- Email: [email protected]
Poster 441 Rare Occlusion of a Baclofen Pump Catheter Due to Rotation of Pump in the Abdominal Pocket: A Case Report
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Abstracts / PM R 8 (2016) S151-S332
worse with cold, alleviated by Tylenol #3 and by adalimumab started years ago, associated with decreased range of motion of neck and bilateral shoulder pain. He denies paresthesias, weakness, or pain radiating down his arms. He is taking cyclobenzaprine at night that helps his sleep, but he is unsure if it helps his pain. He denies trying physical therapy and neck injections. Setting: Outpatient Clinic. Results: Physical exam reveals extremely limited neck flexion, extension, and rotation up to 15 in each direction with almost no lateral bending, and notable kyphosis with limited lumbar flexion to 40 . He has mild tenderness across the superior portion of his trapezius muscle. Cervical xray demonstrates confluent ossification and fusion of the anterior and posterior elements of cervical spine consistent with history of ankylosing spondylitis with no fracture. Discussion: Due to musculoskeletal tenderness, and we performed trigger point injections to the right trapezius muscle. We recommended strengthening exercises for trapezius muscle and range of motion exercises for shoulders. Review of the literature revealed limited studies regarding cervical pain in the ankylosing spondylitic patient without a spinal fracture. One study suggests that therapy with physical exercise and relaxation can benefit the spondyloarthritic patients, but this study does not focus on neck pain. Conclusions: This is a unique case illustrating ossification of the cervical spine without fracture causing neck pain in a patient with AA amyloidosis. Although there is a multitude of literature studying cervical fractures causing neck pain in these patients, there are limited studies focusing on treatment of non-fracture related cervical pain in this patient population. Level of Evidence: Level V Poster 439 Oral Baclofen for the Treatment of Myalgia-Type Pain in the Setting of Dermatomyositis: A Case Report Mark A. DeFord, MD (Medical College of Wisconsin, Milwaukee, Wisconsin, United States), Peter Connelly, MD Disclosures: Mark DeFord: I Have No Relevant Financial Relationships To Disclose Case/Program Description: Patient is a 49-year-old man with longstanding dermatomyositis, non-ischemic cardiomyopathy, and chronic pain. At initial consultation the patient’s primary pain complaint was unremitting aching of the proximal quadriceps muscles. Prior to consultation the patient was discontinued from high-dose opioid therapy, up to 240 morphine equivalents daily, for chronic pain symptoms. At the time of consultation these symptoms were diagnosed as myalgia-type pain secondary to an inflammatory muscle condition previously diagnosed as dermatomyositis. After extensive discussion of opioid alternatives for pain control, the patient was started on oral baclofen 10mg three times a day with the goal of relieving myalgia-type pain. Setting: Tertiary Care Hospital. Results: At three-month follow-up, myalgia-type quadriceps pain was approximately 60% improved. Baclofen was subsequently titrated to 20mg three times a day. At 6-month follow-up, myalgia-type quadriceps pain was approximately 85% improved. As oral baclofen therapy was well tolerated without noticeable side effects, the patient was continued on baclofen 20mg three times a day. The patient was counseled to avoid abrupt cessation of baclofen therapy in the future given risk of baclofen withdrawal. Discussion: Proximal myalgia-type pain is known to be an atypical symptom of inflammatory muscle conditions, including dermatomyositis. As our patient’s history illustrates, this pain symptom can be difficult to effectively treat. Given widespread efforts to decrease usage of chronic opioid therapy for non-malignant chronic pain, there is a need for non-opioid treatment alternatives. Our case illustrates
