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Poster 412: Spinal Cord Compression following Radiofrequency Tumor Ablation and Vertebral Augmentation in a Multiple Myeloma Patient: A Case Report
Abstracts / PM R 9 (2017) S131-S290 in diagnostic difficulty and delays. Delays are often associated with high morbidity and mortality in these patients. Conclusions: It is crucial to maintain a high index of suspicion for infectious etiologies and utilize a combination of laboratory and imaging studies when working up back pain. Level of Evidence: Level V Poster 411: Two-Step Approach with Onabotulinum Toxin Type A Intradermal & Intramuscular Infiltrations for T8-T12 Chronic Post Herpetic Neuralgia: A Case Report Jean C. Gallardo, MD (VA Caribbean Healthcare System, San Juan, Puerto Rico, Puerto Rico), Melissa A. Burgos, MD, Keryl MottaValencia, MD Disclosures: Jean Gallardo: I Have No Relevant Financial Relationships To Disclose Case/Program Description: Male patient with past medical history of herpes zoster who presented to our clinics with complaint of a 6-year course of right sided abdominal wall and flank pain. Pain was described as severe, aching and burning quality associated with bloating/fullness sensation. Patient’s symptoms were refractory to multiple pain management treatment modalities. Initial physical examination was remarkable for allodynia and hyperpathia in right T8T12 dermatomes, consistent with post herpetic neuralgia (PHN). Patient was scheduled for Onabotulinum toxin type A injections which were reconstituted with preservative free saline solution to a concentration of 100Units/1mL. Patient recieved sequential infiltrations with Onabotulinum toxin type A. Initial procedure consisted of intradermal Onabotulinumtoxin type A infiltration at symptomatic anterior right T8-T12 dermatomes of the abdominal wall and flank. After initial procedure patient reported a decrement of pain intensity and neuropathic qualities. A second infiltration was scheduled with a variation consisting of a two-step method with intradermal infiltration of Onabotulinumtoxin type A at affected dermatomes anteriorly and posteriorly at parecentral lines, using electromyography guidance. After second procedure patient presented full resolution of pain, dysesthesias and hyperpathia. Setting: Outpatient Clinic in a VA Hospital. Results: Onabotulinumtoxin type A infiltration, with the described two-step approach method, lead to satisfactory and sustained relief of a severe and refractory post herpetic neuralgia involving the T8-T12 dermatomes with normalization of skin sensation as well. Discussion: To our knowledge, this is a unique case describing a twostep method for combined intramuscular and intradermal infiltration of Onabotulinumtoxin type A showing positive results for treatment of PHN. Conclusions: Chronic post-herpetic neuralgia can be characterized by severe pain, refractory to conventional treatments. A two-step approach for intradermal and intramuscular application of Onabotulinumtoxin type A should be considered among treatment options. Level of Evidence: Level V Poster 412: Spinal Cord Compression following Radiofrequency Tumor Ablation and Vertebral Augmentation in a Multiple Myeloma Patient: A Case Report Thomas Chai, MD (UT MD Anderson Cancer Center, Houston, TX, United States), Girish S. Shroff, MD, Billy K. Huh, MD, PhD Disclosures: Thomas Chai: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 65-year-old man with history of multiple myeloma presented with back pain. Imaging revealed multiple
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vertebral lesions, including involvement of the T5 vertebral body, with associated pathologic compression fracture. Despite radiation therapy to the spine and opioid/adjuvant use, the patient’s severe back pain persisted. Follow-up spine imaging revealed progression of the T5 fracture. Due to unremitting pain, radiofrequency tumor ablation of T5 followed by vertebral augmentation was offered. The patient underwent T5 vertebral body radiofrequency tumor ablation at 50 degrees Celsius. 3.5 mL of polymethylmethacrylate cement was then injected into the vertebral body cavity created by the radiofrequency lesioning. There were no immediate postprocedural complications noted, and the patient was discharged home neurologically intact and in stable condition. Setting: Tertiary care hospital. Results: The patient responded well to the pain procedure; however, 4 days later he reported leg weakness and falls. Repeat spinal imaging revealed further collapse of the T5 vertebral body, with both bone and cement retropulsion into the canal, resulting in ventral effacement of the spinal cord. Given these findings, the patient underwent urgent decompressive spinal surgery, followed by admission to the rehabilitation unit. Discussion: Multiple myeloma is a hematologic cancer of plasma cells in the bone marrow. This disease can cause damage to bone, kidneys, and the immune system, among other manifestations. Bone pain is common in patients with multiple myeloma, with 70% reporting this symptom at disease onset. Pathologic bone fractures occur in about 40% of myeloma patients, with around 55-70% of fractures involving vertebrae. Epidural involvement may occur in up to 20% of myeloma patients at various disease stages. This may lead to cord compression if tumor/bone