S268 S290
Case/Program Description:
A 23-year-old male golfer with right
posterolateral rib pain and mass for 6 months. The patient felt like his
rib “popped out” while sitting in class. He waited approximately one
month, then was evaluated by his primary care physician, who started
patient in physical therapy for one month. Physical therapy improved
his pain slightly. He started having shortness of breath, and his pain
worsened. The patient had a history of tobacco abuse. He was started
on albuterol inhaler and referred for a physiatrist evaluation. Focused
physical exam revealed a large (7 cm x 15 cm), nonmobile, tender,
smooth mass. MRI chest revealed large, solid partially necrotic mass
centered in the right lateral through posterior lower chest wall
through upper abdominal wall with extensive contiguous pleural
metastatic involvement, a medial component extends along the right
lateral margins of multiple lower thoracic vertebral bodies including to
the neural foramina. The mass measures approximately 17 cm AP x 14
cm transverse x 20 cm craniocaudal dimensions. Large associated right
pleural effusion filling the entirety of the right thorax. Prominent
displacement of mediastinal structures into the left thorax. Patient
was admitted to the hospital for shortness of breath and further
evaluation of the mass. CT of the chest showed complete opacification
of the right pleural space with fluid.
Setting:
Academic Clinic.
Results:
Biopsy of the mass was consistent with Alveolar rhabdo-
myosarcoma. Patient was started on Vincristine, Dactinomycin,
Cyclophosphamide, and Mesna. Further developments will be
discussed.
Discussion:
Rhabdomyosarcoma is most common in children under the
age of 18. The two main pediatric subtypes are alveolar and embry-
onic. The subtype that mainly affects adults is pleomorphic. The
treatments for adults are not standardized. Adult patients with
rhabdomyosarcoma have a poor prognosis.
Conclusions:
Alveolar rhabdomyosarcoma is a rare cause of rib pain
with a mass in a young adult golfer.
Level of Evidence:
Level V
Poster 427:
Effective Treatment of Axial Neck Pain and
Cervicogenic Headaches Secondary to Ankylosing
Spondylitis Through a Comprehensive, Multidisciplinary
Pain Management Program: A Case Report
Lauren F. Vernese, DO (McGaw MC of NW Univ NW Med Schl/RIC),
Jeffrey Cara, DO, Karina Bouffard, MD, Trevor Tyner, DO
Disclosures:
Lauren Vernese: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
A 49-year-old woman with ankylosing
spondylitis (AS) presented with chronic posterior neck pain and
radiating headaches. Pain was characterized as 2-9 on the visual
analogue scale, cramping and aching, worsened by standing and
walking, and improved by supine positioning. The severity of symp-
toms forced her to go on disability. Examination revealed diffusely
restricted cervical motion. Palpation induced tenderness over
bilateral upper cervical zygapophyseal joints. Spurling’s test was
positive to the left. MRI revealed C2-C3 anatomical fusion with
osteophyte compression of the left C3 nerve. For pain relief, she had
employed physical therapy, epidural and oral steroids, and bilateral
C3, C4, C5 radiofrequency ablations. She was taking hydrocodone
and tramadol with a morphine equivalent daily dose (MEDD) of 50.
Additionally, she was taking gabapentin, clonazepam, diclofenac,
orphenadrine, and verapamil.
Setting:
The patient enrolled in an outpatient multidisciplinary pain
rehabilitation program (MPRP) involving medical management, phys-
ical and occupational therapies, psychology, postural retraining, and
physical conditioning with a home exercise program.
Results:
Over 4 weeks, Neck Disability Index Score improved from 37/
50 to 13/50. Tampa Scale for Kinesiophobia improved from 32 to 26.
She was transitioned from hydrocodone to tapentadol for more tar-
geted efficacy toward neuropathic pain and MEDD decreased to 20 on
most days. Subjectively, patient perceived a dramatic improvement in
pain and function. Furthermore, she was able to return to work part-
time with a plan to gradually increase to full-time.
Discussion:
AS is a chronic seronegative spondyloarthropathy
affecting 0.7 to 49 per 10,000. Radiological involvement of the cervical
spine is seen in 19.6% after 5 years of disease and 70% after 20 years,
and nearly half of patients will develop prominent neck pain.
Conclusions:
This case demonstrates the efficacy of a MPRP to reduce
disability, opioid burden, and kinesiophobia due to chronic neck pain
and headaches secondary to cervical autofusion from AS.
Level of Evidence:
Level V
Poster 428:
Therapeutic Options for Recalcitrant Spinal
Headache after Cervical Epidural Injection: A Case
Report
Thiru Annaswamy, MD, FAAPMR (VA North Texas Health Care System,
UT Southwestern Medical Center, Dallas), Ankit Patel, MD
Disclosures:
Thiru Annaswamy: I Have No Relevant Financial Re-
lationships To Disclose
Case/Program Description:
A 49-year-old woman with history of
cervical radiculopathy due to degenerative disc disease was referred
for a cervical epidural steroid injection (CESI). The CESI was per-
formed under fluoroscopic guidance using interlaminar approach,
using loss-of-resistance (LOR) technique. When LOR was perceived, a
small amount of CSF backflow was noted in the hub of the needle. The
needle was retracted, and contrast administration revealed epidural
spread, following which corticosteroid was administered and the
needle removed.
Setting:
Outpatient spine clinic and interventional spine clinic.
Results:
Patient called 2 days after CESI reporting persistent spinal
headache (SH) since the CESI, that did not respond to supine lying,
caffeine intake or analgesic use. She was scheduled for an epidural
blood patch (EBP) procedure. Since her spinal procedure, performed
at the cervical level, revealed a rather narrow epidural space, we
decided to perform the EBP at the lumbar level rather than the cer-
vical level. This was based on literature review that suggested similar
results from lumbar EBP as a cervical EBP. Patient underwent lumbar
L4-5 EBP with autologous blood with immediate and excellent relief of
SH.
However, patient called a week later reporting persistent SH symp-
toms albeit of much less intensity. This time, she received IV Infusion
of Cosyntropin 500 mcg, with complete relief of symptoms.
Discussion:
SH is an uncommon complication following ESI proced-
ures. EBP, a common and effective treatment can be performed at a
spinal region remote from the procedure site, with similar effective-
ness. In recalcitrant cases, despite EBP trials, IV infusion of ACTH (or
synthetic analog) can be used with effective results.
Conclusions:
Lumbar epidural blood patch and IV Cosyntropin (ACTH)
infusion can be effective therapeutic options to treat spinal headache
after inadvertent dural puncture that occurred during cervical
epidural steroid injection. Physiatrists performing spinal procedures
need to be aware of treatment options available.
Level of Evidence:
Level V
Poster 429:
Uncovering Central Post-Stroke Pain in the Setting of
Diabetic Neuropathy and Lumbar Radiculopathy: A
Case Report
Kevin C. Pelletier (University of California Irvine)
Disclosures:
Kevin Pelletier: I Have No Relevant Financial Relation-
ships To Disclose
S268
Abstracts / PM R 9 (2017) S131-S290