Poster 451 Schwannoma Presenting as Low Back Pain and Myelopathy: A Case Report

Abstracts / PM R 8 (2016) S151-S332 unchanged two-year history of chronic low back discomfort following motor vehicle collision. Physical exam displayed an antalgic gait, 4+/5 muscle strength throughout major muscle groups of the right lower extremity. Reflexes at the right patella and medial hamstring were decreased when compared to the left and there was decreased sensation to light touch of right leg from level of tibial tuberosity distal to toes. Setting: Outpatient Musculoskeletal Spine Clinic. Results: At initial encounter gabapentin and naproxen were initiated along with single point cane for ambulation aide. Diagnostic tests of the right lower extremity including Doppler ultrasound, Xray imaging, electromyography and nerve conduction study (EMGNCS) were negative for acute pathology. EMG-NCS did display evidence of chronic right L5 radiculopathy and further evaluation with magnetic resonance imaging of the lumbar spine demonstrated right L5 nerve root compression due to extruded nucleus pulposus. A L5-S1 translaminar epidural steroid injection was preformed resulting in significant reduction in lower leg pain, from 10/10 to 3/10. Discussion: Atypical presentation of right L5 radiculopathy in young female with unchanged chronic low back pain and EMG-NCS negative for acute pathology. Only with further evaluation of lumbar imaging and resultant L5-S1 ESI was the patient able to obtain significant pain relief. Conclusions: Lumbar radiculopathies may present in atypical fashion and should be considered in the differential diagnosis even in the absence of classic radicular distribution of pain. Level of Evidence: Level V Poster 448 Obturator Neuropathy after Lumbar Fusion and Resolution with Ultrasound-Guided Obturator Nerve Block: A Case Report Jeremy L. Stanek, MD (University of Missouri-Columbia, Columbia, Missouri, United States), Mohammad Agha, MD Disclosures: Jeremy Stanek: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 64-year-old man presented seven months after having L4-L5 posterior facet and lateral interbody fusions with immediate post-operative “burning” lateral right hip pain radiating to the right testicle and medial thigh. Magnetic resonance imaging of the hip demonstrated mild arthritis and acetabular labrum tear. Electromyography (EMG) of the extremity was normal. Treatments prior to presenting to our clinic included topical lidocaine, transcutaneous electrical nerve stimulation, gabapentin, duloxetine, topiramate, tramadol, trochanteric bursa steroid injection, physical therapy, intra-articular steroid injection of the hip, and L3-L4/L4-L5 laminectomy, all without benefit. On presentation to our clinic, physical exam revealed antalgic gait and difficulty with heel and toe walking on the right. Lower extremity strength was 4/5 in the right adductors and 5/5 in all other muscle groups. Sensation to pinprick was diminished in the right obturator nerve distribution compared to left and normal bilaterally for anterior femoral, lateral femoral cutaneous, tibial, superficial fibular, and deep fibular nerve distributions. The patient underwent ultrasound-guided chemical block of the superficial branch of the obturator nerve with triamcinolone and bupivacaine. Six weeks later, block of the deep branch was performed with triamcinolone and ropivacaine for residual pain in the distal one-third of the thigh. Setting: Academic tertiary care center. Results: Ultrasound-guided chemical blocks completely resolved the groin and medial thigh pain. Discussion: Obturator neuropathy after spine surgery is highly unusual. It was not detected on EMG and failed conservative and

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operative treatments. Once diagnosed and treated in our clinic, pain resolved without change in motor function. Conclusions: Obturator neuropathy should be considered as a cause of groin and medial thigh pain. Ultrasound-guided nerve block is an effective treatment for obturator neuropathy. Level of Evidence: Level V

