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ranged to neutral. Extensive hypertonicity of the trapezius, splenius
capitis and sternocleidomastoid (clavicular component) was noted
bilaterally. Computed Tomography revealed cervical paraspinal
musculature denervation with associated atrophy, degenerative disc
disease, and moderate neural foraminal stenosis. Electromyography
showed active denervation of bilateral cervical and upper thoracic
paraspinal muscles, active denervation of the left trapezius and
inability to recruit motor units in the cervical paraspinals.
Discussion:
The unusual presentation whereby denervation was
limited to cervical and upper thoracic paraspinal musculature posed
a diagnostic challenge with differential for causality including
proximal myopathy versus paraspinal compartment syndrome.
Compensatory hypertonicity of sternocleidomastoid (clavicular
component), trapezius and splenius capitis developed as the patient
attempted to hold his head in neutral. Lack of hypertonicity in the
scalenes or sternocleidomastoid (sternal component) suggested his
head was not being “pulled” forward in dystonic fashion. Treatment
was initiated with adjustable rigid cervical collar to support the neck
with progressive adjustments to bring the neck to neutral. Botox
injections to the hypertonic muscles was averted for concerns
weakening of compensatory cervical extension would worsen the
neck drop. Physical therapy is planned for posterior neck strength-
ening once cervical spine flexion/extension films are completed to
rule out dynamic instability.
Conclusions:
Focused physical examination and electromyography
findings suggested a differential diagnosis of paraspinal compartment
syndrome versus proximal myopathy in a patient with post-traumatic
neck drop and evidence of denervation on imaging.
Level of Evidence:
Level V
Poster 433:
Spinal Cord Stimulator Superior Lead Migration
Results in Focal Neurological Deficits: A Case Report
Daniel K. Reid, MD (WA Hosp Cntr/Georgetown Univ)
Disclosures:
Daniel Reid: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
A 66-year-old woman presented 5 days
after surgical revision of her spinal cord stimulator (SCS) with right
frontal headache, right facial droop, and impaired vision. A CT scan
head and limited skeletal survey was performed that revealed superior
migration of the SCS lead within the right aspect of the thecal sac at
the foramen magnum and superiorly along the right lateral foramen of
Luschka. Previous documentation revealed that the initial lead
placement at the time of revision was confirmed by fluoroscopy to be
at the level of the C2 pedicle.
Setting:
Tertiary Acute Care Hospital
Results:
The patient was taken to the operating room for SCS
explantation. Post-operatively the patient had complete resolution of
her pain and neurological symptoms.
Discussion:
Spinal Cord Stimulator (SCS) implantation is used to treat
chronic pain by exerting pulsed electrical signals to the spinal cord. It
is predominately performed for patients with failed back surgery
syndrome, complex regional pain syndromes, angina pectoris, and
ischemic pain. It is usually a well-tolerated procedure, with minimal
serious complications. Inferior lead migration is the most documented
complication, occurring in up to 20% of cases. In the one previous
documented case of superior lead migration, loss of pain relief was the
only presenting symptom. This case is unique in the fact that not only
did the patient present with loss of pain relief but also focal neuro-
logical symptoms.
Conclusions:
This case shows that while SCS lead migration is usually
a benign complication, more uncommon and serious variations can
occur and should be emergently evaluated. Also, given the high
complication rate of lead migration, alternatives in lead anchoring
techniques should be evaluated. Furthermore, additional investigation
into the true mechanism of lead migration is needed.
Level of Evidence:
Level V
Poster 434:
Case Report: Individualizing Radiofrequency Ablation
Therapy in Two Patients with Bertolotti’s Syndrome
Annie G. Philip, MD (Univ of Rochester Med Ctr, Rochester, NY, United
States), Maya Modzelewska, MD
Disclosures:
Annie Philip: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
Bertolotti’s syndrome is defined as axial
low back pain in the presence of lumbosacral transitional vertebrae.
The morphology can vary, from partial/complete L5 sacralization to
partial/complete S1 lumbarization. We describe the treatment of two
cases of Bertolotti’s syndrome using radiofrequency ablation targeting
levels based on the distribution of each individual’s pain and radio-
logical findings In case one, the patient was a 49-year-old man with
lumbarization of the S1 vertebra. Diagnostic blocks were performed
with 1cc of 0.5% bupivacaine at the L5 medial branch, S1 lateral
branch and along the pseudo-articulations in the upper, middle and
lower border of S1 transverse process and bilateral sacral alae. Radi-
ofrequency ablation was then performed at the same targets at 80
degree centigrade for 80 seconds. In case 2, the patient was a 19-year-
old woman with a partially sacralized L5 transitional vertebra. Diag-
nostic blocks were performed with 1cc of 0.5% bupivacaine at L4 and
L5 medial branches and along the pseudo-articulation in the upper,
middle and lower border bilaterally. Radiofrequency ablation was then
performed at these targets.
Setting:
Outpatient tertiary clinic.
Results:
In case one, the patient received 100% relief of his pain for
ten months allowing him to resume his recreational activities and
continue full time work. In case two, the patient received 80% pain
relief, lasting for 7 months duration allowing her to discontinue
medication use and continue school full time.
Discussion:
Although there have been multiple studies in the litera-
ture about radiofrequency ablation for lumbar facet pain, only one
case report in the literature describes radiofrequency ablation for
Bertolotti’s syndrome.
Conclusions:
There is no consensus about the best method for the
treatment of Bertolotti’s syndrome, which is an uncommon cause of
predominantly axial low back pain. Radiofrequency ablation can be a
successful option using individualized therapy depending on the
morphology of the transitional vertebrae.
Level of Evidence:
Level V
Poster 435:
Immunosuppressant Medication Induced Lower Extremity
Pain after Combined Liver and Kidney Transplant:
A Case Report
Thanzeela K. Mohideen, MD (Med Col of WI, Waukesha, WI, United
States), Hong Wu, MD
Disclosures:
Thanzeela Mohideen: I Have No Relevant Financial Re-
lationships To Disclose
Case/Program Description:
A 35-year-old woman with combined
liver/kidney transplant presented 14-months post-transplant with
aching, stabbing, burning pain in bilateral anterior knees, lateral an-
kles, and dorsum/soles of the feet. She also had numbness/tingling in
bilateral feet. Pain was worse with weight-bearing and better with
elevating lower extremities (LE). Patient was maintained on tacroli-
mus for immunosuppression post-transplant. Physical exam revealed
tenderness over the left medial/lateral knee, bilateral anterior
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Abstracts / PM R 9 (2017) S131-S290