions: Spinal cord stimulation therapy has been adopted as a standard modality for neuropathic pain. Although the development of new neuropathic pain symptoms is an uncommon complication of this procedure, it can be transient if well managed with oral steroids, patient reassurance, and close follow-up.
Poster 319 Retrospective Prevalence of Myofascial Tender and Trigger Points in Patients Presenting With Cervicothoracic and Lumbosacral Spine–related Pain. Akshay Garg (The George Washington University School of Medicine and Health Sciences, Washington, DC, United States); Mehul Desai, Puneet Sayal. Disclosures: A. Garg, none. Objective: To retrospectively report the prevalence of tender points and trigger points at The George Washington University Spine and Pain Center in patients presenting with cervicothoracic and lumbosacral spine pain, differentiating each based on referral patterns. To organize the data according to specific diagnoses and correlate the specific innervations of the associated tender point and trigger point muscles. Design: Retrospective. Setting: Tertiary spine and pain center. Participants: 11 subjects with cervicothoracic spine–related pain, and 13 subjects with lumbosacral spine–related pain. Interventions: We tested for the presence or absence of cervical and/or lumbar tender and/or trigger points and the minimum pain pressure threshold reading of those points by using a digital algometer.
Vol. 3, Iss. 10S1, 2011
S283
Main Outcome Measures: The presence or absence of tender and trigger points, minimum pain pressure threshold. Results: Of patients with cervical spine–related pain, 82% were found to have tender and/or trigger points in specific muscles. Patients with lesions in C3-C4 presented more commonly with both tender and trigger points located in the middle trapezius; C5-C6 lesions with tender points in biceps brachii, brachioradialis, pectoralis major; C5-C6 lesions with trigger points in pectoralis major; and C6-C7 lesions with tender points in latissimus dorsi and triceps brachii. Of patients with lumbar spine–related pain, 62% were found to have tender and/or trigger points in specific muscles. Patients with lesions in L2-L3 and L3-L4 presented more commonly with both tender and trigger points located in adductor longus; and L5-S1 lesions with both tender and trigger points in tibialis anterior, soleus, and biceps femoris. The majority of diagnoses made in these patients with cervical and lumbar spine pain included spondylosis, disk bulging, and spinal stenosis. No adverse effects were noted from pressure algometer usage. Conclusions: Tender and trigger points appear more likely to occur in specific muscles in the presence of spinal pathology.
Poster 320 Efficacy of an Interdisciplinary Pain Management Program: Patient Perception. James Huang, MD (Northwestern, Chicago, IL, United States); Sara D. Barrett, PhD, Christine M. Gagnon, PhD, Steven P. Stanos, DO. Disclosures: J. Huang, none. Objective: To assess patients’ perception of change beyond traditional functional restoration program goals of improved function and decreased pain by using a new questionnaire that consisted of additional patient-centered outcomes. Design: Retrospective chart review. Setting: Academic pain center. Participants: Sixty-six consecutive chronic pain patients participating in a pain management program. Interventions: Patients with intractable chronic pain were assessed by a physician, psychologist, and a vocational counselor (if worker’s compensation related). The patients participated in either an intensive (5 days per week, for up to 4 weeks) or a modified (1-2 half days per week for up to 5 weeks) outpatient program, depending upon identified needs during the initial assessment. Treatment programs included individual and group appointments with pain psychology, physical, and occupational therapy, biofeedback and/or relaxation training, and medical management. The patients also participated in group nursing lectures, vocational lectures, and movement-based classes, including Feldenkrais. Main Outcome Measures: Adaptation to the Patient’s Global Impression of Change. Domains assessed included the following: overall status, overall pain, overall sleep, overall mood, overall physical functioning, overall ability to cope with pain, overall ability to manage pain flare-ups, and the overall efficacy of medication. Each domain could be rated from 1 (very much improved) to 7 (very much worse). Results: Mean ratings showed that patients considered the program effective. Domains perceived to be most improved were “overall status” and “overall ability to cope with pain” (M⫽1.91, SD⫽0.89; M⫽1.95, SD⫽0.94, respectively). Domains perceived as