Poster 450 Addressing Chronic Pain in SCI with Use of Electro-Acupuncture Chestin Jones, FNP (VA North Texas Health Care System, Dallas, TX, United States), Bridget Bennett, MD, Itala M. Wickremasinghe, MD Disclosures: Chestin Jones: I Have No Relevant Financial Relationships To Disclose Case/Program Description: The primary purpose of this study was to test the efficacy of a 4-week pain intervention using a Classical Upper Thoracic Cervical PENs protocol in veterans with SCI/D. Patients were recruited using advertising throughout the SCI Outpatient Clinic and provider referrals. Inclusion criteria included: veterans with documented SCI, musculoskeletal or neuropathic pain lasting greater than 6 months & currently on no more than 2 narcotics. Patients presented for two 30-minute appointment for 4 weeks. Each week they completed a pain journal to track progress to determine efficacy of the intervention. Setting: SCI Outpatient Setting. Results: Patient 1 Disability score improved from 40% to 28%. Patient 2 Disability score improved from 62% to 52%. They also reported improvement in sleep, driving, personal care, and overall pain and intensity. Pain Scores decreased by 50% in both patients. Discussion: Acupuncture is a safe and effective option in managing pain in patients with SCI. Intervention was both time and cost effective and it gives an opportunity to explore using similar methods for other common chronic pain conditions in the SCI population. Conclusions: PENS is effective and is being used to manage chronic pain in the outpatient setting by activating the various innervations in the affected pain lesion. Level of Evidence: Level V

Poster 451 Schwannoma Presenting as Low Back Pain and Myelopathy: A Case Report Brian Pekkerman, DO (SUNY Downstate, Brooklyn, NY, United States), Bhavi Patel, DO, Necolle Morgado-Vega, DO Disclosures: Brian Pekkerman: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 60-year-old man with 8 years of low back pain radiating into bilateral lower extremities. Lumbar CT showed disk herniation at L3-L5. MRI not performed secondary to implantable cardioverter-defibrillator. Pain progressively worsened and patient underwent L3-L5 laminectomy in 2008. Afterwards pain continued to increase with newly developing neurologic deficits characterized by complete lower extremity numbness and urinary retention. Lower extremity weakness progressed and patient required walker for household ambulation and wheelchair for long distances. Repeat imaging could not establish reason for further decline. Treatments including therapy, steroids, high dose opiate medications, and spinal cord stimulator resulted in minor improvement of pain. Neurologic deterioration persisted, leading to stool incontinence and self-catheterization. At this point in 2014,

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Abstracts / PM R 8 (2016) S151-S332

Myelography was performed and a mass noted in the thoraco-lumbar spine. Patient underwent T10-L2 laminectomy with schwannoma resection. Setting: Tertiary Care hospital. Results: Upon admission to rehabilitation patient was maximum assistance with all activities and ambulated 20 feet in parallel bars. Throughout hospitalization patient regained majority of lower extremity sensation, became continent of stool, and was able to decrease opiate dosing. Patient was discharged home with supervision in all activities and ambulated 300feet with rolling walker. Discussion: This case highlights the symptoms and disease progression of extramedullary spinal cord tumors. Myelography can be a useful imaging study in cases where MRI is contraindicated. Conclusions: It is important for physicians to understand alternative imaging techniques when radiology of choice is contraindicated and employ them when necessary. Level of Evidence: Level V Poster 452 Bipolar Radiofrequency Ablation for the Treatment of Hip Joint Pain Using a Perpendicular Approach: A Case Report Rupa P. Austria, MD (University of Minnesota, Minneapolis, MN, United States), Franz Macedo, DO Disclosures: Rupa Austria: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 53-year-old man with chronic intraarticular hip pain presented to a pain clinic with intractable hip pain refractory to conservative treatments including activity modification, physical therapy, oral medications and intra-articular injections (both corticosteroid and viscosupplementation). Physical examination revealed multiple positive provocative tests suggesting hip joint pain. Bilateral hip radiographs demonstrated changes consistent with moderate osteoarthritis and femoral acetabular impingement. Orthopedic evaluation noted that he was a suboptimal candidate for arthroscopy or total hip arthroplasty given his age and moderate degree of arthritis. He elected to undergo radiofrequency ablation of the right hip articular sensory branches from the obturator and femoral nerves. Initial ablation, performed using a conventional radiofrequency (single needle) technique, provided only four weeks of pain reduction. After reevaluation, he consented to a repeat procedure. For the second procedure a bipolar radiofrequency approach was used to provide larger lesion size in order to account for variability in nerve location and size. Setting: Comprehensive Pain Clinic. Results: The Lower Extremity Functional Scale, a validated functional measure, was used to track the patient’s functional changes pre- and post-bipolar radiofrequency procedure. Higher scores indicate greater level of function and a change of 9 points is considered significant. Scores were 18/80 prior to procedure, 53/80 at 2 months and 49/80 at 6 months. Discussion: This is the first reported case, to our knowledge, in which bipolar radiofrequency ablation using a perpendicular (AP) approach has been performed for intraarticular hip pain. The continued improvement in functional status and pain reduction at 6 months demontrates the durability of this procedure. Conclusions: Bipolar radiofrequency ablation of the femoral and oburator aritcular hip branches is a novel procedure which we demonstrate can improve function and pain status for patients who are suboptimal surgical candidates or failed conservative management. Level of Evidence: Level V

