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Poster 501 Painful Legs Moving Toes with Novel Vasomotor and Leg Movement Symptoms: A Case Report
PM&R
Case Description: A 37-year-old man presented with chronic CRPS pain manifestations in his right foot and ankle for 10 years after having multiple orthopedic surgeries and history of neuroma excision. Physical examination of foot demonstrated hyperalgesia, edema, warmth, and shiny skin appearance. NSAIDS, gabapentin, TENS unit, epidural injections, and local lidocaine block were tried in the past but offered minimal relief. His Initial VAS pain score on presentation was a 7/10. Additionally he had functional limitations of having to drive with his left foot, difficulty with prolonged standing greater than 2 minutes, and inability to run or dance. A 30 minute trial of pulsed radiofrequency (PRF) was given with applicator placed directly underneath his R ankle. Settings were regulated at a frequency of 27.12 MHz, 42 microsecond pulse width, and 1000 pulses per second. After the trial patient was then issued a portable PRF generator for home usage. He was instructed to repeat the same treatment twice daily and follow up in clinic at 1 and 2 months. Program Description: N/A Setting: Outpatient Rehabilitation Clinic. Results or Clinical Course: During the initial trial patient had immediate pain relief to a VAS pain score of 4/10. After 1 month follow up his pain was reduced further to a 3/10. At 2 months his pain continued to reduce with a self-reported daily pain score that ranged from 0-3/10. Additionally patient reported functional improvement of being able to walk 2-3 blocks without pain limitations. Also he was able to drive with his R foot again after receiving PRF. Discussion: This is the first reported case, to our knowledge, of transcutaneous PRF successfully being utilized to treat CRPS related pain. This should not be confused with the multiple case reports of percutaneous PRF being used for sympathetic neurolysis which is entirely different. Transcutaneous PRF is a non-invasive approach that does not involve traumatic penetration of the skin nor direct nerve trauma. In this case it provided significant analgesia and functional improvement after multiple alternative treatment modalities failed. Conclusions: Transcutaneous pulsed radiofrequency may have a role in treating CRPS related pain. Further research should be considered on investigating the potential benefits of PRF analgesia for individuals seeking non-invasive treatment options for CRPS. Poster 501 Painful Legs Moving Toes with Novel Vasomotor and Leg Movement Symptoms: A Case Report. Alexander Lloyd (Icahn School of Medicine at Mount Sinai, New York, NY, United States); Yinfei Xu, MD; Parag Sheth, MD. Disclosures: A. Lloyd, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: A 69-year-old woman presented with bilateral, sharp, burning leg pain of several years, worse on the right and accompanied by involuntary flexion/extension of all digits. Symptoms progressed to include muscle spasms and leg jerking, increased pain intensity, and bilateral distribution. She also reported segmental, bilateral color and temperature changes in her right leg. Walking, cold, pressure, ankle movement, and Valsalva exacerbated the pain. Heat and relieving pressure on the feet provided mild relief. Trauma history included a car accident at 31
Vol. 6, Iss. 9S, 2014
S361
(full recovery with rehabilitation), recurrent ankle instability, plantar fasciitis, and an unverified history of feet neuromas. Of note, her sister’s terminal illness and need for significant care coincided with symptom onset. Setting: Tertiary care rehabilitation clinic. Results or Clinical Course: Therapy included trials of amitryptiline, nortryptiline (some relief but unacceptable behavior change), gabapentin, pramipexole, celecoxib, diazepam (temporary relief), oxycodone, and lidocaine patches. Caudal epidural and physical therapy provided no relief and electroacupuncture worsened her pain. Spine MRI showed stable posterior broad based disc bulge at L4-5 with annular fissure. MRI of the foot could not be read due to movement. The patient refused EMG. Lab results showed MGUS. Patient was to follow up with pain management and a sleep study. Discussion: This patient’s rare presentation is typical of PLMT, but her leg jerking, vasomotor dysreglation, and possible pedal neuromas have not been reported in the PLMT literature. They emphasize the significant overlap between descriptions of PLMT and complex regional pain syndrome (CRPS), which is characterized by chronic pain and separated from PLMT by a combination of sensory/vasomotor/sudomotor/motor symptoms. Because of their expertise in rehabilitation, musculoskeletal disease and pain management, physiatrists are likely to see these rare patients and may be positioned to offer treatment once more is known about PLMT. Conclusions: PLMT is debilitating disease potentially encountered by physiatrists and our report helps guide their understanding and care. Their unique perspective is underrepresented in the literature and important as understanding of this disease progresses. Poster 502 Epidural Hematoma and Paraplegia after Spinal Cord Stimulator Trial Lead Removal: A Case Report. Peter Navarro (University of Miami, Miami, FL, United States); Jose Mena, MD. Disclosures: P. Navarro, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: A 63-year-old woman with a history notable for thoracic myelopathy and T7-T8 discectomy who presented to the interventional pain clinic with complaints of burning pain of the ribs and anterior chest. She had already failed conservative measures such as intercostal block, physical therapy and medications by this point, so it was felt she would be a great candidate for a spinal cord stimulator trial. She was given precautions before the trial to prevent lead migration and stop any anticoagulants to prevent any risk of bleeding following the American Society of Regional Anesthesia guidelines. She had a successful 7-day spinal cord stimulator trial with 80% improvement in her pain. After ensuring she had not been taking any potential blood thinners, the spinal cord stimulator lead was removed. The catheter tip was intact and there was no evidence of bleeding; the patient had no immediate complications. Four hours after lead removal she began experiencing lower extremity paraplegia. She presented to an emergency room and a thoracic MRI revealed an epidural hematoma. On examination her lower extremity motor strength was 1/5 bilaterally and also lost control of her bladder function.