the potential role for oral baclofen as an effective alternative to chronic opioids in the treatment of chronic myalgia-type pain due to inflammatory muscle conditions. Conclusions: Pain and general physiatrists should consider the use of oral baclofen in the treatment plan for myalgia-type pain in the setting of dermatomyositis and other inflammatory muscle diagnoses. Level of Evidence: Level V Poster 440 Changes in Central Sensitization Associated with Peripheral Joint Injection Do Not Predict Long-Term Pain Relief Victoria C. Whitehair, MD (MetroHealth Medical Center, Cleveland, OH, United States), Richard D. Wilson, MD, MS Disclosures: Victoria Whitehair: I Have No Relevant Financial Relationships To Disclose Objective: To compare pressure-pain thresholds (PPTs) before and after a peripheral joint injection to determine if local corticosteroid/ lidocaine injection affects local and diffuse pain sensitivity and to learn whether PPT can predict long-term outcomes. Design: Prospective cohort study. Setting: Ambulatory PM&R clinic at an urban, academic hospital. Participants: 30 subjects with chronic shoulder, hip or knee pain and 30 control subjects without chronic pain. Interventions: Subjects with chronic peripheral joint pain received a corticosteroid/lidocaine intra-articular injection into their painful joint. Control subjects underwent a waiting period only. Main Outcome Measures: Affected and unaffected limb PPTs, subjective pain score. Results: There was a statistically significant within group difference in pre-injection and post-injection PPTs at both the affected (P¼.0014) and unaffected (P¼.04) limbs in chronic pain subjects, but not in either location for the control group. There was a statistically significant between-group difference in the affected limb PPT changes between the pain and control groups (P<.0004), but not in the unaffected limb (P¼.20). There was no correlation between change in PPT and either immediate (P¼.56) or long-term (P¼.34) pain reduction. Conclusions: Corticosteroid/lidocaine injection into a chronic painful joint decreases sensitivity to pain locally and diffusely, confirming a central sensitization component to chronic joint pain. When assessed using PPTs, the reduction in central sensitization associated with peripheral joint injection does not predict long-term pain relief from the injection. Level of Evidence: Level II Poster 441 Rare Occlusion of a Baclofen Pump Catheter Due to Rotation of Pump in the Abdominal Pocket: A Case Report Matthew W. Wilson, MD (Vidant Rehab Center/East Carolina University/Brod, Greenville, North Carolina, United States) Disclosures: Matthew Wilson: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 30-year-old female patient with history of T4 ASIA C spinal cord injury, spasticity, and intrathecal baclofen pump placement presented to clinic after an increase in spasticity. The patient began noticing an increase in spasticity in her lower extremities after her baclofen pump dose was decreased by 10% two months earlier. At presentation, she was having difficulty maintaining correct posture in her powered wheelchair due to the progression of the spasticity. Performing
Abstracts / PM R 8 (2016) S151-S332 hygiene maintenance and bathing became increasingly difficult. The pump was refilled. One week later, her spasticity worsened on physical exam. The access port to the pump could not be palpated and the pump was mobile in the intra-abdominal pocket. Upon transfer from her wheelchair to the exam table, the pump rotated 180 and the access port could be palpated. Only one milliliter of baclofen had been used over the last week, indicating a malfunction of the pump. Neurosurgery was called immediately and the patient was admitted to the hospital for pump replacement. Upon removal of the pump, it was noted that the pump had become detached from the anterior abdominal wall. The catheter had multiple twists and kinks, most likely due to constant free rotation of the pump within the pocket. Setting: Outpatient Clinic at an Academic Medical Center. Results: After the pump was replaced and pump settings were optimized, the patient lower extremity spasticity improved to baseline. She was able to perform activities of daily living. Discussion: This is the first reported case, to our knowledge, of an insidious increase in spasticity from a malfunctioning of the intraabdominal anchoring system. This malfunction led to pump rotation and eventual occlusion of the catheter. Conclusions: Rotational movement of a baclofen pump in the intraabdominal pocket can lead to an insidious presentation of increased spasticity due to catheter occlusion from kinking. Level of Evidence: Level V
