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Poster 517 First Reported Case of Menorrhagia Following Intra-articular Facet Steroid Injections: A Case Study
PM&R
on T1 weighted axial MR images. The expected cross sectional area and functional CSA (fCSA) of the muscles were measured by using free hand technique on OsiriXÒ. Then the percentage of muscle atrophy was calculated. Fatty infiltration was graded by using Goutallier and Quartile classifications. Results or Clinical Course: The groups were similar in age, height, weight, body mass index (p>0.05). The symptomatic group had higher Goutallier and Quartile scores for the erector spinae at L5-S1 level (p<0.05). The symptomatic group had smaller multifidus total CSA, and at L2-3, L3-4 and L4-5, L3-L4 (p<0.05) than the asymptomatic group. The symptomatic group had more atrophy in the multifidus at L5-S1 disc level, as the age advanced (p¼0.042 r¼0.619). Conclusions: The fatty infiltration, particularly in the erector spine at L5-S1, is more significant than the atrophy in subjects with symptomatic LSS. The symptomatic group had smaller multifidus fCSA, even though there wasn’t any significant difference in the percentage of the multifidus atrophy. Further studies need to be done to determine the effect of the fatty infiltration and atrophy of paraspinal muscles on the clinical outcomes in patients with LSS and also on the prognosis of LSS. Poster 517 First Reported Case of Menorrhagia Following Intraarticular Facet Steroid Injections: A Case Study. Nasim Chowdhury, MD (New York PresbyterianColumbia and Cornell, New York, NY, United States); George Christolias, MD. Disclosures: N. Chowdhury, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: The patient presented with a chronic history of axial low back pain, having failed multiple treatments including oral steroids, anti-inflammatories, traction, chiropractic care, acupuncture, and epidural steroid injections. Examination was significant for reproduction of pain with extension and rotation bilaterally. MRI was performed demonstrating L4-5 and L5-S1 annular fissures with associated bilateral facet arthritis. Given the provocation of pain with extension with rotation, treatment of the facet arthritis was pursued. She underwent fluoroscopically guided bilateral intra-articular facet injections at both L4-5 and L5-S1. A solution of 20 milligrams Triamcinolone mixed with 0.5 milliliters of 2% Lidocaine was injected into each joint after contrast confirmed placement and evidence of nonvascular flow. Program Description: 43-year-old woman with a history of gastric ulcers. Setting: Outpatient rehabilitation clinic at a University Hospital. Results or Clinical Course: The patient presented for follow up forty eight days post-injection having noted complete relief of pain lasting several weeks, but with subsequent progressive return of pain. She also reported menorrhagia described as a heavier and more prolonged menses. Discussion: This appears to be the first report in the literature that associates menorrhagia and facet joint injections. Increasing amounts of data is emerging linking epidural steroid injections with menorrhagia and other changes to the menstrual cycle, particularly within the sixty days following injection. Menorrhagia may be an under reported side effect of not only epidural steroid injection, but also other interventional procedures that utilize steroids. We suspect this is due to both lack of provider inquiry and patient under-reporting.
Vol. 6, Iss. 9S, 2014
S367
Conclusions: Knowledge of menstrual changes and menorrhagia as potential side effects of interventional spine procedures that utilize steroids may limit unnecessary and costly gynecological evaluation and testing. Poster 518 Acute Disc Herniation Resulting in Unusual Baclofen Catheter Impingement: A Case Report. Priyesh Mehta, DO (New York Presbyterian Hospital, New York, NY, United States); Kenny Chantasi, DO. Disclosures: P. Mehta, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: A 50-year-old woman with cerebral palsy with intrathecal baclofen pump placement in 2011 and scoliosis s/p C2-S1 spinal fusion presented to the emergency room with worsening spasticity. She reports having a previous fall after her leg had acutely given out and subsequently developed severe spasticity of her lower extremities. In the emergency room she was treated for dehydration with intravenous fluids and empiric antibiotics despite a negative infectious work up. She was admitted to the rehabilitation service for management of her spasticity. Her baclofen pump was interrogated and refilled showing no evidence of pump failure and delivering appropriate dose. Her baseline dose was increased a total of 20% with multiple bolus trials resulting in no effect. She acutely developed left leg sensory loss and worsening spasticity. MRI showed a new L2-L3 left paracentral disc extrusion that displaces the thecal sac to the right and posterior. Neurosurgery called for evaluation obtaining upright thoracic and lumbar spine x-rays showing catheter in place at approximately T11-T12 with no disconnections or interruptions noted throughout the catheter length. Contrast dye study showed no evidence of leak or breaks in the catheter system however CT myelogram showed a block secondary to an acute disc herniation at L2L3. Her baclofen was titrated down significantly to avoid a potential baclofen overdose. Patient was taken to the OR for lumbar microdiscetomy of the large disc herniation. Program Description: New York Presbyterian Hospital - Cornell/Columbia Department of Rehabilitation. Setting: Tertiary care hospital. Results or Clinical Course: The patient’s spasticity significantly improved after the procedure and she was slowly titrated up to her baseline baclofen dose until discharge. She was able to ambulate with a walker and perform wheelchair transfers more easily. Discussion: This is the first reported case, to our knowledge of an acute disc herniation resulting in thecal compression and catheter impingement complicating baclofen delivery. Conclusions: Intrathecal baclofen pumps can be a challenge to manage and treat. This case illustrates a rare complication that should be on the list as a potential cause of baclofen catheter complications. Poster 519 Clinical Outcomes and Methodological Quality of Mirror Therapy Interventions to Reduce Phantom Limb Pain. Erik Diebolt, DO (Carolinas Medical Center, Charlotte, NC, United States); Mark A. Hirsch, PhD; Asim Otey, MD. Disclosures: E. Diebolt, No Disclosures: I Have No Relevant Financial Relationships to Disclose.