fragments progressively invade the spinal canal. Conclusions: The risks and benefits of spine interventions for pain must be carefully considered in the cancer patient with pathologic vertebral compression fractures. Level of Evidence: Level V Poster 413: Giving Back Independence and the Ability to Walk: A Spinal Meningioma Mimicking Diabetic Amyotrophy: A Case Report Ryan Thompson, DO (Ohio State Univ Med Cntr, Columbus, Ohio, United States), Laura Gruber, MD, Elizabeth P. Probert, MD, Jennifer Mast, MD, Sam Colachis III, MD Disclosures: Ryan Thompson: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 42-year-old man with history of DM (Type1) presented with a 5-year history of progressive weakness, paresthesias, and neuropathic pain. During this period of time, he experienced gradual worsening upper and lower extremity paresis, paresthesia, and radicular pain. He had recurrent falls resulting in multiple Emergency Department encounters. Evaluation in the past included neurologic and electrodiagnostic evaluations consistent with diabetic amyotrophy. His neurologic status and function continued to worsen until he was non-ambulatory and required assistance for his mobility and daily care for the past year. During a recent admission for a fall resulting in multiple rib fractures, a cervical and thoracic MRI were performed which demonstrated a Grade I cervicothoracic meningioma (C6-T1). He underwent subsequent resection of the meningioma followed by inpatient spinal cord injury rehabilitation. During his rehabilitation hospitalization, he showed remarkable improvement in neurologic and functional status, and by discharge home was independent in his activities of daily living (ADLs), and ambulation. Setting: Inpatient Rehabilitation Hospital. Results: .
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vertebral lesions, including involvement of the T5 vertebral body, with associated pathologic compression fracture. Despite radiation therapy to the spine and opioid/adjuvant use, the patient’s severe back pain persisted. Follow-up spine imaging revealed progression of the T5 fracture. Due to unremitting pain, radiofrequency tumor ablation of T5 followed by vertebral augmentation was offered. The patient underwent T5 vertebral body radiofrequency tumor ablation at 50 degrees Celsius. 3.5 mL of polymethylmethacrylate cement was then injected into the vertebral body cavity created by the radiofrequency lesioning. There were no immediate postprocedural complications noted, and the patient was discharged home neurologically intact and in stable condition. Setting: Tertiary care hospital. Results: The patient responded well to the pain procedure; however, 4 days later he reported leg weakness and falls. Repeat spinal imaging revealed further collapse of the T5 vertebral body, with both bone and cement retropulsion into the canal, resulting in ventral effacement of the spinal cord. Given these findings, the patient underwent urgent decompressive spinal surgery, followed by admission to the rehabilitation unit. Discussion: Multiple myeloma is a hematologic cancer of plasma cells in the bone marrow. This disease can cause damage to bone, kidneys, and the immune system, among other manifestations. Bone pain is common in patients with multiple myeloma, with 70% reporting this symptom at disease onset. Pathologic bone fractures occur in about 40% of myeloma patients, with around 55-70% of fractures involving vertebrae. Epidural involvement may occur in up to 20% of myeloma patients at various disease stages. This may lead to cord compression if tumor/bone fragments progressively invade the spinal canal. Conclusions: The risks and benefits of spine interventions for pain must be carefully considered in the cancer patient with pathologic vertebral compression fractures. Level of Evidence: Level V Poster 413: Giving Back Independence and the Ability to Walk: A Spinal Meningioma Mimicking Diabetic Amyotrophy: A Case Report Ryan Thompson, DO (Ohio State Univ Med Cntr, Columbus, Ohio, United States), Laura Gruber, MD, Elizabeth P. Probert, MD, Jennifer Mast, MD, Sam Colachis III, MD Disclosures: Ryan Thompson: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 42-year-old man with history of DM (Type1) presented with a 5-year history of progressive weakness, paresthesias, and neuropathic pain. During this period of time, he experienced gradual worsening upper and lower extremity paresis, paresthesia, and radicular pain. He had recurrent falls resulting in multiple Emergency Department encounters. Evaluation in the past included neurologic and electrodiagnostic evaluations consistent with diabetic amyotrophy. His neurologic status and function continued to worsen until he was non-ambulatory and required assistance for his mobility and daily care for the past year. During a recent admission for a fall resulting in multiple rib fractures, a cervical and thoracic MRI were performed which demonstrated a Grade I cervicothoracic meningioma (C6-T1). He underwent subsequent resection of the meningioma followed by inpatient spinal cord injury rehabilitation. During his rehabilitation hospitalization, he showed remarkable improvement in neurologic and functional status, and by discharge home was independent in his activities of daily living (ADLs), and ambulation. Setting: Inpatient Rehabilitation Hospital. Results: .