Poster 442 Intractable Pelvic Pain Due to Melorheostosis Managed with Spinal Cord Stimulation: A Case Report Thomas Chai, MD (UT MD Anderson Cancer Center, Houston, TX, United States), Girish S. Shroff, MD Disclosures: Thomas Chai: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 34-year-old woman with history of left ischial and acetabular melorheostosis presented with chronic left-sided pelvic pain, only minimally responsive to opioid and non-opioid analgesics, adjuvants, and local injections. The patient therefore was deemed an appropriate candidate for spinal cord stimulator trial. During the trial, she underwent percutaneous placement of an 8-contact lead and a 16-contact lead, both placed in the epidural space just left of anatomic midline, with distal tip reaching the T10 and T9 vertebral level, respectively. During the 6-day trial, the patient reported up to 80% pain relief. She was reportedly able to sit and to walk for longer periods of time and described her quality of life as much improved. Her reliance on oral analgesics decreased as well. Two weeks after the trial, the patient proceeded to permanent spinal cord stimulator implantation. Setting: Tertiary care hospital. Results: On 1-month postoperative follow up visit, the patient reported continued response to the spinal cord stimulator, without any adverse events. Discussion: Melorheostosis is a rare, sclerosing mesenchymal dysplasia associated with significant pain, physical deformity, and functional limitation of the affected body part. It has a characteristic appearance on imaging of hyperostosis often described as “melting candle wax.” Somatic-nociceptive and neuropathic pelvic pain due to this condition was addressed with a stepwise, multimodal approach. Spinal cord stimulation was proposed once the patient’s pain was deemed refractory to more conservative measures. Conclusions: Spinal cord stimulation may be considered for select patients with unremitting pain from dysplastic disease. Level of Evidence: Level V
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Poster 443 Diving Injury Resulting in a Jefferson Fracture, Vertebral Artery Thrombosis and Brown Sequard Syndrome: A Case Report Rafael E. Arias-Berrios, MD (University of Puerto Rico, San Juan, Puerto Rico, United States), Shirley A. Grigg Ortiz, MD, Natalia M. Betances Ramı´rez, MD, Ana M. Ortiz Santiago, BS, Jose´ A. Ba´ez, MD Disclosures: Rafael Arias-Berrios: I Have No Relevant Financial Relationships To Disclose Case/Program Description: Case of a 20-year-old male patient with no past medical history of systemic illness suffered a diving injury with head and cervical trauma. He reported transient generalized weakness followed by tingling sensation in all extremities. Cervical spine magnetic resonance imaging (MRI) showed C1 Jefferson Fracture with underlying cord contusion, edema and right vertebral artery thrombosis. He underwent an open reduction of C1 fracture and posterolateral arthrodesis and instrumentation from Occiput to C3. Subsequent motor strength evaluation showed significant right sided weakness (upper more than lower extremity) with contralateral loss of pain and temperature sensation as well as decreased sensation on soft touch and pin-prick below C4 level on right hemibody. Right Brachial Plexus MRI showed no evidence of nerve injury. Setting: Tertiary Care Trauma Center Hospital and Inpatient Rehabilitation Facility. Results: Patient with Brown Sequard like syndrome. The patient was admitted to an inpatient rehabilitation facility for rehabilitation with a score of 66 on the Functional Independence Measure initial evaluation and discharged after 8 days with a score of 98. Discussion: Brown Sequard Syndrome (BSS) caused by spinal cord hemisection. Clinically, patients present with an ipsilateral motor loss and contralateral loss of sensitivity to pain and temperature below the level of the lesion. Cervical spine trauma due to diving is responsible for 35% of burst fractures among them Jefferson fracture. BSS is a rare event in patients with diving injury. Patients with BSS have the best prognosis for ambulation of the SCI clinical syndromes. The most important predictor of function is lower limb strength. Conclusions: The clinical presentation of a BSS secondary to Jefferson fracture and concomitant vertebral artery thrombosis after a diving injury is rare. Patients have the potential for good recovery with aggressive rehabilitation. We report an unusual presentation of a relatively uncommon condition. Level of Evidence: Level V Poster 444 Bilateral Lower Extremity Numbness and Weakness Caused by Primary Thoracic Spinal Stenosis: A Case Report Katherine Power, MD (Montefiore Medical Center, Bronx, NY, United States), Michelle Stern, MD Disclosures: Katherine Power: I Have No Relevant Financial Relationships To Disclose Case/Program Description: Patient is a 48-year-old woman with history of fibromyalgia and obesity who presented to hospital after a fall at home. She was descending the stairs when her knees suddenly felt weak and legs went numb causing her to fall. She stated 2 months previously she had a similar episode that resulted in right bimalleolar fracture. Ortho casted her and were following her progress. During this time she also had decreased sensation in her right leg which was attributed to radiculopathy. An MRI of lumbar spine was ordered but denied by insurance so she was reassured and recommended to stay active. She was admitted for