Case Description: A 37-year-old man presented with chronic CRPS pain manifestations in his right foot and ankle for 10 years after having multiple orthopedic surgeries and history of neuroma excision. Physical examination of foot demonstrated hyperalgesia, edema, warmth, and shiny skin appearance. NSAIDS, gabapentin, TENS unit, epidural injections, and local lidocaine block were tried in the past but offered minimal relief. His Initial VAS pain score on presentation was a 7/10. Additionally he had functional limitations of having to drive with his left foot, difficulty with prolonged standing greater than 2 minutes, and inability to run or dance. A 30 minute trial of pulsed radiofrequency (PRF) was given with applicator placed directly underneath his R ankle. Settings were regulated at a frequency of 27.12 MHz, 42 microsecond pulse width, and 1000 pulses per second. After the trial patient was then issued a portable PRF generator for home usage. He was instructed to repeat the same treatment twice daily and follow up in clinic at 1 and 2 months. Program Description: N/A Setting: Outpatient Rehabilitation Clinic. Results or Clinical Course: During the initial trial patient had immediate pain relief to a VAS pain score of 4/10. After 1 month follow up his pain was reduced further to a 3/10. At 2 months his pain continued to reduce with a self-reported daily pain score that ranged from 0-3/10. Additionally patient reported functional improvement of being able to walk 2-3 blocks without pain limitations. Also he was able to drive with his R foot again after receiving PRF. Discussion: This is the first reported case, to our knowledge, of transcutaneous PRF successfully being utilized to treat CRPS related pain. This should not be confused with the multiple case reports of percutaneous PRF being used for sympathetic neurolysis which is entirely different. Transcutaneous PRF is a non-invasive approach that does not involve traumatic penetration of the skin nor direct nerve trauma. In this case it provided significant analgesia and functional improvement after multiple alternative treatment modalities failed. Conclusions: Transcutaneous pulsed radiofrequency may have a role in treating CRPS related pain. Further research should be considered on investigating the potential benefits of PRF analgesia for individuals seeking non-invasive treatment options for CRPS. Poster 501 Painful Legs Moving Toes with Novel Vasomotor and Leg Movement Symptoms: A Case Report. Alexander Lloyd (Icahn School of Medicine at Mount Sinai, New York, NY, United States); Yinfei Xu, MD; Parag Sheth, MD. Disclosures: A. Lloyd, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: A 69-year-old woman presented with bilateral, sharp, burning leg pain of several years, worse on the right and accompanied by involuntary flexion/extension of all digits. Symptoms progressed to include muscle spasms and leg jerking, increased pain intensity, and bilateral distribution. She also reported segmental, bilateral color and temperature changes in her right leg. Walking, cold, pressure, ankle movement, and Valsalva exacerbated the pain. Heat and relieving pressure on the feet provided mild relief. Trauma history included a car accident at 31
Vol. 6, Iss. 9S, 2014
S361
(full recovery with rehabilitation), recurrent ankle instability, plantar fasciitis, and an unverified history of feet neuromas. Of note, her sister’s terminal illness and need for significant care coincided with symptom onset. Setting: Tertiary care rehabilitation clinic. Results or Clinical Course: Therapy included trials of amitryptiline, nortryptiline (some relief but unacceptable behavior change), gabapentin, pramipexole, celecoxib, diazepam (temporary relief), oxycodone, and lidocaine patches. Caudal epidural and physical therapy provided no relief and electroacupuncture worsened her pain. Spine MRI showed stable posterior broad based disc bulge at L4-5 with annular fissure. MRI of the foot could not be read due to movement. The patient refused EMG. Lab results showed MGUS. Patient was to follow up with pain management and a sleep study. Discussion: This patient’s rare presentation is typical of PLMT, but her leg jerking, vasomotor dysreglation, and possible pedal neuromas have not been reported in the PLMT literature. They emphasize the significant overlap between descriptions of PLMT and complex regional pain syndrome (CRPS), which is characterized by chronic pain and separated from PLMT by a combination of sensory/vasomotor/sudomotor/motor symptoms. Because of their expertise in rehabilitation, musculoskeletal disease and pain management, physiatrists are likely to see these rare patients and may be positioned to offer treatment once more is known about PLMT. Conclusions: PLMT is debilitating disease potentially encountered by physiatrists and our report helps guide their understanding and care. Their unique perspective is underrepresented in the literature and important as understanding of this disease progresses. Poster 502 Epidural Hematoma and Paraplegia after Spinal Cord Stimulator Trial Lead Removal: A Case Report. Peter Navarro (University of Miami, Miami, FL, United States); Jose Mena, MD. Disclosures: P. Navarro, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: A 63-year-old woman with a history notable for thoracic myelopathy and T7-T8 discectomy who presented to the interventional pain clinic with complaints of burning pain of the ribs and anterior chest. She had already failed conservative measures such as intercostal block, physical therapy and medications by this point, so it was felt she would be a great candidate for a spinal cord stimulator trial. She was given precautions before the trial to prevent lead migration and stop any anticoagulants to prevent any risk of bleeding following the American Society of Regional Anesthesia guidelines. She had a successful 7-day spinal cord stimulator trial with 80% improvement in her pain. After ensuring she had not been taking any potential blood thinners, the spinal cord stimulator lead was removed. The catheter tip was intact and there was no evidence of bleeding; the patient had no immediate complications. Four hours after lead removal she began experiencing lower extremity paraplegia. She presented to an emergency room and a thoracic MRI revealed an epidural hematoma. On examination her lower extremity motor strength was 1/5 bilaterally and also lost control of her bladder function.