S269 S290
Case/Program Description:
A 58-year-old man who suffered a stroke
4 years ago (resulted in mild right hemiparesis with eventual reso-
lution of deficits) presented to his PCP with right lower extremity
pain of 1 year duration. Given the patient’s history of uncontrolled
diabetes (A1c 13%), he was initially treated for diabetic neuropathy
and given gabapentin 300mg TID. Despite this, the patient’s pain
was unabated. He had 5/5 strength in his bilateral lower extremities
and only mildly decreased sensation on the bottom of his feet;
however, he complained of severe, intermittent, sharp, shooting
pain down his right leg to the foot. A lumbar spine MRI revealed
minimal neural foraminal narrowing from L3-S1 bilaterally. A sub-
sequent NCS/EMG revealed mild slowing of right peroneal, tibial and
sural nerves, as well as mildly enlarged MUAPs with reduced
recruitment in right L5 innervated muscles. Patient was determined
to have chronic mild right L5 radiculopathy and his gabapentin was
increased to 600mg TID with only minimal improvement. While
obtaining the patient’s history in our clinic, he mentioned that cold
temperature produced severe pain in his right foot. On examination,
he had allodynia (became tearful upon assessing sensation in right
foot), but did not have asymmetric changes in skin color, temper-
ature or hidrosis. Although brain MRI from 4 years ago was unavai-
lable, repeat brain MRI revealed chronic lacunar infarcts in bilateral
thalami.
Setting:
Outpatient PM&R Clinic.
Results:
The patient was treated with amitriptyline (titrated up to
100 mg daily) for presumed central post-stroke pain with significant
pain relief.
Discussion:
This case highlights the consideration of central post-
stroke pain in patients with severe and not otherwise well-explained
pain status post stroke.
Conclusions:
Although it is helpful for patients to receive an expla-
nation for their pain, there is no definitive cure for central post-stroke
pain, and treatment with neuropathic agents can have a limited
effect.
Level of Evidence:
Level V
Poster 430:
Heterotopic Ossification Treated with Etidronate for
Eight Years
Brittni Micham (UPMC Medical Education PM&R Program, Pittsburgh,
PA, USA), Amanda L. Harrington, MD
Disclosures:
Brittni Micham: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
A 33-year-old man with a history of
thoracic paraplegia had been started on etidronate 1000mg daily for
left hip heterotopic ossification (HO) in 2007. In 2015, he presented to
clinic for a new patient evaluation. When reviewing his medications, it
was discovered that he had remained on bisphosphonate therapy for
eight years. On exam, he had a large, firm pelvic mass and decreased
range of motion of the left hip. Discussion with the patient’s PCP,
Endocrinologist and previous physiatrist revealed no satisfactory
explanation for continuing bisphosphonate therapy. The patient was
weaned off etidronate by 100mg per week. Immediately after
completing the wean, the patient endorsed decreased range of motion
of the left hip, which was confirmed by his outpatient therapist. CT
scan revealed extensive HO in the pelvic bones and bilateral hips. Bone
scan showed moderately increased uptake in the left iliac bone and hip
suggestive of active bony turnover. The patient was restarted on eti-
dronate 1000mg daily for presumed rebound HO with subsequent
improvement in left hip range of motion.
Setting:
Outpatient clinic.
Results:
Due to risks of long-term bisphosphonate therapy, a more
gradual etidronate wean was initiated decreasing by only 100mg per
month. Four months into the slow taper, he had not yet reported any
further symptomatic progression of HO.
Discussion:
This is the first reported case, to our knowledge, of a
patient on bisphosphonate therapy for HO continuously for several
years. Given the adverse effects of bisphosphonates, treatment for
several years is not recommended. The management of a long-term
bisphosphonate wean in the setting of rebound HO is difficult due to
the lack of literature regarding these topics.
Conclusions:
This case illustrates the importance of reviewing medi-
cations over the course of treatment. The holistic approach encour-
aged in physiatry uniquely positions the field to mitigate risks
associated with medication oversights.
Level of Evidence:
Level V
Poster 431:
Ultrasound Guided Dextrose Prolotherapy with
Platelet Rich Plasma for Sacroiliac Pain: A Case
Report
Glenna Tolbert, MD (Ctr for Rehab and Wellness)
Disclosures:
Glenna Tolbert: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
We present a case report which dem-
onstrates the successful use of Dextrose- PRP (platelet rich plasma)
spine injection therapy utilizing Hackett’s Method. With the addition
of an ultrasound guided approach to identify the sacroiliac (SI) joint
and ligaments, the procedure was performed safely and accurately
in an office setting [10]. Although ultrasound has limited diagnostic
value in the spine, it aids in identifying target structures and land-
marks. This approach diminishes costs and potential complications
by negating the need for radiological and parenteral analgesia
exposure.
Setting:
Private Practice, Office.
Results:
At 1-year follow-up, the subject maintained pain reduction,
decrease or elimination of pain medications and achievement of
functional goals. Given the preliminary positive outcomes in this
patient with SI pain refractory to myriad treatments, including radio-
frequency ablation, the use of Dextrose-PRP injection therapy
warrants more vigorous investigations.
Discussion:
Sacroiliac (SI) joint pain is commonly associated with
various arthritic conditions. For patients with osteoarthritis (OA)
involving the spine, proper diagnosis, pain management and functional
outcomes remain poor and inconsistent. This is despite widely used
therapies such as steroid and Botulinum Toxin injections, chemo-
nucleolysis, radio-frequency denervation, intradiscal electrothermal
therapy, pain pumps, spinal cord stimulators and surgery [1],[2]. Most
of these options include adverse side effects and significant compli-
cation risks.
Conclusions:
These results suggest an exciting, convenient, and
effective method of managing SI Joint pain, particularly in the geri-
atric population.
Level of Evidence:
Level V
Poster 432:
An Unusual Presentation of Cervical Paraspinal
Denervation Resulting in Neck Drop: A Case Report
Katie Hatt, DO (Temple Univ Hosp, Philadelphia, PA, United States),
Nicholas C. Kinback, MD, Peter Riedel, DO, Michael M. Weinik, DO
Disclosures:
Katie Hatt: I Have No Relevant Financial Relationships To
Disclose
Case/Program Description:
A 82-year-old man presented with acute
onset neck stiffness with neck drop after falling
w
13 steps. He
described difficulty holding his head in the upright position as opposed
to feeling his neck was being pulled forward.
Setting:
Outpatient rehabilitation clinic.
Results:
On examination, the cervical spine was flexed forward. He
was unable to actively extend his neck into neutral. Passively, his neck
S269
Abstracts / PM R 9 (2017) S131-S290