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Predicting Chronic Stinger Syndrome Using the Mean Subaxial Space

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Predicting Chronic Stinger Syndrome Using the Mean Subaxial Space PM&R Vol. 2, Iss. 9S, 2010 S89 paresthesias, swelling or erythema. No prior cardiac or pul- Results: Approximately 6 months after her injury, the pa- monary disease except for mild hypertension managed with a tient was seen in our office for initial consultation of torticol- low sodium diet. No history of smoking. Radiographs were lis. Our clinical findings revealed left rotational torticollis, negative for any significant abnormalities. Venous ultrasound significant decrease in range of motion, and normal neuro- did not show any thrombus formation. She continued to logic examination. Her dynamic CT scan was reviewed show- complain of persistent posterior knee pain and calf spasms in ing a right C1-C2 facet joint subluxation without significant spite of several weeks of physical therapy. change upon rotation. She was diagnosed with atlantoaxial Setting: An outpatient physical medicine and rehabilitation rotatory fixation (AARF) and underwent an open reduction clinic at a tertiary medical center. and internal fixation of the C1-C2 vertebrae. At her 3-week Results: She was subsequently referred to our clinic for follow-up visit, there was resolution of her torticollis and a evaluation of intractable posterior knee pain and leg spasms physical therapy program focusing on range of motion, flex- thought to be related to a muscle strain. Our neurologic ibility and strengthening was implemented. examination was essentially normal. She had a non-antalgic Discussion: AARF is a fixed subluxation or dislocation in gait and was able to perform 5 toe raises without pain. There the cervical spine involving the inferior atlantal and superior was mottling and dryness of her skin at the feet with de- axial facets. This is a rare condition more frequently found in creased dorsalis pedis pulses bilaterally. The left gastrocne- children with minor trauma or upper respiratory infections, mius was tender to palpation. Slight pain associated with inflammatory conditions, or predisposition to ligamentous resisted plantar-flexion. Given her history and physical ex- laxity. AARF is seldom reported in adults and proper diag- amination findings we obtained vascular studies, which dem- nosis is often delayed. Torticollis is a typical presentation and onstrated severe arterial occlusive disease in the left lower neurologic injury is uncommon. Dynamic cervical CT scan extremity. can aid in diagnosis. Treatment options include conservative Discussion: After carotid ultrasound did not reveal any care, immobilization, traction, manual reduction, and sur- significant stenosis, she was started on a walking program. A gery. Surgery is indicated when there is transverse ligamen- follow-up appointment was scheduled with vascular medi- tous injury, spinal instability, neurologic injury, or failure of cine to discuss angioplasty or stent placement as a treatment conservative measures. option if her pain did not improve after 3 months. Unfortu- Conclusions: AARF in an adult is rare and torticollis is a nately, the patient had a ST-elevation myocardial infarction 6 typical presentation. AARF should be considered in an adult weeks into her walking program. with torticollis after a posttraumatic event. Conclusions: This case underscores the importance of including ischemic disease in the differential diagnosis for leg Poster 196 muscle pain and spasms and even more so when the history Predicting Chronic Stinger Syndrome Using and examination findings are not suggestive of a muscle the Mean Subaxial Space Available for the strain injury. This case also raises the question of whether Cord Index (MSCSAC): A Case Report. patients with ischemic disease should undergo cardiac eval- Jennifer Kendall, DO (University of Michigan, Ann uation before embarking on an exercise program. Arbor, MI); Jared Greenberg, MD; Daniel Leung, DO. Poster 195 Disclosures: J. Kendall, None. Posttraumatic Atlanto-Axial Rotatory Fixation Patients or Programs: A 21-year-old Division I collegiate in an Adult Presenting as Torticollis. football player with a “stinger.” Amit Dholakia (Rothman Institute, Philadelphia, Program Description: The patient, who had a history of PA); Zach Broyer, MD; Theodore D. Conliffe, MD. several prior stingers, presented with 5 days of persistent left Disclosures: A. Dholakia, None. neck and shoulder pain associated with paresthesias and Patients or Programs: A 21-year-old woman with torti- upper extremity weakness. This injury was caused by left collis. lateral neck flexion and extension. Examination and electro- Program Description: A 21-year-old woman presented diagnostic evaluation was consistent with a left C5 radiculop- with a 6-month history of torticollis after a severe