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Discussion:
Ultrasound-guided superficial cervical plexus hydro-
dissection is an effective and long-lasting way to separate the
entrapped nerve from the adhesive scar tissues and alleviate the pain.
Instead of lidocaine or corticosteroid, we used pure D5W, which
resupplied the glucopenic, neuropathic nerve without the risk of sys-
temic complications. The remaining pain may be related to myofascial
imbalance due to trapezius muscle weakness. The axonal damage of
the accessory nerve may take some more time to reinnervate in order
to possibly correct the shoulder dyskinesis.
Conclusions:
Ultrasound-guided superficial cervical plexus hydro-
dissection can effectively and sustainably alleviate the pain from su-
perficial cervical plexus entrapment.
Level of Evidence:
Level V
Poster 445:
Treatment with Botulinum Toxin Type A Injection in a
Patient with Notalgia Paresthetica: A Case Report
David Q. Atkins, MD (San Juan VA Medical Center, Carolina, Puerto
Rico, Puerto Rico), Eduardo J. Otero-Loperena, MD, David A. Soto-
Quijano, MD
Disclosures:
David Atkins: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
Case of a 65-year-old woman with history
of nummular dermatitis and notalgia paresthetica who presented with
a 5-year history of pruritus and burning sensation in her left upper
back. She had tried topical corticosteroids, lidocaine cream and pra-
moxine hydrochloride cream 1% with minimal improvement. She re-
ported scratching her back more 10 times a day. On physical exam
there was a hyperpigmented patch medial to the left scapula within
the dermatomes of T2
e
T6, with associated hyperesthesia. Para-
vertebral nerve block with Lidocaine1% was injected into 5 sites, with
a total of 10ml. She was seen 1 month later and reported relief which
only lasted 2 weeks, therefore decision was made to infiltrate Botu-
linum Toxin type A. The Botulinum toxin was reconstituted with 0.9%
normal saline to a concentration of 4U/0.1cc. Injection points were
marked 2 cm apart and 4 U of botulinum toxin type A was injected into
each point, with a total of 20U distributed.
Setting:
Tertiary care hospital.
Results:
At 6 weeks post-injection, the patient reported considerable
improvement in symptoms with decrease pruritus and scratching her
back less. The patient denied adverse reaction from procedure.
Physical exam was remarkable for hyper-pigmentation decrease in size
and color which are evaluated with patient photographs before and
after Botulinum Toxin type A infiltration.
Discussion:
Notalgia paresthetica (NP) is generally believed that is
a sensory neuropathy, characterized by pruritus in a unilateral
located in the mid-back which may be accompanied by pain,
numbness or hyperesthesia. We present the case of an off label use
of botulinum toxin injection to reduce itchiness and neuropathic
pain.
Conclusions:
Botulinum Toxin type A injections may be useful in
reducing pruritus and neuropathic pain in patients with notalgia par-
esthetica who have failed to conservative management. In persistent
cases that interfere with quality of life, this may be an alternative
option.
Level of Evidence:
Level V
Poster 447:
Possible Pilocytic Astrocytoma Presenting as Migraines
and Bilateral Cervical Myalgia in Adulthood: A Case
Report
Agnieszka M. Cain, MS2, MBA (Albert Einstein College of Medicine,
New York, NY, United States), Nirvi Shah, DO, Neil Mandalaywala, MD,
Young IL Seo, MD, Charles Kim, MD, Salvador Portugal, DO, FAAPMR,
Kimberly A. Sackheim, DO, FAAPMR
Disclosures:
Agnieszka Cain: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
A 43-year-old woman with history of
migraines since childhood presents to our outpatient pain clinic for
evaluation of migraines that are increasing in frequency, severity
along with bilateral cervical paraspinal and upper trapezius
myalgia. She localizes the pain to the frontal and occipital regions
and describes them as severe, pulsating and with associated aura,
photophobia, and phonophobia. Examination was notable for the
tenderness of the bilateral cervical paraspinal muscles and bilat-
eral upper trapezius muscle without other focal neurological
symptoms.
Setting:
Outpatient Spine Center.
Results:
After history and examination, imaging was obtained to
assess for possible musculoskeletal etiologies. Cervical radiographs
were unremarkable. A brain MRI was obtained given the prolonged
headache history. MRI revealed two lesions: a 0.6 cm hyperintense
lesion along the left sylvian aqueduct/periaqueductal gray matter
resulting in dilation of the lateral and third ventricles and mild mass
effect on the cerebral aqueduct and a separate 1.2 cm cystic struc-
ture in the left thalamus. The patient was immediately referred to
neuro-oncology for further assessment and repeat MRI was obtained
which confirmed the above findings. The patient was discussed at
Neuro-Oncology tumor board where the lesions, based on history and
imaging findings, were speculated to be Grade I pilocytic
astrocytomas.
Discussion:
This case is a unique presentation of a CNS neoplasm.
The patient’s only symptoms at the time of presentation were
headache and neck pain absent other neurological symptoms. A
migraine could be the first sign of metastatic disease of the brain
and may present without other significant symptoms. Pilocytic as-
trocytoma is highly unusual in the location of the found lesions or
for a patient of an older age and could result in diagnostic
difficulty.
Conclusions:
It is crucial to maintain a broad differential when eval-
uating patients with migraines and to consider rarer etiologies
including tumors such as pilocytic astrocytomas.
Level of Evidence:
Level V
Poster 448:
Prolotherapy for the Treatment of Interspinous Ligament Injury:
A Case Report
G. Sunny Sharma, MD (UCLA, Santa Monica, CA, United States),
Rohit Jayakar, BA, Quynh Pham, MD
Disclosures:
G. Sunny Sharma, MD: I Have No Relevant Financial Re-
lationships To Disclose
Case/Program Description:
Patient is a 38-year-old man referred
for chronic mid to low back pain. He denied history of trauma but
endorsed past exertional back strains. His symptoms were pri-
marily axial, localized to the lower thoracic and lumbar regions
without radiation to the limbs. Exam showed tenderness to
palpation midline, between the spinous processes in the thoracic
and lumbar spine, worse with flexion. Lumbar plain films were
normal. Magnetic resonance imaging (MRI) showed mild disc bulge
along the L5-S1 level with mass effect upon the left S1 nerve
root.
Setting:
Tertiary Care Hospital.
Results:
A course of anti-inflammatory medications and physical
therapy did not improve his symptoms. Epidural injections were
not indicated due to lack of limb symptoms. Patient received a
trial of three dextrose prolotherapy injections, each 2 months
apart, to the lower thoracic and upper lumbar interspinous
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Abstracts / PM R 9 (2017) S131-S290