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upper extremities consistent with neuralgic amyotrophy also known as
Parsonage-Turner syndrome.
Setting:
Tertiary care hospital outpatient clinic.
Results:
At 4 months after the onset of symptoms the patient regained
significant amount of strength and function in bilateral upper ex-
tremities. He has continued with his prescribed physical therapy and
home exercise program.
Discussion:
Neuralgic amyotrophy is a rare condition presenting usually
unilaterally. It is thought to be caused by immune-mediated processes but
exact cause is unknown. As per previous studies, the recovery usually
takes few years and is associated with residual weakness. This is the first
reported case, to my knowledge, of significant recovery in bilateral
neuralgic amyotrophy before 6 months after the onset of disease.
Conclusions:
Recovery of strength and function in bilateral neuralgic
amyotrophy may occur earlier in the course of the disease than pre-
viously thought.
Level of Evidence:
Level V
Poster 268:
Metastatic and Radiation Brachial Plexopathy Masquerading
as Carpal Tunnel Syndrome: A Case Report
Yue-Shan L. Yang (WA Hosp Cntr/Georgetown Univ), Joseph Connor,
MD, Eric Wisotzky, MD
Disclosures:
Yue-Shan Yang: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
A 70-year-old woman with a past medical
history of right breast adenocarcinoma status-post lumpectomy, radia-
tion, mastectomy, and lymph node dissection 24 years ago presentedwith
complaints of persistent right hand burning and stinging for 2 years. This
was associated with progressive weakness and increasing right arm
edema. Prior to presentation in our clinic, she was diagnosed with carpal
tunnel syndrome (CTS) of the right wrist and had a carpal tunnel release
without relief. This was complicated by scar tissue resulting in a 2nd
release. Physical examination was significant for weakness of the right
triceps, wrist extensors, and finger abductors with decreased sensation
over antebrachial, median, and ulnar dermatomes. Prior electromyog-
raphy (EMG) demonstrated right median neuropathy and possible ulnar
and radial neuropathy with absent sensory responses.
Setting:
Outpatient academic rehabilitation center.
Results:
Brachial plexopathy was suspected after our evaluation and
magnetic resonance imaging (MRI) was ordered. MRI revealed an 8 by 3
cm fibrotic mass encompassing the brachial plexus, suspicious for ra-
diation fibrosis. Upon surgical dissection of the mass, a nodule was
discovered in the right lateral pectoralis muscle. It was excised and
pathology was conclusive for metastatic breast adenocarcinoma.
Discussion:
This is an example of a serious life threatening medical
condition (recurrent breast cancer) that was mistaken for a common
medical condition (CTS). The patient’s radiation and metastatic plex-
opathy presented resembling aspects of CTS, with hand dysesthesias and
weakness. Multiple surgical procedures for CTS were performed,
resulting in no clinical benefit. Therefore, in the presence of findings
suggesting other etiologies, a clinician should rethink the diagnosis of
CTS after failed therapies.
Conclusions:
In this case, the above physical examination and EMG
findings should alarm a clinician that a more complex diagnosis than CTS
was involved.When treatment fails, other diagnoses should be considered.
Level of Evidence:
Level V
Poster 269:
Acute Onset Patchy Upper Extremity Weakness: A
Case Report
Eric S. Larsen (Philadelphia Col of Osteo Med), Ziva Petrin, MD,
Jeffery Gehret, DO
Disclosures:
Eric Larsen: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
A healthy left handed male police officer
presented with acute painless weakness in his left shoulder and arm.
Four week prior to evaluation, he woke up with weakness, unable to
strap on his gun holster. There was no preceding trauma, illness,
surgery, or associated sensory changes. Upon extensive questioning,
the only pain preceding the event occurred 1 week prior to the
weakness in the trapezius region, was mild and resolved after a few
hours with massage. There was no family history of weakness or
episodic shoulder girdle pain consistent with myopathy or hereditary
neuralgic amyotrophy.
Setting:
Outpatient musculoskeletal clinic.
Results:
Exam revealed preserved muscle bulk with 4/5 weakness of the
left external rotators, deltoid and biceps, with normal sensation and re-
flexes. Electrodiagnostic studies 6 weeks after onset of symptoms showed
normal conductions except borderline reduced lateral antebrachial
cutaneous amplitudewith normal distal latency, and fibrillation potentials
in the left deltoid, biceps, supraspinatus, infraspinatus and paraspinals,
suggestive of an acute C5 radiculopathy. MRI of the cervical spine showed
an acute left sided foraminal disk herniation at C4-C5. He was referred for
surgery but opted for conservative treatment with physical therapy. His
weakness had fully resolved by follow up 7 weeks post EMG.
Discussion:
The patient was initially suspected to have an atypical
case of neuralgic amyotrophy, based on history of acute asymmetric
painless shoulder weakness. Cervical MRI and EMG confirmed acute C5
radiculopathy secondary to a large foraminal herniation. Interestingly,
the patient had no pain or sensory changes typical for radiculopathy.
Conclusions:
This case describes acute foraminal cervical herniation
presenting with acute onset of weakness without other symptoms.
Further research involving MRI findings of painless lesions would help
delineate why this large herniation presented with weakness only,
without any pain or sensation changes compared to typical presenta-
tion of radiculopathy.
Level of Evidence:
Level V
Poster 270:
Manual Medicine as Effective Treatment for Post-
Laminectomy Syndrome Chronic Low Back Pain: A
Case Report
Michael D. Smith, OMS-III (Nova Southeastern University College of
Osteopathic Medicine, Orlando, FL, United States), Yasmin Qureshi,
DPT, MHS (osteo)
Disclosures:
Michael Smith: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
The patient is a 35-year-old man pre-
senting with chronic low back pain (LBP), first appearing at age 15
when he sustained a weight lifting injury. Shortly after he underwent a
lumbar laminectomy, physical therapy, and pharmacologic treatment.
His pain persisted and has significantly worsening over the last 2 years.
Physical exam revealed normal muscle strength, sensation, and deep
tendon reflexes bilaterally. Taught lumbar paraspinals, quadratus
lumborum, and gluteus medius musculature was appreciated with
positive left sided straight leg raise. Lumbar X-ray showed no patho-
logic findings. A specific manual medicine protocol was performed a
total of 5 times over an 8-week period consisting of techniques to
increase range of motion, loosen musculature and align boney struc-
tures. Prior to each treatment and 2 months after final treatment, pain
and functional disability was measured using the Visual Analog Pain
Scale (VAS) and Oswestry Disability Index (ODI), respectively.
Setting:
Outpatient medical clinic.
Results:
On first visit, the patient reported a VAS of 8/10 and an ODI
score of 32%. By the 5th visit, the patient reported a VAS of 2/10 and
an ODI score of 16%. Two months after the final treatment, VAS and
ODI were measured to evaluate if treatments had lasting results. VAS
was a 0/10 and ODI score of 12% 2-month post-treatment.
Discussion:
Many patients who undergo surgical laminectomy experi-
ence ongoing pain symptoms. Etiology of pain may not be corrected by
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Abstracts / PM R 9 (2017) S131-S290