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Poster 70 Lymphoma Presenting as a Cervical Radiculoplexus Neuropathy: A Case Report
PM&R
Poster 69 Waiting to Inhale: Electrodiagnosis of A Left Phrenic Nerve Palsy After Chiropractic Cervical Manipulation: A Case Report. Christine M. Roque-Dang, DO (UMDNJ, New Jersey Medical School, Newark, NJ, United States); Jeffrey L. Cole, MD. Disclosures: C. M. Roque-Dang, none. Patients or Programs: A 50-year-old man. Program Description: The patient had presented with the chief complaint of dyspnea for several months. He reported that he had chiropractic treatment for cervicalgia and, on the day after cervical manipulation, developed unexplained dyspnea with mild exertional activities. Due to his worsening symptoms, he terminated his chiropractic visits and was evaluated by his primary care physician and a neurologist. Pertinent radiographic imaging included a SNIFF fluoroscopic examination, which revealed left hemidiaphragmatic paralysis and a chest radiograph that demonstrated an elevated left hemidiaphragm. Based on the patient’s history and radiographic imaging a electrodiagnostic testing was then performed to rule out a left phrenic nerve palsy. Setting: Outpatient private practice office. Results: On motor nerve conduction studies, he was found to have delayed distal latencies of the left phrenic nerve. Electromyography revealed reduced recruitment throughout the left hemidiaphragm, rare spontaneous denervation potentials in the left lateral diaphragm, and complex and nascent polyphasic single motor unit potentials in the left anterior diaphragm. The electrodiagnostic findings were consistent a left phrenic nerve segmental demyelinated injury. We referred the patient to a plastic surgeon, who performed a left phrenic nerve reconstruction. After surgery, the patient had improved respiratory function and activity tolerance. Discussion: A phrenic nerve injury that resulted in symptomatic diaphragmatic paralysis is most commonly associated with cardiothoracic surgery or malignancy. There are only a few cases that report phrenic nerve palsies sustained from chiropractic cervical manipulation. In these isolated reports, electrodiagnosis was not routinely used to detect these lesions. Conclusions: Reported is an unusual case of unilateral phrenic nerve palsy sustained after chiropractic manipulation. Before receiving cervical spine manipulation, patients should be counseled of this possible and serious complication. Electrodiagnostic studies are useful in phrenic nerve injury diagnosis and treatment determination. Poster 70 Lymphoma Presenting as a Cervical Radiculoplexus Neuropathy: A Case Report. Jacob L. Sellon, MD (Mayo Clinic, Rochester, MN, United States); Nathan P. Staff, MD, Stephen J. Wisniewski, MD. Disclosures: J. L. Sellon, none. Patients or Programs: A 64-year-old man with right arm pain and weakness. Program Description: The patient presented with insidious onset of burning pain in his right radial forearm with radiation into the thumb and index finger. On examination, although the Spurling test was negative, reduced triceps and brachioradialis reflexes suggested a cervical radiculopathy. The patient’s symptoms worsened
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despite a trial of physical therapy. After 2 months of arm pain, he developed right arm weakness across myotomes and was evaluated in a multidisciplinary spine clinic by physiatry, neurology, and neurosurgery. Setting: A tertiary care academic center. Results: Nerve conduction studies showed decreased right median and radial sensory nerve action potentials. Needle electromyography revealed fibrillation potentials and poorly recruited motor unit potentials in right C7-innervated muscles, opponens pollicis, and cervical paraspinal muscles. The electrodiagnostic findings were consistent with a cervical radiculoplexus neuropathy. Magnetic resonance imaging of the cervical spine and brachial plexus was unrevealing. A computed tomographic myelogram showed moderate neuroforaminal narrowing at C6-C7, with displacement of the exiting right C7 nerve root. After the patient’s arm pain transiently improved with a C6-C7 transforaminal epidural steroid injection, the decision was made to proceed with C6-C7 decompressive foraminotomies. After surgery, his