S199 S290
with total assistance. By discharge, her gait improved to 220 feet on a
level surface with minimum assistance.
Discussion:
This is a case where the efficacy of medication was
limited, but inpatient rehabilitation seemed to lead to more functional
gains than medication alone.
Conclusions:
Inpatient rehabilitation with weighted exercises and
traditional therapy techniques along with medication can lead to
modest gains in function in a patient with Lance-Adams syndrome.
Level of Evidence:
Level V
Poster 209:
Ulnar Neuropathy in the Setting of a Normal Nerve
Conduction Study: An Ultrasound Case Report
Monal H. Desai, MD (Ohio State Univ Med Cntr), Jayesh C. Vallabh,
MD, MBA
Disclosures:
Monal Desai: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
A 43-year-old woman presented for
electrodiagnostic evaluation for symptoms of persistent right 4th and
5th digit pain, numbness and tingling with a positive elbow flexion test
and tinel sign 4 months status post cubital tunnel release. Physical
exam was normal including, bilateral upper limb sensation and manual
muscle testing including finger flexors and hand intrinsic muscles.
Setting:
Outpatient Clinic.
Results:
Nerve conduction study conducted on a warmed limb showed
normal median, radial and medial antibrachial nerves. Ulnar nerve
evaluation conducted at 90 degrees of elbow flexion displayed a normal
latency, amplitude and conduction velocity, with the exception of a
borderline amplitude loss distal to the elbow relative to the wrist.
Electromyography displayed spontaneous activity in the flexor carpi
ulnaris (FCU) and first dorsal interosseous but not in distal median
innervated or paraspinal musculature. Ultrasound revealed evidence for
a right ulnar neuropathy with an increase in ulnar cross-sectional area
from 0.7 cm
2
above the elbow to 0.11 cm
2
and 0.13 cm
2
at the medial
epicondyle and FCU, respectively. Additionally, abnormal fascicular
architecture was noted around the elbow segment. Utilizing ultrasound,
this patient’s persistent ulnar injury was effectively localized at the FCU
further assisting surgical versus non-surgical decision-making.
Discussion:
Ulnar neuropathy at the elbow is the second most common
form of entrapment neuropathy of the upper limb. Some case reports
have shown ultrasound abnormalities in the setting of normal ulnar nerve
conductions, but not necessarily with signs of axonal injury. Ultrasound
neurography should continue to play a significant role in the assessment of
nerve injury and localization to help determine further management.
Conclusions:
This case substantiates the importance of using ultrasound
in conjuncture with electrodiagnostics to evaluate ulnar neuropathy,
especially in the setting of equivocal or unclear results and localization.
Level of Evidence:
Level V
Poster 210:
Delayed Presentation of CSF Leak During Concussion
Management: A Case Report
Lawrence M. Asprec (Thomas Jefferson University Hospital, Belle
Mead, NJ, USA), Tulasi Gude, MD
Disclosures:
Lawrence Asprec: I Have No Relevant Financial Re-
lationships To Disclose
Case/Program Description:
Eleven months following the onset of mild
traumatic brain injury due to a fall in her bathroom, a 53-year-old
woman presented to an outpatient concussion center with waxing and
waning symptoms of diplopia and positional headaches. Symptoms
remained present 1 month following initial evaluation, despite relative
rest and medications including clonazepam, nortriptyline, and trazo-
done. She failed to respond to relative rest, control of essential hy-
pertension, sleep hygiene improvements, and vestibular therapy.
Several weeks later, the patient returned with uncontrolled hyper-
tension, ongoing blurred vision and diplopia, prompting a STAT MRI.
Imaging revealed presence of meningeal enhancement and proteina-
ceous fluid located subdurally in the cortex and tentorium, findings
consistent with intracranial hypotension, and fullness in venous spaces
and sella tursica, suggesting CSF leak. She was treated with an initial
blood patch, sent home, but returned for repeat blood patches on two
subsequent occasions.
Setting:
Outpatient Concussion Clinic.
Results:
Four weeks following the final blood patch and 15 months
after the initial fall, the patient demonstrated improved postural
control, sleep patterns, and oral intake. Her total evaluation and
management in our clinic spanned over 4 months.
Discussion:
This case is notable for the delayed presentation of CSF
leak and the failure of conservative measures, until a structural defect
had been identified and aggressively treated.
Conclusions:
Serious consideration for CSF leak should be given in the
setting of worsening symptoms or functional plateau, despite standard
physiatric interventions for concussion and pharmacologic manage-
ment of hypertension and associated post-concussive symptoms.
Level of Evidence:
Level V
Poster 211:
Asymmetric Weakness Following a Polysubstance
Overdose: A Case Report
Michelle E. Lalonde, MD (Spaulding Rehab Hosp/Harvard Med Schl),
Meijuan Zhao, MD, Jeffrey C. Schneider, MD
Disclosures:
Michelle Lalonde: I Have No Relevant Financial Re-
lationships To Disclose
Case/Program Description:
A 23-year-old man was found down sec-
ondary to a polysubstance overdose (APAP, ETOH, amphetamines and
cocaine). He was down for approximately 24 hours in the prone posi-
tion. Neurology was consulted at the acute hospital for evaluation of
left shoulder weakness notable for 2/5 strength with abduction,
flexion and external rotation, and sensory loss over his left lateral
deltoid. An EMG was deferred and he was discharged to acute inpa-
tient rehabilitation without a formal diagnosis for his upper extremity
injury. Upon admission to inpatient rehabilitation, his exam was also
notable for right knee extension weakness, graded 2/5, and right
anterior tibial sensory loss. The differential diagnosis was broadened
at this time to include mononeuritis multiplex, multiple mono-
neuropathies, cervical root avulsion injury, brachial plexopathy, and
multiple compression myopathies.
Setting:
Inpatient rehabilitation hospital.
Results:
At discharge from inpatient rehabilitation, his shoulder
strength was unchanged, but he gained antigravity strength for right
knee extension. An EMG obtained 5 weeks post-injury was significant
for severe acute axonal axillary and suprascapular neuropathy in the
left upper extremity. Additionally, there was evidence of acute
denervation and reduced recruitment in the right quadricep muscle
with sparing of other L4 limb and paraspinal muscles, consistent with
an incomplete right femoral neuropathy.
Discussion:
The patient’s prolonged positioning likely contributed to
his multiple compression neuropathies. Given the incomplete nature
of the right femoral neuropathy, full recovery is possible. This case
represents a unique presentation and etiology of multiple
mononeuropathies.
Conclusions:
The relevance of this case is highlighted by the rising
national incidence of drug overdoses occurring annually, and it re-
minds providers that a thorough neurologic exam is a key element for
all patients admitted to inpatient rehabilitation. Additionally, pursuing
EMG for asymmetric weakness can help guide the rehabilitation team
and provide patients and providers with important prognostic
information.
Level of Evidence:
Level V
S199
Abstracts / PM R 9 (2017) S131-S290