Abstracts / PM R 7 (2015) S83-S222 Twenty-one muscles were selected for injection at Visit 1; of these the 5 most commonly injected were splenius capitis (93% of patients), sternocleidomastoid (SCM) (91%), trapezius (63%), levator scapulae (42%), and the semispinalis capitis (27%). Other muscles were injected with a frequency between 0.4e6%. The mean total injected volumes were 1.05 1.16 mL for splenius capitis, 0.68 0.78 mL for SCM, 0.67 0.58 mL for trapezius, 0.42 0.26 mL for levator scapulae and 0.56 0.33 mL for semispinalis capitis. Mean number of injection points were: splenius capitis (2.7 1.5), SCM (2.2 1.2), trapezius (2.7 1.6), levator scapulae (1.5 0.7), and semispinalis capitis (2.0 1.3). At Visit 2 the frequency of muscles injected, the injected volume, and injection points were similar to Visit 1. Injection guidance techniques were used in 37% (SCM) to 57% (levator scapulae) of Visit 1 injections, and this did not change at Visit 2. Analyses by study center revealed that when an injector uses guidance for one muscle, they generally use it for all muscles. Conclusion: In these interim analyses, 5 muscles were identified as being most frequently injected for CD, with other muscles being injected at much lower rates. The muscles and injection method (volume and number of injection points) are in line with recommendations in the literature and did not change between visits.
Poster 305 Patterns of Cervical Dystonia of Patients Receiving BoNT-A Treatment Peter Misra, MD, FRCP (National Hospital for Neurology & Neurosurgery, London, United Kingdom), Richard Trosch, MD, Pascal Maisonobe, MSc, Savary Om, MD Disclosures: P. Misra: Consulting Fees or Other Remuneration - Ipsen Pharma Objective: To characterize the dystonic pattern of patients with cervical dystonia (CD) treated with botulinum neurotoxin type A (BoNT-A) in clinical practice. Design: A meta-analysis was conducted on the baseline data from 3 observational studies. Data from a pre-planned interim analysis were used for one study (INTEREST IN CD2). Setting: 2 international studies (INTEREST IN CD1 & 2, encompassing 9 and 8 countries, respectively) and 1 US registry (ANCHOR-CD). Participants: 752 patients with idiopathic CD. Interventions: Not applicable Main Outcome Measures: Clinical examination Results or Clinical Course: Most patients (92%) presented with focal dystonia, followed by 5% with segmental dystonia, 2% with multifocal dystonia and 1% with generalized dystonia. The predominant dystonic posture in the majority of patients was a pattern of rotational torticollis (71.4%) followed by 20.4% of patients with laterocollis, 4.4% with retrocollis and 2.5% with anterocollis. Only 23.6% of patients had a simple pattern of CD, while 76.4% had a complex pattern (2 patterns and associated components); 22% of patients had at least 4 documented patterns. Overall, 27.8% of patients had rotational torticollis as a secondary pattern, 39.4% had laterocollis, 16.6% had retrocollis, 11.7% had anterocollis, 14.1% had a lateral shift of the column and 6.1% had a sagittal shift. Shoulder elevation was also a relatively common secondary pattern (31.6%). Almost half of patients (49%) had a head tremor, which was mostly mild. Of those patients with tremor, 52% had occasional tremor and 48% had continuous tremor. Conclusion: Most patients presenting for routine injections of BoNT-A for CD have a predominant pattern of rotational torticollis/laterocollis. The majority had a complex pattern of CD, and almost half of all patients were experiencing tremor. These
data highlight the need to tailor treatment to each individual patient. Poster 306 Clinical Characteristics of Cervical Dystonia: Differences between Patients Previously Treated with Botulinum Neurotoxin Type A and Naı¨ve Patients Peter Misra, MD, FRCP, Richard Trosch, MD, Savary Om, MD, Pascal Maisonobe, MSc (Ipsen Pharma, Boulogne-Billancourt, France) Disclosures: P. Maisonobe: Employment - Ipsen Objective: To compare the clinical characteristics (as assessed by Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS)) of naı¨ve patients with cervical dystonia (CD) presenting for treatment to those previously treated with BoNT-A who are at the end of their injection cycle and requiring reinjection. Design: A meta-analysis