Abstracts / PM R 8 (2016) S151-S332
worse with cold, alleviated by Tylenol #3 and by adalimumab started years ago, associated with decreased range of motion of neck and bilateral shoulder pain. He denies paresthesias, weakness, or pain radiating down his arms. He is taking cyclobenzaprine at night that helps his sleep, but he is unsure if it helps his pain. He denies trying physical therapy and neck injections. Setting: Outpatient Clinic. Results: Physical exam reveals extremely limited neck flexion, extension, and rotation up to 15 in each direction with almost no lateral bending, and notable kyphosis with limited lumbar flexion to 40 . He has mild tenderness across the superior portion of his trapezius muscle. Cervical xray demonstrates confluent ossification and fusion of the anterior and posterior elements of cervical spine consistent with history of ankylosing spondylitis with no fracture. Discussion: Due to musculoskeletal tenderness, and we performed trigger point injections to the right trapezius muscle. We recommended strengthening exercises for trapezius muscle and range of motion exercises for shoulders. Review of the literature revealed limited studies regarding cervical pain in the ankylosing spondylitic patient without a spinal fracture. One study suggests that therapy with physical exercise and relaxation can benefit the spondyloarthritic patients, but this study does not focus on neck pain. Conclusions: This is a unique case illustrating ossification of the cervical spine without fracture causing neck pain in a patient with AA amyloidosis. Although there is a multitude of literature studying cervical fractures causing neck pain in these patients, there are limited studies focusing on treatment of non-fracture related cervical pain in this patient population. Level of Evidence: Level V Poster 439 Oral Baclofen for the Treatment of Myalgia-Type Pain in the Setting of Dermatomyositis: A Case Report Mark A. DeFord, MD (Medical College of Wisconsin, Milwaukee, Wisconsin, United States), Peter Connelly, MD Disclosures: Mark DeFord: I Have No Relevant Financial Relationships To Disclose Case/Program Description: Patient is a 49-year-old man with longstanding dermatomyositis, non-ischemic cardiomyopathy, and chronic pain. At initial consultation the patient’s primary pain complaint was unremitting aching of the proximal quadriceps muscles. Prior to consultation the patient was discontinued from high-dose opioid therapy, up to 240 morphine equivalents daily, for chronic pain symptoms. At the time of consultation these symptoms were diagnosed as myalgia-type pain secondary to an inflammatory muscle condition previously diagnosed as dermatomyositis. After extensive discussion of opioid alternatives for pain control, the patient was started on oral baclofen 10mg three times a day with the goal of relieving myalgia-type pain. Setting: Tertiary Care Hospital. Results: At three-month follow-up, myalgia-type quadriceps pain was approximately 60% improved. Baclofen was subsequently titrated to 20mg three times a day. At 6-month follow-up, myalgia-type quadriceps pain was approximately 85% improved. As oral baclofen therapy was well tolerated without noticeable side effects, the patient was continued on baclofen 20mg three times a day. The patient was counseled to avoid abrupt cessation of baclofen therapy in the future given risk of baclofen withdrawal. Discussion: Proximal myalgia-type pain is known to be an atypical symptom of inflammatory muscle conditions, including dermatomyositis. As our patient’s history illustrates, this pain symptom can be difficult to effectively treat. Given widespread efforts to decrease usage of chronic opioid therapy for non-malignant chronic pain, there is a need for non-opioid treatment alternatives. Our case illustrates
the potential role for oral baclofen as an effective alternative to chronic opioids in the treatment of chronic myalgia-type pain due to inflammatory muscle conditions. Conclusions: Pain and general physiatrists should consider the use of oral baclofen in the treatment plan for myalgia-type pain in the setting of dermatomyositis and other inflammatory muscle diagnoses. Level of Evidence: Level V Poster 440 Changes in Central Sensitization Associated with Peripheral Joint Injection Do Not Predict Long-Term Pain Relief Victoria C. Whitehair, MD (MetroHealth Medical Center, Cleveland, OH, United States), Richard D. Wilson, MD, MS Disclosures: Victoria Whitehair: I Have No Relevant Financial Relationships To Disclose Objective: To compare pressure-pain