Results: She underwent a L5-S1 interlaminar injection andreported pain relief with restored hip flexion for 2 months,but her symptoms gradually recurred. After a repeated injec-tion, she reinitiated a physical therapy program and onfollow-up had sustained relief of symptoms with restorationof hip flexion to 70°; comparable to unaffected side.Discussion: Lumbosacral radiculopathy can present with avariety of neuromusculoskeletal signs and symptoms. “Tighthamstring syndrome” has been reported in adolescents as aresult of lumbar disk herniation. To our knowledge, there areno reported cases of L5/S1 radiculopathy secondary to diskherniation presenting with isolated hamstring tightness.Conclusions: Severely shortened and painful hamstringsmay be the presenting symptom of L5/S1 radiculopathy.

Poster 169Heterotopic Ossification Presenting as KneePain in a Critical Illness Patient: A CaseReport.An Ngo, DO (Loma Linda University Medical Cen-ter, Loma Linda, CA); Murray Brandstater, MD;Scott R. Strum, MD.

Disclosures: A. Ngo, None.Patients or Programs: A 27-year-old woman with het-erotopic ossification (HO).Program Description: A previously healthy woman pre-sented to a local hospital in labor and delivered a full-termbaby. However, postpartum, she developed bilateral H1N1pneumonia, and multi-organ dysfunction including respira-tory failure with acute respiratory distress syndrome. Whenshe was weaned off the ventilator 6 weeks later, she hadpersistent complaints of bilateral upper and lower extremitypain, numbness, and weakness. Patient was transferred toour acute rehabilitation unit for an intensive regimen ofphysical and occupational therapies. Radiographs of herknees and elbows revealed extensive HO of the right elbowand bilateral knees. Patient was started on etidronate fortreatment of HO and continued on a program that encour-aged range of motion, stretching, strengthening, and pulmo-nary rehabilitation.Setting: Acute rehabilitation unit.Results: This patient tolerated a 3-week course of acuterehabilitation with improved elbow and knee range of mo-tion and significantly reduced pain. On discharge to home,she was ambulating 250 feet at a supervised level with awalker.Discussion: There have been only a few case reports doc-umenting HO in critical illness patients, mainly in patientswith sepsis or respiratory failure. In the intensive care unit,this patient’s joint pain was attributed to critical illness my-opathy and the HO was not diagnosed until the patient wasevaluated on our rehabilitation unit. This patient was man-aged accordingly, with significant improvement in function.Conclusions: HO is often diagnosed and treated by

physiatrists in brain injury, spinal cord injury, burn, andtrauma patients. It may occur early after an injury or after aperiod of critical illness, and may not be recognized. It isimportant for clinicians on both the acute medical and reha-bilitation setting to recognize HO as both preventative andearly treatment interventions lead to noteworthy functionaloutcomes.

Poster 170Identification and Treatment of DiabeticLumbosacral Radiculoplexus Neuropathy:A Case Report.Jeremy Collins, MD (MossRehab, Philadelphia,PA); Andrew D. Egger, MD; Inai M. Mkandawire,DO; Robert Rankin, MD; Channarayapatna R.Sridhara, MD.

Disclosures: J. Collins, None.Patients or Programs: An 83-year-old diabetic womanwith acute low back and leg pain, proximal leg weakness andambulatory dysfunction.Program Description: The patient was admitted to acutecare for pain management and ruled out for cauda equinasyndrome. She had L3-L5 spinal stenosis and decompressivespinal surgery was recommended, but declined. She wastransferred to subacute rehabilitation, where review of herMRI revealed no lesions that fully explained her symptoms.The patient was referred for electrodiagnostic testing, and theresults were consistent with diabetic lumbosacral radiculo-plexus neuropathy (DLRPN). She was prescribed high-doseoral prednisone, and shortly thereafter she showed markedimprovements in pain and function.Setting: Subacute inpatient rehabilitation.Results: Within 2 days the patient’s pain resolved andtransfers improved from requiring a Hoyer lift to only need-ing moderate assistance. Within 2 weeks she was ambulatingwith a rolling walker.Discussion: DLRPN is often overlooked when a patientpresents with leg pain and weakness. These patients are oftenmistaken for having compressive lumbar radiculopathy orspinal stenosis (especially when there are incidental MRIfindings) and may undergo unnecessary surgeries. Othermisdiagnoses that could delay appropriate treatment includecompressive plexopathies and peripheral neuropathies.Once diagnosed, DLRPN could be treated with steroids orIVIG. Because this disease is often described in diabeticpatients, there is misunderstanding that it is due to poorglycemic control, which leads to hesitancy in initiating ste-roid therapy. However, recent histological evidence supportsan immune-mediated pathogenesis. This disease has alsobeen described in diabetic patients with good glycemic con-trol and in non-diabetics.Conclusions: This case demonstrates the value of a thor-ough history and physical and electrodiagnostic examinations incorrectly identifying DLRPN from other diseases that present

S78 PRESENTATIONS

with similar symptoms. It illustrates the importance of under-standing this disease process, which can be treated with conser-vative management instead of invasive and risky procedures.

