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Conclusions:
There have been less than one hundred cases doc-
umenting the complications of NMO during pregnancy. The use of
immunosuppressant and muscle relaxants to treat the neurological and
musculoskeletal clinical manifestation of NMO is limited in pregnancy.
It is therefore prudent to investigate response to physical therapy
modalities in this patient population. This case illustrates the neces-
sity for a multidisplinary approach for successful rehabilitation of
patients with NMO complicated by pregnancy.
Level of Evidence:
Level V
Poster 417:
Improving Amputation Outcomes with Ketamine
Infusions in Treatment-Resistant Complex Regional
Pain Syndrome: A Case Report
Ian D. Dworkin, MD (UCLA/Greater Los Angeles VA Healthcare system,
Los Angeles, CA, United States), Edward K. Pang, DO,
Milena D. Zirovich, MD, Sanjog S. Pangarkar, MD
Disclosures:
Ian Dworkin: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
A 33-year-old man presented to pain
clinic with progressive right leg pain following knee surgery. The
diagnosis of Complex Regional Pain Syndrome (CRPS) was made using
International Association of the Study of Pain criteria. For 17 years,
the patient trialed multidisciplinary therapy, neuropathic medica-
tions, lumbar sympathectomies, dorsal column stimulator and high
doses of opioids; however, he developed significant co-morbidities
including diabetes, contractures, and severe depression. Because of
this, a different treatment approach became necessary. Monthly ke-
tamine infusions improved pain control and helped wean opioid use,
and the patient underwent transfemoral amputation. Following sur-
gery, two post-operative ketamine infusions were completed along
with aggressive physical therapy.
Setting:
Outpatient Pain Clinic.
Results:
Now 2 years after amputation, the patient has stopped all
opioid medications, and has not demonstrated phantom limb pain or
the spread of CRPS. He has met his therapeutic goals in all outcome
measurements, including basic and advanced locomotor capabilities
index, timed-up-and-go, and 2-minute walk test. He has also pro-
gressed to independent ambulation with a prosthetic limb and serves
as a peer-mentor.
Discussion:
Amputation may become necessary in patients with CRPS.
Several trials have demonstrated success with amputation compared
to non-operative treatments. Ketamine is believed to inhibit windup
and central sensitization, pathways likely involved in CRPS. Prior
studies of patients with CRPS have demonstrated significant short and
long-term pain relief with ketamine infusions alone. By utilizing these
infusions in conjunction with amputation, our patient was able to
wean opioid use, decrease pain, improve quality-of-life and ambulate
with prosthetic assistance. To our knowledge, this is the first case that
reports long-term outcomes utilizing ketamine infusions concurrently
with amputation in CRPS.
Conclusions:
Although currently an end-stage treatment option in
treatment-resistant CRPS, amputation with peri-surgical ketamine
infusions may help prevent CRPS spread and phantom limb pain.
Level of Evidence:
Level V
Poster 418:
Urinary Incontinence and Lumbar Radicular Pain
Attributed to a Large Tarlov Cyst: A Case Report
Ankur A. Patel, BS (Edward Via College of Osteopathic Medici, Laurel,
MD, USA), Arpit Patel, DO, Enrique Galang, MD, Devang Padalia, MD
Disclosures:
Ankur Patel: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
42-year-old woman presented with low
back pain and new onset of episodic urinary incontinence. She was
ruled out for any neurosurgical compromise and was told it was likely
attributed to spasms and degenerative disc disease. She had a
cystoscopy work up from urology, which was unremarkable. Patient
described the pain as a constant sharp and burning sensation that
radiates down both sides of the buttocks, intermittent radiation
down to bilateral feet and burning sensation concentrating near the
rectum. MRI of the L-spine indicated multilevel bulging discs, bilat-
eral lumbar spondylosis and a large perineurial Tarlov cyst in the
sacral thecal sac at the level of S2 (imaging provided). The precise
location of this cyst and after collaboration with urology, it was
deemed the urinary incontinence was attributed to the location of
the cyst.
Setting:
Outpatient academic practice.
Results:
The patient underwent a lumbar epidural steroid injection.
We hypothesized that the epidural would decrease the inflammation
around the cyst thus lessen the pressure on the nearby nerve roots and
ultimately provide symptomatic relief.
Discussion:
Tarlov cysts are nerve root cysts filled with cerebrospinal
fluid commonly found in the sacral roots between the endoneurium
and perineurium space of the posterior nerve root sheath at the dorsal
root ganglion. The hallmark is the presence of nerve root fibers within
the cyst wall or cavity. Tarlov cysts are commonly benign lesions and
do not require surgical intervention. However, when the Tarlov cyst is
present in the sacral neural canal and foramina, it produces symptoms
of low back pain, leg pain, bowel and bladder dysfunction and sexual
dysfunction.
Conclusions:
This case outlines a rare cause of lumbosacral pain and
radiculopathy. Since most Tarlov cysts are asymptomatic, they are
often overlooked; however, it should be considered in the differential
of urinary incontinence in the setting of radicular low back pain.
Level of Evidence:
Level V
Poster 419:
Ganglion Cyst of the Tibiofibular Joint Mimicking Lumbar
Radiculopathy
Natacha S. Falcon, DO (Rothman Institute), Fotios Toumakaris, MD
Disclosures:
Natacha Falcon: Receipt of royalties - Pfizer-Lyrica
Case/Program Description:
A 66-year-old man presented with acute
foot drop on the left. Patient had mild back pain without specific leg
pain. He had sensory deficits on the anterolateral aspect of the left leg
and foot. MRI of the lumbar spine revealed mild stenosis at L4-5. As a
result of the significant foot drop in the setting of MRI without sig-
nificant findings, an EMG/NCS of the left lower extremity was ordered.
Setting:
Outpatient orthopedic spine and joint center.
Results:
Patient’s MRI lumbar spine revealed mild stenosis at L4-5.
EMG/NCS revealed sponateous activity in tibialis anterior. Compound
muscle action potential (CMAP) and sensory nerve action potential
(SNAP) latencies of the left peroneal nerve were absent. As a result of
the EMG/NCS an MRI of the left knee was ordered. MRI of the left knee
revealed ganglion cyst extending anteriorly from the tibiofibular joint
with a thickened common peroneal nerve.
Discussion:
The patient was diagnosed with an acute left lower ex-
tremity foot drop secondary to peroneal neuropathy. The patient un-
derwent neurolysis and decompression of the peroneal nerve and
debridement of the proximal tibiofibular joint.
Conclusions:
Clinicians must consider additional workup for patient
who present with drop foot without significant back and leg pain.
Peroneal neuropathy is important to rule out in the differential diag-
nosis. Patients can have a ganglion cyst in the knee that may cause a
compressive neuropathy. As in this case, external compression on the
deep peroneal nerve by ganglion cyst can cause peroneal neuropathy.
History, physical exam, and diagnostic testing, to include MRI of
lumbar spine and EMG/NCS are warranted, when clinical presentation
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Abstracts / PM R 9 (2017) S131-S290