Faculty Bibliography

Case Description: 33-year-old female with history of lumbar disc herniation with radiculopathy presents with radiating left sided neck pain for 1 week without inciting event. Cervical spine exam revealed left cervical paraspinal muscle, facet joint, upper trapezius and levator scapulae tenderness, and equivocal Spurling's sign. Patient was diagnosed with cervical radiculopathy likely secondary to cervical disc herniation. Oral steroids and physical therapy were prescribed. Six days later, patient presented to the ED with left arm/face numbness. Exam revealed decreased sensation in the V1/3 distribution and left arm. CTA head/neck revealed left cervical vertebral artery dissection, patient was started on daily aspirin and outpatient neurology follow up was advised.
Setting(s): Outpatient spine clinic Patient: 33-year-old female with radiating left sided neck pain Assessment/Results: Patient with clinical presentation of progressive left cervical radiculopathy was found to have a vertebral artery dissection as the true etiology of neck pain.
Discussion(s): Neck pain is a common complaint in spine clinic and the majority of cases are not life threatening. Incidence of cervical artery dissection is low; however, it is a common cause of stroke in adults younger than 50. Similar to cervical radiculopathy, cervical artery dissection can present with gradual neck pain and tenderness to palpation on exam, however the majority of patients also have severe headache which was not seen in this case.
Conclusion(s): Cervical artery dissection is a serious, albeit rare, cause of neck pain with a high potential for fatal sequelae. In cases of progressive neck pain despite use of oral steroids, cervical vertebral artery dissection should be considered as a potential cause of neck pain particularly in the context of new onset facial and arm numbness

Case Description: To report the use of a leukocyte-rich platelet-rich plasma injection in a patient with a T11-L1 interspinous ligament (ISL) sprain who had previously failed conservative management and corticosteroid injections.
Setting(s): Outpatient sports medicine clinic.
Patient(s): An otherwise healthy 25-year-old female. Assessment/Results: The patient presented to the clinic with a chief complaint of chronic upper lumbar and mid-thoracic back pain. Physical exam revealed full range of motion with pain at endpoint of lumbar flexion and tenderness to palpation. After a full examination, the patient was provided an initial ultrasound guided T11-L1 ISL injection with triamcinolone and referred for a course of physical therapy. Her pain had not resolved thus a second injection was performed with betamethasone. Several weeks post-procedurally, her pain persisted. Ultrasound examination revealed hypervascularity and edema in the soft tissue consistent with the diagnosis of an ISL sprain. This was subsequently confirmed with MRI. Afterwards, an injection of 3 mL of leukocyte-rich platelet rich plasma (LR-PRP; Arthrex Angel) was performed.
Discussion(s): The diagnosis of ISL sprains can be an elusive, particularly in a patient who presents with a chief complaint of back pain without prior trauma. Management of an ISL sprain typically involves activity modification. While it is impossible to prove, the repeat injection with a more potent corticosteroid may have contributed to the patient's ISL sprain. Thus, the use LR-PRP was employed given the theoretical benefit of promoting ligamentous healing with the various growth factors isolated in the injectate. Upon follow up with patient 3 months later, the patient noted improvement in pain and will be receiving an additional LR-PRP injection and further physical therapy.
Conclusion(s): For ISL sprains, the use of LR-PRP may be helpful in promoting tendon repair. This case report demonstrates an index case and further study of this application for PRP is warranted

Case/Program Description: The patient is an 88-year-old woman with history of hysterectomy who was referred for evaluation of acute onset low back and buttock pain of 2 weeks duration without any reported provocation or injury. The pain was 4/10, intermittent, aching, exacerbated by walking, alleviated by resting, sitting, Tylenol and Advil. There were no associated fevers, chills, radicular symptoms, bowel or bladder dysfunction, reported changes in weight, prior or recent injections or instrumentation of the spine. Exam was notable for an antalgic gait, pain with end flexion and bilateral oblique extension, tenderness over paraspinal muscles and facet joints as well as the left sacroiliac joint and posterior superior iliac spine. Motor, sensory, and deep tendon reflexes were intact. Setting: Outpatient Spine Center. Results: Lumbar radiographs showed multilevel degenerative disc disease, spondylosis, and multilevel facet arthrosis. Patient was started on naproxen and referred to outpatient physical therapy. She presented for early follow up 11 days later, with increasing 7/10 pain radiating to left anterior thigh. Exam notable for new tenderness over anterior midthigh, positive left Ober test, reproduction of left anterior thigh pain with Ely test, mild weakness of left hip flexors and diminished left lower reflexes. Lumbar MRI showed left L3-4 facet joint abnormality, adjacent marrow edema, and soft tissue abscess of the multifidus and psoas muscles. She was emergently referred for inpatient admission, and required a prolonged hospitalization. Discussion: Psoas abscess is a rare infectious disease with nonspecific clinical presentation and often insidious onset that frequently results in diagnostic difficulty and delays. Delays are often associated with high morbidity and mortality in these patients. Conclusions: It is crucial to maintain a high index of suspicion for infectious etiologies and utilize a combination of laboratory and imaging studies when working up back pain

Case/Program Description: A 68-year-old woman with a past medical history of osteoporosis and bilateral knee replacements was referred due to clinical concern for lumbar radiculopathy. She suffered a fall 7 weeks prior to presentation however had no radicular symptoms at that time. She presented with 1 week of left-sided radiating groin pain and weaknessoftheleftleg. She wasunabletobear weight withoutpainand pain worsened with prolonged walking and improved with rest. She had previously been prescribed oxycodone and oral steroids. Her previous imaging included hip radiographs which revealed no evidence of frac-tureandMRIofthelumbarspinewhichrevealedmoderatecanalstenosis at L4-5 and multilevel neuroforaminal stenosis without compromise. Sacral insufficiency fractures were seen on the right greater than left, but incompletely evaluated. Her exam was notable for pain with hip flexion, internal and external rotation, Stinchfield test, log roll test, and Patrick's test. Occult hip fracture and lumbar radiculopathy were considered as possible explanations for her symptoms.A left hip MRI was ordered to better characterize her injury. Setting: Quaternary care hospital. Results: Left hip MRI revealed a left obturator externus avulsion as well as bilateral sacral alar fractures and left parasymphyseal fracture. She was given oxycodone for pain management, and a manual wheelchair until she was able to bear weight without pain. She began a physical therapy program and 9 weeks after her injury she was able to walk with a rollator. Her osteoporosis treatment was addressed. Further developments will be discussed. Discussion: Pelvic ring fractures involving the sacral ala and the parasymphyseal region can be managed nonoperatively, and may present similarly to radiculopathy. In addition, this is the first reported case, to our knowledge, of obturator externus avulsion. Conclusions: Obturator externus avulsions should be considered in the setting of presumed occult hip fracture