was conducted on the baseline data from 3 observational studies. A pre-planned interim analysis were used for one of the study (INTEREST IN CD2). Setting: 2 international studies (INTEREST IN CD1 & 2, with 9 and 8 countries, respectively) and 1 US registry (ANCHOR-CD). Participants: 752 patients with idiopathic CD (616 previously treated with BoNT-A and 136 naı¨ve). Interventions: Not applicable Main Outcome Measures: TWSTRS Results or Clinical Course: There were no significant differences between subgroups in terms of patient demographics, but small differences in the predominant pattern of CD (previously treated vs. BoNT-A naı¨ve) were noted: (rotational torticollis: 73% vs. 64%; laterocollis 19% vs. 26%; retrocollis 4% vs. 6%; other patterns <3% of patients). Previously treated patients had received a median of 8 (range 1-99) injection cycles; median time since their first BoNT-A injection was 44.7 (range 2-280) months. Overall, 60% patients had previously been treated with abobotulinumtoxinA, DysportÒ (median dose 500 U), 37% with OnabotulinumtoxinA, BotoxÒ (190 U) and 3% with IncobotulinumtoxinA, XeominÒ (150 U). BoNT-A naı¨ve patients trended towards having higher TWSTRS total (meanSD) (38.412.4 vs. 34.511.7), disability (11.76.6 vs. 9.86.0) and pain scores (8.95.1 vs. 6.65.0) at baseline. TWSTRS severity scores (meanSD) were similar (17.95.0 vs. 18.04.7, respectively for BoNT-A naı¨ve and previously treated patients). Conclusion: When compared to previously treated CD patients, ‘new’ patients presenting for treatment with BoNT-A tend to have higher levels of pain and disability. This suggests that continued treatment reduces the severity of CD pain and disability or that the therapeutic effects of their prior injection series has not yet worn off and the benefits of BoNT-A may last longer than patients perceive.
Poster 307 Osteitis Condensans Ilii and Acetabular Labral Tear after Pregnancy: A Case Report Jennifer E. Miller, MD (Spaulding Rehabilitation Hospital/Harvard Medical School, Charlestown, MA, United States), Vaishali Mittal, Minna Kohler, MD Disclosures: J. E. Miller: I Have No Relevant Financial Relationships To Disclose. Case Description: Patient presented with a 5-year history of chronic right greater than left hip pain which began after her first pregnancy. Examination demonstrated pain with right hip range of motion, and tenderness of the bilateral sacroiliac (SI) joints and right greater trochanter. MRI revealed edema adjacent to the inferior aspect of the iliac side of the SI joints bilaterally, corresponding with areas of sclerosis seen on a prior abdominal CT, and a minimally displaced anterosuperior
Abstracts / PM R 7 (2015) S83-S222
labral tear of the right hip. Point-of-care musculoskeletal ultrasound showed no joint effusion amenable to aspiration and additionally confirmed hip joint synovitis and gluteus medius tendinosis. Setting: Tertiary care outpatient clinic. Results or Clinical Course: Diagnosis: osteitis condensans ilii (OCI) with secondary right acetabular labral tear and gluteus medius tendinopathy. MRI edema of the SI joints often raises suspicion for underlying inflammatory sacroiliitis or metastatic bone lesions. Clinical history and examination were negative for other symptoms suggestive of underlying seronegative spondyloarthropathy (SpA) or malignancy, and laboratory tests, including ESR, returned normal. Discussion: OCI is a rare radiographic condition characterized by benign sclerosis of the ilium adjacent to the SI joint, seen almost exclusively postpartum. OCI presents with nonspecific and varying low back and hip symptoms making the diagnosis difficult based on symptoms alone. OCI is easily confused for inflammatory sacroiliitis and metastatic bone lesions. SpA is differentiated from OCI by MRI edema affecting both subchondral and inferior aspects of SI joints; erosions and enthesitis may also be seen. This patient demonstrates history, lab, and imaging findings consistent with OCI and additional acetabular labral tear which can occur postpartum due to torsional forces during labor. Conclusion: OCI can mimic symptoms and image findings of SpA, but a thorough history, exam, and image review localizing MRI edema to specific areas of the SI joint can distinguish these two entities.
