Poster 437 Pain in Spinal Cord Injury - An Unusual Presentation of Complex Regional Pain Syndrome: A Case Report

Abstracts / PM R 8 (2016) S151-S332 Setting: Tertiary Care Hospital. Results: Clinical examination was consistent with anterior cord syndrome. The presence of hypotension and abrupt presentation were suggestive of a hypotensive etiology. Given the mid-thoracic localization and sparing of the posterior spinal column we surmised he experienced spinal cord infarction resulting from hypoperfusion of the artery of Adamkiewicz. A non-contrast CT scan was unrevealing. He could not undergo MR imaging for confirmation of acute ischemia due to a non-compatible pacemaker. Discussion: Anterior cord syndrome following hemodialysis is an extremely rare yet devastating complication. The anterior spinal artery supplies blood to the anterior two-thirds of the spinal cord. The artery receives its blood supply from segmental radicular arteries supplied from multiple sources depending on cervical, thoracic or lumbar location. The artery of Ademkiewicz can vary in its extension from midthoracic to lumbar levels and generally supplies the majority of blood flow to the thoracic and lumbar cord segments. Injury, thrombosis, embolism or occlusion of this artery can result in spinal cord ischemia. We report an unusual presentation of spinal cord ischemia resulting from profound systemic hypotension during hemodialysis. Conclusions: Clinicians should be aware of patients with a history of compromised vasculature and should be mindful of iatrogenic interventions that could lead to hypotension, compromising the blood flow to the spinal cord. Level of Evidence: Level V Poster 436 Hard to Swallow. Dysphagia Secondary to Cervical Spine Osteophytes: A Case Series Andrea Cordova, MD (Montefiore Medical Center, Riverdale, NY, United States), Sikha Guha, MD, Grigory Syrkin, MD, Nrupen Baxi, MD Disclosures: Andrea Cordova: I Have No Relevant Financial Relationships To Disclose Case/Program Description: Case 1. 70-year-old man presenting with difficulty swallowing for 5 months of with associated 20-pound weight loss over 5 weeks. Imaging disclosed extensive anterior cervical osteophytes obstructing the posterior aspect of the airway and upper esophagus. Barium swallow showed moderate oropharyngeal dysmotility with deep laryngeal penetration. Flexible endoscopy was unremarkable. Case 2. 71 year-old woman referred with 1-year history of neck pain, hand numbness, gait imbalance and progressive dysphagia. Imaging revealed anterior cervical osteophytes from C3-C6 causing anterior tracheo-esophageal deviation, along with canal and neuroforaminal stenosis due to other degenerative changes. Flexible laryngoscopy showed trace posterior wall fullness. Case 3. 73-year-old man admitted with a 2-month history of worsening dysphagia and 25pound weight loss. Imaging revealed a prominent anterior osteophyte at C3-C4, deviating the aero-digestive tract. Flexible endoscopy revealed posterior wall compression likely secondary to prominent osteophytes. Setting: Tertiary Care Hospital. Results: The first and second cases underwent surgical decompression and experienced immediate postoperative resolution of dysphagia. The third case was treated conservatively with modified diet. Discussion: Dysphagia caused by mechanical compression by anterior cervical osteophytes in the setting of spondylosis is a rare event. Symptoms can occur secondary to obstruction of the esophagus or hypopharynx by the osteophytes themselves, or by tissue edema due to inflammation and friction between the structures. Conclusions: Anterior cervical osteophytosis should be included among the differential diagnosis of dysphagia in adult patients. The relationship between dysphagia and cervical osteophytic disease is difficult to diagnose and treat. Patients should undergo thorough diagnostic workup to establish positive and differential diagnosis.

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Those with mild symptoms can be managed conservatively with dietary measures or oral agents such as steroids or muscle relaxants. Adequate surgical compression can reestablish normal function of the esophagus if symptoms are severe or if conservative measures fail. Level of Evidence: Level V Poster 437 Pain in Spinal Cord Injury - An Unusual Presentation of Complex Regional Pain Syndrome: A Case Report Siddarth Thakur, MD (Baylor College of Medicine, Houston, TX, United States), Benjamin Garmezy, MD, Cole R. Linville, DO, MBA, Thomas Chai, MD, Lisa Wenzel, MD Disclosures: Siddarth Thakur: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 49-year-old man sustained a traumatic cervical spinal cord injury (SCI) after a tree branch fell on him. The accident resulted in C3-C7 vertebral fractures and complete tetraparesis (C4 AIS A). He was treated with anterior cervical diskectomy and fusion of C3-5 and subsequently transferred to an acute rehabilitation hospital. Setting: Inpatient rehabilitation hospital. Results: During rehabilitation, he suffered severe, refractory right neck pain and increased muscle spasms. Massage, oral and transdermal medication provided inadequate pain relief. On exam, he had allodynia of the neck and right hand with associated edema, and increased temperature in the right arm. Lab work-up revealed elevated CRP and ESR. A three-phase bone scan ordered for evaluation of heterotopic ossification showed increased radiotracer activity, diffuse uptake at right hand and wrist, periarticular accentuation of small in an asymmetric pattern (changes absent on left hand and wrist), suggestive of Complex Regional Pain Syndrome (CRPS). The patient received a fluoroscopically guided right stellate ganglion block. The same day, the patient’s pain had completely resolved. Discussion: CRPS is a progressive disease of the sympathetic nervous system that leads to pain out of proportion to the original injury. According to the Budapest Criteria, a diagnosis of CRPS II requires a major nerve injury, continued disproportionate pain, and at least one symptom in the following categories: sensory, vasomotor, sudomotor/edema, motor/trophic. This case is atypical presentation e as the patient had allodynia, edema, and temperature change, neck pain and increased spasticity after spinal cord injury. The findings in his hand were subtle, consistent with CRPS II, and could be easily missed. Stellate ganglion block previously has been reported as a successful treatment for CRPS in patients with traumatic myelopathy. Conclusions: Physicians should consider CRPS in tetraplegic patients that have otherwise-unexplained pain and spasms. It is important to consider a pathological focus within an insensate region. Level of Evidence: Level V Poster 438 Bamboo Cervical Spine and Neck Pain in a Patient with AA Amyloidosis: A Case Report Annie R. Layno-Moses, MD (Schwab Rehab Hospital, Chicago, IL, United States), Tariq Malik, MD, Joshua J. Minori, DO Disclosures: Annie Layno-Moses: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 55-year-old man with history of ankylosing spondylitis on adalimumab with thoracic to lumbar fusion, AA amyloidosis status post renal transplant in 1980s on tacrolimus and mycophenolate mofetil who presents with 7-year history of cervical pain. Patient complains of moderate constant aching cervical pain,