thresholds (PPTs) before and after a peripheral joint injection to determine if local corticosteroid/ lidocaine injection affects local and diffuse pain sensitivity and to learn whether PPT can predict long-term outcomes. Design: Prospective cohort study. Setting: Ambulatory PM&R clinic at an urban, academic hospital. Participants: 30 subjects with chronic shoulder, hip or knee pain and 30 control subjects without chronic pain. Interventions: Subjects with chronic peripheral joint pain received a corticosteroid/lidocaine intra-articular injection into their painful joint. Control subjects underwent a waiting period only. Main Outcome Measures: Affected and unaffected limb PPTs, subjective pain score. Results: There was a statistically significant within group difference in pre-injection and post-injection PPTs at both the affected (P¼.0014) and unaffected (P¼.04) limbs in chronic pain subjects, but not in either location for the control group. There was a statistically significant between-group difference in the affected limb PPT changes between the pain and control groups (P<.0004), but not in the unaffected limb (P¼.20). There was no correlation between change in PPT and either immediate (P¼.56) or long-term (P¼.34) pain reduction. Conclusions: Corticosteroid/lidocaine injection into a chronic painful joint decreases sensitivity to pain locally and diffusely, confirming a central sensitization component to chronic joint pain. When assessed using PPTs, the reduction in central sensitization associated with peripheral joint injection does not predict long-term pain relief from the injection. Level of Evidence: Level II Poster 441 Rare Occlusion of a Baclofen Pump Catheter Due to Rotation of Pump in the Abdominal Pocket: A Case Report Matthew W. Wilson, MD (Vidant Rehab Center/East Carolina University/Brod, Greenville, North Carolina, United States) Disclosures: Matthew Wilson: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 30-year-old female patient with history of T4 ASIA C spinal cord injury, spasticity, and intrathecal baclofen pump placement presented to clinic after an increase in spasticity. The patient began noticing an increase in spasticity in her lower extremities after her baclofen pump dose was decreased by 10% two months earlier. At presentation, she was having difficulty maintaining correct posture in her powered wheelchair due to the progression of the spasticity. Performing
Abstracts / PM R 8 (2016) S151-S332 hygiene maintenance and bathing became increasingly difficult. The pump was refilled. One week later, her spasticity worsened on physical exam. The access port to the pump could not be palpated and the pump was mobile in the intra-abdominal pocket. Upon transfer from her wheelchair to the exam table, the pump rotated 180 and the access port could be palpated. Only one milliliter of baclofen had been used over the last week, indicating a malfunction of the pump. Neurosurgery was called immediately and the patient was admitted to the hospital for pump replacement. Upon removal of the pump, it was noted that the pump had become detached from the anterior abdominal wall. The catheter had multiple twists and kinks, most likely due to constant free rotation of the pump within the pocket. Setting: Outpatient Clinic at an Academic Medical Center. Results: After the pump was replaced and pump settings were optimized, the patient lower extremity spasticity improved to baseline. She was able to perform activities of daily living. Discussion: This is the first reported case, to our knowledge, of an insidious increase in spasticity from a malfunctioning of the intraabdominal anchoring system. This malfunction led to pump rotation and eventual occlusion of the catheter. Conclusions: Rotational movement of a baclofen pump in the intraabdominal pocket can lead to an insidious presentation of increased spasticity due to catheter occlusion from kinking. Level of Evidence: Level V
Poster 442 Intractable Pelvic Pain Due to Melorheostosis Managed with Spinal Cord Stimulation: A Case Report Thomas Chai, MD (UT MD Anderson Cancer Center, Houston, TX, United States), Girish S. Shroff, MD Disclosures: Thomas Chai: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 34-year-old woman with history of left ischial and acetabular melorheostosis presented with chronic left-sided pelvic pain, only minimally responsive to opioid and non-opioid analgesics, adjuvants, and local injections. The patient therefore was deemed an appropriate candidate for spinal cord stimulator trial. During the trial, she underwent percutaneous placement of an 8-contact lead and a 16-contact lead, both placed in the epidural space just left of anatomic