motor athy, but MRI of the cervical spine was “normal.” The calcu- vehicle accident as a restrained front seat passenger. She was lated mean subaxial cervical space available for the cord previously diagnosed with spasmodic torticollis, which led to index (MSCSAC) score was 3.2 mm. a multiple ineffective treatments, including muscle relaxants, Setting: University outpatient clinic. chiropractic care, physical therapy, and botulinum toxin Results: Patient had complete resolution of symptoms and injections. She was seen by a neurosurgeon who ordered a returned to play. dynamic CT scan for suspicion of atlantoaxial instability but Discussion: A “stinger,” also known as a “burner” is a failed to follow-up after completion of radiological imaging. transient, reversible peripheral nerve injury of the upper Setting: Outpatient orthopedic center. extremity caused by injury to the cervical spine and shoulder, S90 PRESENTATIONS usually occurring during contact sports. A wide range of Poster 198 clinical courses have been described, however, pain lasting Puddle Slip Injury Resulting in a Complete longer than 24 hours is generally uncommon. The MSCSAC Proximal Avulsion of the Semimembranosus is a novel tool to predict chronic stinger syndrome. It is Tendon in a Nonathlete: A Case Report. calculated by subtracting the sagittal diameter of the spinal Christine M. Roque-Dang, DO (UMDNJ-New Jer- cord from the disk level sagittal diameter of the spinal canal at sey Medical School, Newark, NJ); Todd Stitik, MD. the C3-6 levels and then averaging these values. A cutoff of Disclosures: Ͻ4.3 mm has been shown to predict a greater than 13-fold C. M. Roque-Dang, None. Patients or Programs: increase in risk of developing chronic stinger syndrome. The A 42-year-old female nursing MSCSAC score of 3.2 mm correlated with the patient’s his- assistant. Program Description: tory of multiple stingers. In discussing return to play, it was The patient complained of severe emphasized that he is at greater risk for future stinger injuries right hip region and lower limb pain after she slipped on a based on MSCSAC index. puddle of water. She stated that her right knee was flexed, her Conclusions: The MSCSAC is a novel, sensitive tool that ankle was dorsiflexed, and she recalled hearing a “pop” while may be used to predict chronic stinger syndrome. slipping. She complained of “burning” posterior and medial thigh pain with radiation to the posterior ankle and noted Poster 197 resolution of her initial right hip pain. On physical examina- Progressive Radiculopathy Due to Cervical tion, she had an antalgic gait, ecchymoses were visualized Arteriovenous Fistula: A Case Report. over the posterior thigh, and she had decreased sensation to Andrew Illig, DO (Rusk, New York, NY); Jeffrey M. light touch in the distribution of the sciatic nerve. Setting: Cohen, MD. Outpatient private practice office. Results: Musculoskeletal ultrasound examination revealed Disclosures: A. Illig, None. architectural distortion of the biceps femoris and semimem- Program Description: A 64-year-old woman was re- branosus muscles with surrounding edema. A subsequent ferred to rehabilitation clinic with a 2-year history of progres- MRI showed complete avulsion tear of the semimembrano- sive left arm weakness without pain or sensory disturbances. sus tendon from the ischial tuberosity. At subsequent follow- Physical examination was significant for atrophy of the left ups, the patient’s sciatica resolved as local edema subsided. deltoid, biceps, scapular, and parascapular muscles. Muscle An orthopedic surgery consult was obtained and, at 1-month strength testing was 0/5 in the deltoid and biceps, 3/5 in the postinjury, the patient underwent a right proximal hamstring triceps, and 4/5 in the wrist extensors, wrist flexors, and hand tendon repair with good outcome. intrinsic muscles. Electrodiagnostic testing showed neuro- Discussion: Complete proximal origin avulsions of the pathic changes in the distribution of the C5, C6, and C7 hamstring tendons are rare and usually result from injuries nerves and related paraspinal muscles. Radiological workup with a flexed hip and extended knee. Most of these injuries revealed an extradural vertebral artery arteriovenous (AV) occur in young athletes and several cases involve water plexus fistula at the level of C2-3 compressing the anterolat- skiers. In nonathletes, there is no consensus regarding con- eral cervical cord from the skull base extending down within servative versus operative management. Few cases exist the spinal canal through C6-7. The enlarged vessels also filled where concomitant temporary sciatica is described. the C2-3 through C6-7 neural foramina causing root com- Conclusions: Reported is an unusual case with an atypical pression. The patient was referred to vascular surgery but presentation of a complete proximal hamstring tendon
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