Poster 453 Correlation of Sacroiliac Joint Injection Response to Outcomes After Minimally Invasive Sacroiliac Joint Fusion Raghavendra R. Nayak, DO (University of Minnesota, Saint Paul, Minnesota, United States) Disclosures: Raghavendra Nayak: I Have No Relevant Financial Relationships To Disclose Objective: To determine whether response to a sacroiliac joint injection (SIJ) can be used as a predictor of outcomes after minimally invasive sacroiliac joint fusion surgery. Design: Retrospective chart review. Data gathered included: Age, gender, response to pre-operative SIJ steroid injection, Pre- and postoperative Oswestry Disability Index (ODI) and Visual Analog Scale (VAS). Setting: Academic Health Center. Participants: Patients who underwent minimally invasive SIJ fusion with one year of follow-up. Exclusion criteria included: prior SIJ fusion, cancer related pathology and revision surgery or traumatic injury within 1 year. Interventions: Not applicable. Main Outcome Measures: Main outcome measures were Oswestry disability index (ODI) and visual analog scale (VAS). Patients were grouped according to reported relief after pre-operative SIJ injection: (A) 75-100%, (B) 50-74% and (C) 0-49%. T-test was used to analyze for differences between groups (a¼0.05). Results: From February 2010 to February 2014, 39 cases that met inclusion criteria were reviewed. There were 25 females and 14 males. Average age 49 years (Range: 24-69). There were 27 patients in group A, 8 in group B and 4 in group C. Average ODI improvement at one year follow-up in group A was 3 (Pre-op 53, Post-op 50); there was no improvement in VAS (Pre-op 6, Post-op 6). Average ODI improvement in group B was 4 (Pre-op 59, Post-op 55); average VAS improvement was 2 (Pre-op 8, Post-op 6). Average ODI improvement in group C was 7 (Pre-op 43, post-op 36); average VAS improvement was 2 (Pre-op 5, post-op 5). There were no statistically significant differences found between the 3 groups (ODI A vs B, P¼.77; A vs C, P¼.74; B vs C, P¼.81; VAS A vs B, P¼.08; A vs C, P¼ .46; B vs C, P¼.78). Conclusions: Response to pre-operative sacroiliac joint injection does not seem to be predictive of outcomes after minimally invasive sacroiliac joint fusion. Level of Evidence: Level III Poster 454 Improving Urine Drug Testing in New Patients at a University-Affiliated Pain Clinic and Analysis of Gender Differences in Urine Drug Testing Jack M. Smith, MD (VCUHS, North Chesterfield, VA, United States), Ajit Pai, MD Disclosures: Jack Smith: I Have No Relevant Financial Relationships To Disclose Objective: The aim of this quality improvement project and retrospective observational study was to improve urine drug screening of patients initiated on long term opioid therapy. Patient demographic data were assessed to see if there were any gender differences in initiation of chronic opioid therapy. Design: Prospective Cohort Study Setting: An outpatient university-affiliated pain clinic. Participants: 300 new patients at a pain clinic. Interventions: A chart review of 148 new patients at a pain clinic was conducted. The following data were extracted: patient gender, opioid prescriptions from a previous provider, opioid