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in diagnostic difficulty and delays. Delays are often associated with
high morbidity and mortality in these patients.
Conclusions:
It is crucial to maintain a high index of suspicion for
infectious etiologies and utilize a combination of laboratory and im-
aging studies when working up back pain.
Level of Evidence:
Level V
Poster 411:
Two-Step Approach with Onabotulinum Toxin Type A
Intradermal & Intramuscular Infiltrations for T8-T12
Chronic Post Herpetic Neuralgia: A Case Report
Jean C. Gallardo, MD (VA Caribbean Healthcare System, San Juan,
Puerto Rico, Puerto Rico), Melissa A. Burgos, MD, Keryl Motta-
Valencia, MD
Disclosures:
Jean Gallardo: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
Male patient with past medical history of
herpes zoster who presented to our clinics with complaint of a 6-year
course of right sided abdominal wall and flank pain. Pain was
described as severe, aching and burning quality associated with
bloating/fullness sensation. Patient’s symptoms were refractory to
multiple pain management treatment modalities. Initial physical ex-
amination was remarkable for allodynia and hyperpathia in right T8-
T12 dermatomes, consistent with post herpetic neuralgia (PHN). Pa-
tient was scheduled for Onabotulinum toxin type A injections which
were reconstituted with preservative free saline solution to a con-
centration of 100Units/1mL. Patient recieved sequential infiltrations
with Onabotulinum toxin type A. Initial procedure consisted of intra-
dermal Onabotulinumtoxin type A infiltration at symptomatic anterior
right T8-T12 dermatomes of the abdominal wall and flank. After initial
procedure patient reported a decrement of pain intensity and
neuropathic qualities. A second infiltration was scheduled with a
variation consisting of a two-step method with intradermal infiltration
of Onabotulinumtoxin type A at affected dermatomes anteriorly and
posteriorly at parecentral lines, using electromyography guidance.
After second procedure patient presented full resolution of pain,
dysesthesias and hyperpathia.
Setting:
Outpatient Clinic in a VA Hospital.
Results:
Onabotulinumtoxin type A infiltration, with the described
two-step approach method, lead to satisfactory and sustained relief of
a severe and refractory post herpetic neuralgia involving the T8-T12
dermatomes with normalization of skin sensation as well.
Discussion:
To our knowledge, this is a unique case describing a two-
step method for combined intramuscular and intradermal infiltration
of Onabotulinumtoxin type A showing positive results for treatment of
PHN.
Conclusions:
Chronic post-herpetic neuralgia can be characterized by
severe pain, refractory to conventional treatments. A two-step
approach for intradermal and intramuscular application of Onabotu-
linumtoxin type A should be considered among treatment options.
Level of Evidence:
Level V
Poster 412:
Spinal Cord Compression following Radiofrequency
Tumor Ablation and Vertebral Augmentation in a
Multiple Myeloma Patient: A Case Report
Thomas Chai, MD (UT MD Anderson Cancer Center, Houston, TX,
United States), Girish S. Shroff, MD, Billy K. Huh, MD, PhD
Disclosures:
Thomas Chai: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
A 65-year-old man with history of multi-
ple myeloma presented with back pain. Imaging revealed multiple
vertebral lesions, including involvement of the T5 vertebral body, with
associated pathologic compression fracture. Despite radiation therapy
to the spine and opioid/adjuvant use, the patient’s severe back pain
persisted. Follow-up spine imaging revealed progression of the T5
fracture. Due to unremitting pain, radiofrequency tumor ablation of
T5 followed by vertebral augmentation was offered. The patient un-
derwent T5 vertebral body radiofrequency tumor ablation at 50 de-
grees Celsius. 3.5 mL of polymethylmethacrylate cement was then
injected into the vertebral body cavity created by the radiofrequency
lesioning. There were no immediate postprocedural complications
noted, and the patient was discharged home neurologically intact and
in stable condition.
Setting:
Tertiary care hospital.
Results:
The patient responded well to the pain procedure; however,
4 days later he reported leg weakness and falls. Repeat spinal imaging
revealed further collapse of the T5 vertebral body, with both bone and
cement retropulsion into the canal, resulting in ventral effacement of
the spinal cord. Given these findings, the patient underwent urgent
decompressive spinal surgery, followed by admission to the rehabili-
tation unit.
Discussion:
Multiple myeloma is a hematologic cancer of plasma
cells in the bone marrow. This disease can cause damage to bone,
kidneys, and the immune system, among other manifestations. Bone
pain is common in patients with multiple myeloma, with 70%
reporting this symptom at disease onset. Pathologic bone fractures
occur in about 40% of myeloma patients, with around 55-70% of
fractures involving vertebrae. Epidural involvement may occur in up
to 20% of myeloma patients at various disease stages. This may lead
to cord compression if tumor/bone fragments progressively invade
the spinal canal.
Conclusions:
The risks and benefits of spine interventions for pain
must be carefully considered in the cancer patient with pathologic
vertebral compression fractures.
Level of Evidence:
Level V
Poster 413:
Giving Back Independence and the Ability to Walk: A
Spinal Meningioma Mimicking Diabetic Amyotrophy: A
Case Report
Ryan Thompson, DO (Ohio State Univ Med Cntr, Columbus, Ohio,
United States), Laura Gruber, MD, Elizabeth P. Probert, MD,
Jennifer Mast, MD, Sam Colachis III, MD
Disclosures:
Ryan Thompson: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
A 42-year-old man with history of DM
(Type1) presented with a 5-year history of progressive weakness,
paresthesias, and neuropathic pain. During this period of time, he
experienced gradual worsening upper and lower extremity paresis,
paresthesia, and radicular pain. He had recurrent falls resulting in
multiple Emergency Department encounters. Evaluation in the past
included neurologic and electrodiagnostic evaluations consistent
with diabetic amyotrophy. His neurologic status and function
continued to worsen until he was non-ambulatory and required
assistance for his mobility and daily care for the past year. During
a recent admission for a fall resulting in multiple rib fractures, a
cervical and thoracic MRI were performed which demonstrated a
Grade I cervicothoracic meningioma (C6-T1). He underwent subse-
quent resection of the meningioma followed by inpatient spinal cord
injury rehabilitation. During his rehabilitation hospitalization, he
showed remarkable improvement in neurologic and functional sta-
tus, and by discharge home was independent in his activities of daily
living (ADLs), and ambulation.
Setting:
Inpatient Rehabilitation Hospital.
Results:
.
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Abstracts / PM R 9 (2017) S131-S290