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Discussion:
Pudendal neuralgia is a diagnostic and therapeutic chal-
lenge for many. There are no definitive diagnostic exams to date and
there is often a paucity of physical exam findings. Common etiologies
typically include compression due to childbirth and pelvic surgery, but
we must now also recognize Nuvaring use as an alternative cause of
pudendal neuralgia and the successful treatment of recalcitrant pu-
dendal neuralgia with electro-stimulation.
Conclusions:
This is the first reported case of pudendal neuralgia
related to Nuvaring use to date. Recognizing the possible pre-
sentations and etiologies of pudendal neuralgia, as well as effective
treatment modalities, can lead to better diagnosis and prompt treat-
ment of an otherwise poorly understood and undertreated syndrome.
Level of Evidence:
Level V
Poster 442:
Lumbosacral Radiculopathy Pain Symptoms
Secondary to Pregnancy Associated Sacral Fracture:
A Case Report
Christopher J. Rizik, DO (Wm Beaumont Hosp, Royal Oak, MI, United
States), Evan Halchishick, DO
Disclosures:
Christopher Rizik: I Have No Relevant Financial Re-
lationships To Disclose
Case/Program Description:
A 33-year-old gravida 2, para 2 woman
presented to the office 10 days following induced vaginal delivery of
her second daughter. She experienced right-sided low back pain
throughout her pregnancy, to the point of difficulty with ambulation.
Induced delivery was pursued secondary to increased late stage pain.
When evaluated following unremarkable delivery, she reported
radicular back pain and paresthesias coursing the posterior right thigh
and calf. She also endorsed right lower extremity weakness and
limping gait. On exam, she exhibited weakness with right sided calf
raises, tenderness of the right lower facet and sacroiliac joints, and
positive right straight leg raise. Clinical assessment of pain was of right
lower lumbar facet arthropathy, sacroiliitis, and right S1 radiculop-
athy. The patient was referred for MRI of the lumbar spine.
Setting:
Outpatient office.
Results:
MRI of the lumbar spine demonstrated no evidence of disc
herniation to explain an S1 radiculopathy; however, bone marrow
edema and a fracture line were seen in the right aspect of the sacrum.
A dedicated MRI sacrum confirmed a non-displaced right sacral ala
fracture. She was referred for pregnancy associated osteoporosis
workup that was ultimately negative. She was managed conserva-
tively, with recommendation for relative rest and non-steroidal anti-
inflammatory drug use as needed. Several months later, a repeat MRI
sacrum demonstrated fracture healing. She nevertheless has
continued to experience discomfort in the area, assessed as most
likely secondary to residual SI dysfunction.
Discussion:
This post-gravid patient presented with a pain pattern
typical of lumbosacral radiculopathy, which was ultimately attributed
to an otherwise idiopathic sacral alar fracture. Similar cases of preg-
nancy associated fractures presenting as lumbosacral radiculopathy
have been reported, but are rare.
Conclusions:
We report a case of a recently post-gravid woman pre-
senting with radicular back pain secondary to underlying idiopathic
sacral fracture.
Level of Evidence:
Level V
Poster 443:
Baastrup’s Disease - An Easily Missed Cause of Low
Back Pain In Elderly Patients: A Case Report
Allison Bean (Ichan School of Medicine at Mount Sinai, New York, NY,
USA), Anokhi Mehta, MD, Parag Sheth, MD
Disclosures:
Allison Bean: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
An 82-year-old woman with a history of
hypertension and hyperlipidemia presented with complaints of low
back pain for 2 months. Pain was intermittent and described as a
“grabbing pain that took [her] breath away” and worsened with
standing from a bent position. Pain did not radiate and she denied
numbness, tingling, or weakness. She denied history of trauma or
inciting events.
Setting:
Sports and spine clinic.
Results:
Patient had tenderness to palpation over the lumbar par-
aspinal muscles, L4-L5 spinous processes, and facet joints. Kemp’s
test was positive bilaterally. Straight leg raise and FABER testing
were negative. Radiologist reading of the patient’s lumbosacral
xrays noted generalized degenerative disease and grade 1 ante-
rolisthesis, but no mention of decreased space between spinous
processes. On our review of the xray, we noted contact between
spinous processes, consistent with Baastrup’s disease. The patient
was given injections of kenalog/lidocaine into the interspinous lig-
ament at the L4-L5 level with immediate pain relief. On follow up
one month later, she continued to have nearly complete resolution
of her pain.
Discussion:
Baastrup’s disease, also known as kissing spines syn-
drome, occurs due to close approximation of adjacent spinous pro-
cesses as a result of degenerative changes. It is often effectively
treated with interspinous ligament injections which can be easily
performed with or without ultrasound guidance. Baastrup’s disease is
likely underdiagnosed as it commonly occurs in elderly individuals,
who often have multiple degenerative abnormalities on imaging. This
can lead to focus on other possible pain generators and unnecessary
imaging and more invasive procedures may be performed as a result.
Conclusions:
Baastrup’s disease should be considered in elderly in-
dividuals who present with axial low back pain that worsens with
extension. Careful history-taking, clinical examination, and review of
imaging can lead to accurate diagnosis and effective treatment in an
office setting.
Level of Evidence:
Level V
Poster 444:
Ultrasound-Guided Hydrodissection of Superficial
Cervical Plexus in Patient with Severe Neck Pain after
Neck Lymphoma Excision Surgery: A Case Report
Yun-Shan Yen, MD (Chi Mei Medical Center, Tainan City, North Dist.,
Taiwan, Province of China), Daniel Chiung Jui Su, MD, Willy Chou, MD
Disclosures:
Yun-Shan Yen: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
A 66-year-old woman presented with
severe right neck and upper shoulder pain since receiving neck
lymphoma excision surgery 7 months ago. Right upper trapezius
muscle atrophy was noted with allodynia and hyperesthesia over the
upper shoulder and lateral neck. Nerve conduction study and elec-
tromyography (NCV/EMG) revealed axonal injury over right spinal
accessory nerve. Ultrasound revealed swollen supraclavicular nerve,
transverse cervical nerve and greater auricular nerve, and the
accessory nerve was encased inside the hyperechoic scar tissues.
Superficial cervical plexus entrapment and accessory nerve injury
were diagnosed.
Setting:
Tertiary medical center.
Results:
Ultrasound-guided superficial cervical plexus hydrodissection
including supraclavicular nerve, transverse cervical nerve and greater
auricular nerve were performed. Dextrose 5% (D5W) was infused from
the posterior, middle third of the SCM caudally and cephalically in
order to free up the superficial cervical plexus and accessory nerve.
Her neck and shoulder pain was alleviated immediately after the in-
jection as VAS scale dropped from 10 to 3. After the first treatment,
hydrodissection was done in a total of 3 times, one week apart. Her
pain scale remained 3 out of 10 without recurrence when following 3
months later.
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Abstracts / PM R 9 (2017) S131-S290