on T1 weighted axial MR images. The expected cross sectional area and functional CSA (fCSA) of the muscles were measured by using free hand technique on OsiriXÒ. Then the percentage of muscle atrophy was calculated. Fatty infiltration was graded by using Goutallier and Quartile classifications. Results or Clinical Course: The groups were similar in age, height, weight, body mass index (p>0.05). The symptomatic group had higher Goutallier and Quartile scores for the erector spinae at L5-S1 level (p<0.05). The symptomatic group had smaller multifidus total CSA, and at L2-3, L3-4 and L4-5, L3-L4 (p<0.05) than the asymptomatic group. The symptomatic group had more atrophy in the multifidus at L5-S1 disc level, as the age advanced (p¼0.042 r¼0.619). Conclusions: The fatty infiltration, particularly in the erector spine at L5-S1, is more significant than the atrophy in subjects with symptomatic LSS. The symptomatic group had smaller multifidus fCSA, even though there wasn’t any significant difference in the percentage of the multifidus atrophy. Further studies need to be done to determine the effect of the fatty infiltration and atrophy of paraspinal muscles on the clinical outcomes in patients with LSS and also on the prognosis of LSS. Poster 517 First Reported Case of Menorrhagia Following Intraarticular Facet Steroid Injections: A Case Study. Nasim Chowdhury, MD (New York PresbyterianColumbia and Cornell, New York, NY, United States); George Christolias, MD. Disclosures: N. Chowdhury, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: The patient presented with a chronic history of axial low back pain, having failed multiple treatments including oral steroids, anti-inflammatories, traction, chiropractic care, acupuncture, and epidural steroid injections. Examination was significant for reproduction of pain with extension and rotation bilaterally. MRI was performed demonstrating L4-5 and L5-S1 annular fissures with associated bilateral facet arthritis. Given the provocation of pain with extension with rotation, treatment of the facet arthritis was pursued. She underwent fluoroscopically guided bilateral intra-articular facet injections at both L4-5 and L5-S1. A solution of 20 milligrams Triamcinolone mixed with 0.5 milliliters of 2% Lidocaine was injected into each joint after contrast confirmed placement and evidence of nonvascular flow. Program Description: 43-year-old woman with a history of gastric ulcers. Setting: Outpatient rehabilitation clinic at a University Hospital. Results or Clinical Course: The patient presented for follow up forty eight days post-injection having noted complete relief of pain lasting several weeks, but with subsequent progressive return of pain. She also reported menorrhagia described as a heavier and more prolonged menses. Discussion: This appears to be the first report in the literature that associates menorrhagia and facet joint injections. Increasing amounts of data is emerging linking epidural steroid injections with menorrhagia and other changes to the menstrual cycle, particularly within the sixty days following injection. Menorrhagia may be an under reported side effect of not only epidural steroid injection, but also other interventional procedures that utilize steroids. We suspect this is due to both lack of provider inquiry and patient under-reporting.
Vol. 6, Iss. 9S, 2014
S367
Conclusions: Knowledge of menstrual changes and menorrhagia as potential side effects of interventional spine procedures that utilize steroids may limit unnecessary and costly gynecological evaluation and testing. Poster 518 Acute Disc Herniation Resulting in Unusual Baclofen Catheter Impingement: A Case Report. Priyesh Mehta, DO (New York Presbyterian Hospital, New York, NY, United States); Kenny Chantasi, DO. Disclosures: P. Mehta, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: A 50-year-old woman with cerebral palsy with intrathecal baclofen pump placement in 2011 and scoliosis s/p C2-S1 spinal fusion presented to the emergency room with worsening spasticity. She reports having a previous fall after her leg had acutely given out and subsequently developed severe spasticity of her lower extremities. In the emergency room she was treated for dehydration with intravenous fluids and empiric antibiotics despite a negative infectious work up. She was admitted to the rehabilitation service for management of her spasticity. Her baclofen pump was interrogated and refilled showing no evidence of pump failure and delivering appropriate dose. Her baseline dose was increased a total of 20% with multiple bolus trials resulting in no effect. She acutely developed left leg sensory loss and worsening spasticity. MRI showed a new L2-L3 left paracentral disc extrusion that displaces the thecal sac to the right and posterior. Neurosurgery called for evaluation obtaining upright thoracic and lumbar spine x-rays showing catheter in place at approximately T11-T12 with no disconnections or interruptions noted throughout the catheter length. Contrast dye study showed no evidence of leak or breaks in the catheter system however CT myelogram showed a block secondary to an acute disc herniation at L2L3. Her baclofen was titrated down significantly to avoid a potential baclofen overdose. Patient was taken to the OR for lumbar microdiscetomy of the large disc herniation. Program Description: New York Presbyterian Hospital - Cornell/Columbia Department of Rehabilitation. Setting: Tertiary care hospital. Results or Clinical Course: The patient’s spasticity significantly improved after the procedure and she was slowly titrated up to her baseline baclofen dose until discharge. She was able to ambulate with a walker and perform wheelchair transfers more easily. Discussion: This is the first reported case, to our knowledge of an acute disc herniation resulting in thecal compression and catheter impingement complicating baclofen delivery. Conclusions: Intrathecal baclofen pumps can be a challenge to manage and treat. This case illustrates a rare complication that should be on the list as a potential cause of baclofen catheter complications. Poster 519 Clinical Outcomes and Methodological Quality of Mirror Therapy Interventions to Reduce Phantom Limb Pain. Erik Diebolt, DO (Carolinas Medical Center, Charlotte, NC, United States); Mark A. Hirsch, PhD; Asim Otey, MD. Disclosures: E. Diebolt, No Disclosures: I Have No Relevant Financial Relationships to Disclose.