midline, with distal tip reaching the T10 and T9 vertebral level, respectively. During the 6-day trial, the patient reported up to 80% pain relief. She was reportedly able to sit and to walk for longer periods of time and described her quality of life as much improved. Her reliance on oral analgesics decreased as well. Two weeks after the trial, the patient proceeded to permanent spinal cord stimulator implantation. Setting: Tertiary care hospital. Results: On 1-month postoperative follow up visit, the patient reported continued response to the spinal cord stimulator, without any adverse events. Discussion: Melorheostosis is a rare, sclerosing mesenchymal dysplasia associated with significant pain, physical deformity, and functional limitation of the affected body part. It has a characteristic appearance on imaging of hyperostosis often described as “melting candle wax.” Somatic-nociceptive and neuropathic pelvic pain due to this condition was addressed with a stepwise, multimodal approach. Spinal cord stimulation was proposed once the patient’s pain was deemed refractory to more conservative measures. Conclusions: Spinal cord stimulation may be considered for select patients with unremitting pain from dysplastic disease. Level of Evidence: Level V
S305
Poster 443 Diving Injury Resulting in a Jefferson Fracture, Vertebral Artery Thrombosis and Brown Sequard Syndrome: A Case Report Rafael E. Arias-Berrios, MD (University of Puerto Rico, San Juan, Puerto Rico, United States), Shirley A. Grigg Ortiz, MD, Natalia M. Betances Ramı´rez, MD, Ana M. Ortiz Santiago, BS, Jose´ A. Ba´ez, MD Disclosures: Rafael Arias-Berrios: I Have No Relevant Financial Relationships To Disclose Case/Program Description: Case of a 20-year-old male patient with no past medical history of systemic illness suffered a diving injury with head and cervical trauma. He reported transient generalized weakness followed by tingling sensation in all extremities. Cervical spine magnetic resonance imaging (MRI) showed C1 Jefferson Fracture with underlying cord contusion, edema and right vertebral artery thrombosis. He underwent an open reduction of C1 fracture and posterolateral arthrodesis and instrumentation from Occiput to C3. Subsequent motor strength evaluation showed significant right sided weakness (upper more than lower extremity) with contralateral loss of pain and temperature sensation as well as decreased sensation on soft touch and pin-prick below C4 level on right hemibody. Right Brachial Plexus MRI showed no evidence of nerve injury. Setting: Tertiary Care Trauma Center Hospital and Inpatient Rehabilitation Facility. Results: Patient with Brown Sequard like syndrome. The patient was admitted to an inpatient rehabilitation facility for rehabilitation with a score of 66 on the Functional Independence Measure initial evaluation and discharged after 8 days with a score of 98. Discussion: Brown Sequard Syndrome (BSS) caused by spinal cord hemisection. Clinically, patients present with an ipsilateral motor loss and contralateral loss of sensitivity to pain and temperature below the level of the lesion. Cervical spine trauma due to diving is responsible for 35% of burst fractures among them Jefferson fracture. BSS is a rare event in patients with diving injury. Patients with BSS have the best prognosis for ambulation of the SCI clinical syndromes. The most important predictor of function is lower limb strength. Conclusions: The clinical presentation of a BSS secondary to Jefferson fracture and concomitant vertebral artery thrombosis after a diving injury is rare. Patients have the potential for good recovery with aggressive rehabilitation. We report an unusual presentation of a relatively uncommon condition. Level of Evidence: Level V Poster 444 Bilateral Lower Extremity Numbness and Weakness Caused by Primary Thoracic Spinal Stenosis: A Case Report Katherine Power, MD (Montefiore Medical Center, Bronx, NY, United States), Michelle Stern, MD Disclosures: Katherine Power: I Have No Relevant Financial Relationships To Disclose Case/Program Description: Patient is a 48-year-old woman with history of fibromyalgia and obesity who presented to hospital after a fall at home. She was descending the stairs when her knees suddenly felt weak and legs went numb causing her to fall. She stated 2 months previously she had a similar episode that resulted in right bimalleolar fracture. Ortho casted her and were following her progress. During this time she also had decreased sensation in her right leg which was attributed to radiculopathy. An MRI of lumbar spine was ordered but denied by insurance so she was reassured and recommended to stay active. She was admitted for