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PAIN & SPINE MEDICINE POSTER HALL: CASE REPORTS
Poster 408:
Patient-Administered Sphenopalatine Ganglia Block:
A Case Report
Natasha C. Mehta, MD (NJ Med Schl/Rutgers), Jeffrey L. Cole, MD
Disclosures:
Natasha Mehta: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
Sphenopalatine ganglia (SPG) is sus-
pended in the pterygopalatine fossa with sympathetic, para-
sympathetic, and somatosensory contributions from the superior
cervical ganglion, greater petrosal nerve, and maxillary nerve,
respectively. This ganglion has been linked to trigeminal autonomic
cephalgias and migraines. Few patients are refractory to conservative
treatments. SPG blocks have been utilized for pain management in
these cases. A 54-year-old woman presented with photo-oculodynia
syndrome and cluster-type hemicephalgias that initially improved with
vocational modifications. Over the years she failed monotherapies,
including oxygen, but had partial relief with topirimate, oxcarbaze-
pine, gabapentin, and naproxen. She still experienced functionally
debilitating photophobia, atypical facial pain, and trigeminal neural-
gia. Exam significant for photophobia producing severe right ocular
headaches.
Setting:
Outpatient Rehabilitation Center.
Results:
Transnasal SPG blocks improved visual convergence and
drilling facial pain. She was taught self-administration of SPG blocks
with lidocaine applied with Q-Tips every other day and photo-oculo-
dynia exacerbations gradual improved. Over the last 2 years she
regained tolerance for sunlight and fluorescent lights without the need
for shading.
Discussion:
The SPG is accessible via a transnasal approach posterior
to the middle turbinate, lateral approach through the infratemporal
fossa, or transoral approach through the greater palatine foramen.
Adverse effects of intranasal approach with anesthetic include
epistaxis, dysesthesia, and temporary diplopia. Due to the rare risk
of anesthetic toxicity or infection, this patient started with 1%
lidocaine solution. The transoral and lateral approaches are complex,
sometimes done with imaging guidance. The transnasal approach is
technically simpler and can be taught to the correctly selected
patient.
Conclusions:
SPG blocks have been successfully performed for over a
century, utilizing various agents or neuromodulation. Limitations to
topical hydrophobic anesthetic are duration of effect and accuracy.
There have been case reports of cumulative relief over time with re-
petitive SPG blocks. This person was able to learn the technique to
perform independently as needed.
Level of Evidence:
Level V
Poster 409:
Toxicology Immunoassay to Evaluate for the Presence
of Tetrahydrocannabinol (THC) in a Commercially
Sold Cannabidiol (CBD) Formulation: A Case Report
G. Sunny Sharma, MD (VA Greater LA Health Care System/UCLA),
Ian D. Dworkin, MD, Sanjog S. Pangarkar, MD
Disclosures:
G. Sunny Sharma: I Have No Relevant Financial Re-
lationships To Disclose
Case/Program Description:
Patient is a 53-year-old man referred for
chronic lumbar radiculopathy and spinal stenosis. He had previously
trialed physical therapy, anti-inflammatory medications, and epidural
steroid injections without relief. He was started on opiate therapy by
his primary care provider and random urine toxicology screen revealed
presence of THC. Patient denied use of marijuana but reported use of
cannabidiol (CBD) products including ingestible oils and topical
creams. This finding triggered the question of whether use of CBD
products can result in marijuana positive routine drug screens.
Setting:
Tertiary Hospital.
Results:
A commercially available sample of “100% natural” CBD oil
(Canabe Botanicals, Venice CA) containing 250mg of cannabidiol was
obtained. Using enzyme multiplied immunoassay technique (EMIT),
the pathology department was able to analyze the sample for the
presence of THC. THC was not detected in this single CBD sample.
Discussion:
With recent legislation, marijuana has been legalized for
medical use in 26 states. CBD is a non-psychoactive cannabinoid pre-
sent in cannabis believed to have a wide range of medical applica-
tions. THC is the psychoactive component traditionally tested for in
urine toxicology screens. Controversy arises when considering
different portions of the cannabis plant may have varying levels of CBD
and THC present. Although commercial CBD products for medical use
are thought to be derived from industrial hemp plants and contain less
than 0.3% THC, impure formulations may contain high amounts of THC
resulting in positive drug screens. Even “pure” CBD samples ingested in
high quantities can theoretically produce positive drug screens. As
medical and recreational use of marijuana increases, further studies
are warranted to explore how its use may affect clinical decision
making.
Conclusions:
While CBD formulations may provide medical benefit for
some patients, there is still limited oversight regarding its composi-
tion. Physiatrists should recognize obstacles that may be encountered
when treating patients using CBD products.
Level of Evidence:
Level V
Poster 410:
Psoas Abscess Mimicking Facetogenic Pain on Initial
Presentation: A Case Report
Maria Vanushkina, MD (New York University School of Medicine, New
York, NY, United States), Neil Mandalaywala, MD, Margarita Cantir,
MD, Young IL Seo, MD, Kimberly A. Sackheim, DO, FAAPMR,
Charles Kim, MD, Salvador Portugal, DO, FAAPMR
Disclosures:
Maria Vanushkina, MD: I Have No Relevant Financial Re-
lationships To Disclose
Case/Program Description:
The patient is an 88-year-old woman with
history of hysterectomy who was referred for evaluation of acute
onset low back and buttock pain of 2 weeks duration without any re-
ported provocation or injury. The pain was 4/10, intermittent, aching,
exacerbated by walking, alleviated by resting, sitting, Tylenol and
Advil. There were no associated fevers, chills, radicular symptoms,
bowel or bladder dysfunction, reported changes in weight, prior or
recent injections or instrumentation of the spine. Exam was notable
for an antalgic gait, pain with end flexion and bilateral oblique
extension, tenderness over paraspinal muscles and facet joints as well
as the left sacroiliac joint and posterior superior iliac spine. Motor,
sensory, and deep tendon reflexes were intact.
Setting:
Outpatient Spine Center.
Results:
Lumbar radiographs showed multilevel degenerative disc
disease, spondylosis, and multilevel facet arthrosis. Patient was
started on naproxen and referred to outpatient physical therapy. She
presented for early follow up 11 days later, with increasing 7/10 pain
radiating to left anterior thigh. Exam notable for new tenderness
over anterior midthigh, positive left Ober test, reproduction of left
anterior thigh pain with Ely test, mild weakness of left hip flexors
and diminished left lower reflexes. Lumbar MRI showed left L3-4
facet joint abnormality, adjacent marrow edema, and soft tissue
abscess of the multifidus and psoas muscles. She was emergently
referred for inpatient admission, and required a prolonged
hospitalization.
Discussion:
Psoas abscess is a rare infectious disease with nonspecific
clinical presentation and often insidious onset that frequently results
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Abstracts / PM R 9 (2017) S131-S290