Poster 308 Trigger Point with Associated Myoclonic Reaction: A Case Report Chirag Vora, DO, MS (VA GLA/UCLA, Los Angeles, CA, United States), Sophia Chun, MD Disclosures: C. Vora: I Have No Relevant Financial Relationships To Disclose. Case Description: 83-year-old woman with long standing history of post-polio syndrome presented with right posterior scapular pain. On exam, the patient had less than antigravity muscle strength in her right elbow flexors with volitional control; she had almost full strength on the left elbow flexors. Examination of the right infraspinatus muscle demonstrated a trigger point that when palpated, caused uncontrolled myoclonus of the right elbow flexors. This uncontrolled movement was with almost full strength. Setting: Outpatient post-polio clinic. Results or Clinical Course: Trigger point injection consisting of lidocaine was administered to the trigger point identified at the right infraspinatus muscle. The patient reported decrease in posterior scapular pain and had immediate resolution of her myoclonic jerking movement of the right elbow flexors. Discussion: This is the first reported case, to our knowledge, of a myofascial trigger point with an associated myoclonic reaction. We have been administering trigger point injections to this patient which have provided significant control of the myoclonic reaction, usually lasting around 3 months at a time. Conclusion: The mechanism of the trigger point causing the myoclonic reaction is unclear. However, we propose that the patient’s post-polio condition has altered the physiologic neuronal signal pathway, causing this unique reaction. Further research is required to better understand this phenomenon. Poster 309 Anterolateral Ankle Pain in an Elite Swimmer Daniel Lueders, MD (Mayo Clinic, Rochester, MN, United States), Adam Pourcho, DO, Jay Smith, MD Disclosures: D. Lueders: I Have No Relevant Financial Relationships To Disclose.
Case Description: A 16-year-old elite swimmer presented with a 3year history of atraumatic, right anterolateral (AL) ankle and midfoot pain during swimming with kicking and pushing off described as achy, sore discomfort. Previous treatment included therapy, image guided sinus tarsi (ST) and 4th -5th TMT cortisone injections, and ST platelet rich plasma injections (type unknown) without significant benefit. Exam: Palpatory tenderness at ST, calcaneocuboid, and cuboidmetatarsal articulations. Increased plantarflexion (PF)-inversion motion reproducing ST pain extending to (AL) hindfoot-midfoot junction. Negative superficial peroneal nerve (SPN) Tinel’s. Normal ankle MRI. Diagnostic ultrasound suggested an enlarged lateral branch of the deep peroneal nerve (LB-DPN), normal SPN, and absence of muscular herniation. Setting: Sports medicine clinic. Results or Clinical Course: LB-DPN USGI diagnostic block provided 100% short term relief during swimming. Detailed questioning revealed SPN sensory territory overflow that confounded LB-DPN diagnostic block interpretation. A Neurontin trial gave modest relief. Sequential DPN and SPN anesthetic blocks confirmed SPNmediated pain. Neurosurgery consulted and performed a right superficial peroneal neurectomy in the distal leg. Intra-operatively, the SPN appeared thinned at the level of fascial emergence. Neurectomy afforded complete pain relief and return to elite competition at 3 months post-surgery. Patient remains asymptomatic at 16 months. Discussion: SPN injury is uncommon but can be related to fascial entrapment, distal fibular fracture or associated hematoma, and arthroscopic surgery. We report an elite swimmer with superficial peroneal neuropathy unassociated with obvious anatomic abnormality and likely related to chronic irritation secondary to kicking activities. Initial diagnostic LB-DPN block was confounded by overflow into the traversing SPN territory, revealed only by careful follow-up questioning. Subsequent sequential USGIs identified SPNmediated pain and facilitated definitive management. Conclusion: Superficial peroneal neuropathy should be considered in an athlete with AL ankle pain and PF-inversion hyperflexibility. Attention to injectate volume and location of post-injection pain relief are necessary to optimally interpret diagnostic injection results.
Poster 310 Acute Exercise Induced Compartment Syndrome Involving the Lumbar Paraspinals and Posterior Thighs: A Case Report Jay M. Shah, MD (Montefiore Medical Center/AECOM, Bronx, NY, United States), Eathar Saad, MD, Todd Miller, MD Disclosures: J. M. Shah: I Have No Relevant Financial Relationships To Disclose. Case Description: A 25-year-old man with no medical history presented to the emergency department with acute onset low back pain, bilateral thigh pain, and dark urine after a two hour workout consisting of five-hundred pound dead-lift squats. The patient denied bowel/bladder incontinence, focal neurologic deficits, and displayed pain limited lower extremity weakness. He was found to have an elevated creatinine kinase and was started on treatment for rhabdomyolysis. On hospital day three the patient reported worsening low back pain. Magnetic resonace imaging and compartment pressure measurements were ordered. Imaging showed edema and enhancement of the posterior thigh and lumbar paraspinal muscles, and compartment pressures were elevated in these areas as well. Emergent fasciotomies of the lumbar paraspinals and posterior thigh compartment was performed. The patient was ambulatory on discharge with significant decrease in pain. Setting: Inpatient hospital setting e Medical Floor.