symptoms progressed. Repeated electrodiagnostic testing showed evidence of a widespread cervical radiculoplexus neuropathy and prompted a lumbar puncture, which revealed non-Hodgkin large B-cell lymphoma. A subsequent positron emission tomography showed intense uptake of the right C7 nerve root with distribution into the brachial plexus, which confirmed earlier electrodiagnostic findings. Discussion: Neurolymphomatosis is a rare manifestation of lymphoma characterized by peripheral nerve infiltration. Neurolymphomatosis of the nerve roots or brachial plexus may mimic nonneoplastic processes, and a diagnosis is often delayed. As this case demonstrates, electrodiagnostic studies may reveal the patchy neuropathic findings of neurolymphomatosis before it is evident on imaging studies. Conclusions: Neurolymphomatosis should be included in the differential diagnosis in cases of progressive radiculopathy or plexopathy. Poster 71 Belatedly Diagnosed Acute Motor Axonal Neuropathy After Cardiac Surgery: A Case Report. Chong Tae Kim, MD, PhD (The Children’s Hospital of Philadelphia, Philadelphia, PA, United States); Todd Beery, DO. Disclosures: C. Kim, none. Patients or Programs: A 24-year-old woman with a history of surgical repair of tetralogy of Fallot at age 2. Program Description: A 24-year-old woman with a history of surgical repair of tetralogy of Fallot at age 2 developed generalized fatigue for several months. Cardiac evaluation revealed cardiac failure with pulmonary stenosis. Consequently, she underwent elective pulmonic valve replacement and revision of the right ventricle to the pulmonary artery conduit under the standard cardiopulmonary bypass. On postoperative day 2, the patient complained of paresthesias and weakness of her bilateral lower extremities. The first magnetic resonance imaging studies of the spine at postoperative day 3 and initial electrodiagnostic study at postoperative day 5 were both normal. A repeated spine magnetic resonance imaging on postoperative day 7 demonstrated disseminated enhancement of the peripheral nerve roots of the cauda equina. Cerebrospinal fluid (postoperative day 8) protein was elevated and otherwise normal. The patient was diagnosed Guillain-Barré syndrome and received
Poster 69 Waiting to Inhale: Electrodiagnosis of A Left Phrenic Nerve Palsy After Chiropractic Cervical Manipulation: A Case Report. Christine M. Roque-Dang, DO (UMDNJ, New Jersey Medical School, Newark, NJ, United States); Jeffrey L. Cole, MD. Disclosures: C. M. Roque-Dang, none. Patients or Programs: A 50-year-old man. Program Description: The patient had presented with the chief complaint of dyspnea for several months. He reported that he had chiropractic treatment for cervicalgia and, on the day after cervical manipulation, developed unexplained dyspnea with mild exertional activities. Due to his worsening symptoms, he terminated his chiropractic visits and was evaluated by his primary care physician and a neurologist. Pertinent radiographic imaging included a SNIFF fluoroscopic examination, which revealed left hemidiaphragmatic paralysis and a chest radiograph that demonstrated an elevated left hemidiaphragm. Based on the patient’s history and radiographic imaging a electrodiagnostic testing was then performed to rule out a left phrenic nerve palsy. Setting: Outpatient private practice office. Results: On motor nerve conduction studies, he was found to have delayed distal latencies of the left phrenic nerve. Electromyography revealed reduced recruitment throughout the left hemidiaphragm, rare spontaneous denervation potentials in the left lateral diaphragm, and complex and nascent polyphasic single motor unit potentials in the left anterior diaphragm. The electrodiagnostic findings were consistent a left phrenic nerve segmental demyelinated injury. We referred the patient to a plastic surgeon, who performed a left phrenic nerve reconstruction. After surgery, the patient had improved respiratory function and activity tolerance. Discussion: A phrenic nerve injury that resulted in symptomatic diaphragmatic paralysis is most commonly associated with cardiothoracic surgery or malignancy. There are only a few cases that report phrenic nerve palsies sustained from chiropractic cervical manipulation. In these isolated reports, electrodiagnosis was not