Poster 171Incomplete Spinal Cord Injury FollowingThoracic Transforaminal Epidural SteroidInjection: A Case Report.James R. Babington, MD (University of Washington,Seattle, WA); David J. Kennedy, MD; Joshua D.Rittenberg, MD.

Disclosures: J. R. Babington, None.Patients or Programs: A 43-year-old woman undergoinga thoracic transforaminal epidural steroid (TFESI) injectionfor chronic left T6 radicular pain.Program Description: The patient presented with chronicradicular pain from a left T5-6 paracentral disk protrusionrecalcitrant to conservative care. She underwent a left T6 TFESIinjection. Injectate consisted of 1.5 mL triamcinolone 40 mg/mLand 1.5 mL 2% MPF free lidocaine mixture that was injectedunder fluoroscopic visualization without the use of digital sub-traction angiography. Intraoperatively, no vascular infiltrationwas observed on epidurography. Patient developed sensory andmotor impairment 20 minutes after injection. MRI performed 7days after injection revealed a T2 hyperintense signal at T5cranial from injection site.Setting: Ambulatory surgery center.Results: The patient sustained a T5 ASIA D spinal cordinjury after thoracic TFESI. Vascular uptake of contrast wasnoted upon post hoc review of the intraoperative fluoro-scopic images. As previously observed in the cervical andlumbar spine, this finding suggests that intraoperative vascu-lar infiltration may pose a risk for spinal cord injury.Discussion: This is the first case report of spinal cordinjury after TFESI in the thoracic spine. The data supportingthe use of this procedure is currently extrapolated fromstudies in the lumbar and cervical regions or based on anec-dotal evidence. Complex anatomy creates a high level of riskin performing this procedure.Conclusions: Although digital subtraction angiographyand non-particulate steroids may aid in performing thisprocedure with the highest margin of safety, a highly experi-enced and well-trained operator is essential. It is imperativethat further randomized controlled trials be performed todemonstrate efficacy.

Poster 172Intercostal Neuralgia Improvement byUltrasound-Guided Nerve Block: A CaseReport.Phillip J. Smith (LAGS Spine & Sportscare, SantaMaria, CA); Moshe Ben-Roohi, MD; Sawey A.Harhash, MD; Francis P. Lagattuta, PhD; VincenzoVitto, DO.

Disclosures: P. J. Smith, None.Patients or Programs: A 41-year-old male patient.Program Description: A 41-year-old man in outpatientmusculoskeletal clinic with intractable intercostal neuralgiadue to history of rib fractures. Pain is constant and localizedto the lateral bodies of the left 7th and 8th ribs with referralposteriorly and anteriorly; with allodynic features. Failedtreatments include physical therapy with modalities, T7/ T8transforaminal epidural steroid injections, and trigger pointinjections. He had moderate relief from oral pain medicationsand transdermal anesthetic patches. Ultrasound-guided in-jections of T7 and T8 intercostal nerves were done 7 cmlateral to the spinous processes of the corresponding levels.At each of the 2 locations, a 3-mL mixture of 0.5 mL dexa-methasone and 2.5 mL 1% lidocaine was injected.Setting: Outpatient musculoskeletal clinic.Results: The patient experienced relief of his pain begin-ning the following day and lasting many months, with de-creased use of oral pain medications and improvement ofdaily living activities.Discussion: Intercostal nerves are extensions of the ventralramus of thoracic spinal nerves and are found in the costalgroove. The intercostal artery and vein run in parallel. Lateralcutaneous nerves of the chest branch off the intercostalnerves at the posterior axillary line. Pain syndromes mediatedby intercostal nerves may include postthoracotomy pain,posttraumatic pain, idiopathic intercostal neuralgia, thoracicradiculopathy, post-herpetic neuralgia, and musculoskeletalconditions such as myofascial pain syndromes. Medical liter-ature includes limited descriptions of ultrasoundguided in-tercostal nerve blocks and indications. The benefits of ultra-sound guidance include direct visualization of the costalgroove and depth in regard to pleura. A limitation of ultra-sound investigation is inability to demonstrate pathology ofthe nerve itself due to depth under the rib.Conclusions: Intercostal nerve block can be an efficaciousprocedure for thoracic pain syndromes, and guidance byultrasound provides optimal placement of medication andreduction of complications.

Poster 173Interdigital Neuritis Mimicking LumbosacralRadiculopathy Among Patients Referred forElectrodiagnostic Study: Case Series.Jiyoung Ryu, MD (Montefiore Medical Center,New York, NY); Dennis D. Kim, MD; Se Won Lee;Mooyeon Oh-Park, MD, MS.

Disclosures: J. Ryu, None.Patients or Programs: Three patients with lower backpain with concurrent foot pain.Program Description: Three patients were referred forelectrodiagnostic evaluation to rule out lumbosacral radicu-lopathy. These patients had poorly localized foot and lowerleg numbness along with lower back axial pain. Lumbosacral

S79PM&R Vol. 2, Iss. 9S, 2010