routinely used to detect these lesions. Conclusions: Reported is an unusual case of unilateral phrenic nerve palsy sustained after chiropractic manipulation. Before receiving cervical spine manipulation, patients should be counseled of this possible and serious complication. Electrodiagnostic studies are useful in phrenic nerve injury diagnosis and treatment determination. Poster 70 Lymphoma Presenting as a Cervical Radiculoplexus Neuropathy: A Case Report. Jacob L. Sellon, MD (Mayo Clinic, Rochester, MN, United States); Nathan P. Staff, MD, Stephen J. Wisniewski, MD. Disclosures: J. L. Sellon, none. Patients or Programs: A 64-year-old man with right arm pain and weakness. Program Description: The patient presented with insidious onset of burning pain in his right radial forearm with radiation into the thumb and index finger. On examination, although the Spurling test was negative, reduced triceps and brachioradialis reflexes suggested a cervical radiculopathy. The patient’s symptoms worsened
Vol. 3, Iss. 10S1, 2011
S201
despite a trial of physical therapy. After 2 months of arm pain, he developed right arm weakness across myotomes and was evaluated in a multidisciplinary spine clinic by physiatry, neurology, and neurosurgery. Setting: A tertiary care academic center. Results: Nerve conduction studies showed decreased right median and radial sensory nerve action potentials. Needle electromyography revealed fibrillation potentials and poorly recruited motor unit potentials in right C7-innervated muscles, opponens pollicis, and cervical paraspinal muscles. The electrodiagnostic findings were consistent with a cervical radiculoplexus neuropathy. Magnetic resonance imaging of the cervical spine and brachial plexus was unrevealing. A computed tomographic myelogram showed moderate neuroforaminal narrowing at C6-C7, with displacement of the exiting right C7 nerve root. After the patient’s arm pain transiently improved with a C6-C7 transforaminal epidural steroid injection, the decision was made to proceed with C6-C7 decompressive foraminotomies. After surgery, his symptoms progressed. Repeated electrodiagnostic testing showed evidence of a widespread cervical radiculoplexus neuropathy and prompted a lumbar puncture, which revealed non-Hodgkin large B-cell lymphoma. A subsequent positron emission tomography showed intense uptake of the right C7 nerve root with distribution into the brachial plexus, which confirmed earlier electrodiagnostic findings. Discussion: Neurolymphomatosis is a rare manifestation of lymphoma characterized by peripheral nerve infiltration. Neurolymphomatosis of the nerve roots or brachial plexus may mimic nonneoplastic processes, and a diagnosis is often delayed. As this case demonstrates, electrodiagnostic studies may reveal the patchy neuropathic findings of neurolymphomatosis before it is evident on imaging studies. Conclusions: Neurolymphomatosis should be included in the differential diagnosis in cases of progressive radiculopathy or plexopathy. Poster 71 Belatedly Diagnosed Acute Motor Axonal Neuropathy After Cardiac Surgery: A Case Report. Chong Tae Kim, MD, PhD (The Children’s Hospital of Philadelphia, Philadelphia, PA, United States); Todd Beery, DO. Disclosures: C. Kim, none. Patients or Programs: A 24-year-old woman with a history of surgical repair of tetralogy of Fallot at age 2. Program Description: A 24-year-old woman with a history of surgical repair of tetralogy of Fallot at age 2 developed generalized fatigue for several months. Cardiac evaluation revealed cardiac failure with pulmonary stenosis. Consequently, she underwent elective pulmonic valve replacement and revision of the right ventricle to the pulmonary artery conduit under the standard cardiopulmonary bypass. On postoperative day 2, the patient complained of paresthesias and weakness of her bilateral lower extremities. The first magnetic resonance imaging studies of the spine at postoperative day 3 and initial electrodiagnostic study at postoperative day 5 were both normal. A repeated spine magnetic resonance imaging on postoperative day 7 demonstrated disseminated enhancement of the peripheral nerve roots of the cauda equina. Cerebrospinal fluid (postoperative day 8) protein was elevated and otherwise normal. The patient was diagnosed Guillain-Barré syndrome and received