Sacral insufficiency fractures: a report of two cases and a review of the literature.

Sacral insufficiency fractures (SIF) are a type of stress fracture that occur primarily in postmenopausal women. They were first described in 1982 by Lourie and have since been frequently overlooked as a cause of low back, buttock, or groin pain. We present two cases of SIF to demonstrate the clinical presentation, diagnosis, and treatment of patients with SIF. Both patients were elderly women with complaints of pelvic and low back pain in the absence of significant trauma. Physical examination was significant for marked sacral tenderness. Diagnostic imaging supported the diagnosis of SIF. Both patients underwent early rehabilitation, including early ambulation, and had good functional outcomes. These patients serve to illustrate how conservative treatment yields excellent clinical results in the majority of patients, with most reporting improvement within 1-2 weeks after fracture and complete resolution of symptoms after 6-12 months of treatment.

Thoracic disk herniation presenting as abdominal and pelvic pain: a case report.

We report the case of a young woman who presented with a 2-month history of severe abdominal and pelvic pain. The past history was significant for a fall from a bicycle 1 week before the onset of her pain. Physical examination was remarkable for periumbilical tenderness. Work-up including pelvic sonogram and diagnostic laparoscopy suggested endomyometritis. The pain was minimally relieved by nonsteroidal anti-inflammatory drugs and narcotic analgesics. Thoracic spine magnetic resonance imaging (MRI) revealed a large disk herniation at the T9-10 level compressing the spinal cord. The patient subsequently underwent T9-10 diskectomy and laminectomy with dramatic relief of her symptoms. Postoperative rehabilitation hastened her functional improvement. This is a rare case of symptomatic thoracic disk herniation after trauma presenting as abdominal and pelvic pain. Physicians should be aware of this unusual presentation of thoracic disk herniation to avoid invasive diagnostic procedures.

Unilateral extremity swelling in female patients with cancer.

Unilateral extremity swelling may be secondary to two major causes in female patients with cancer, deep venous thrombosis (DVT) and lymphedema. In women of all ages, DVT is high on the differential diagnosis list for unilateral extremity swelling. However, in women with an underlying malignancy, DVT and lymphedema must both be considered. Appropriate diagnosis and treatment are necessary to improve the quality of life and function of the female patient with cancer.

Paraneoplastic cerebellar degeneration as the first manifestation of cancer.

Paraneoplastic cerebellar degeneration (PCD) is a type of paraneoplastic syndrome that primarily affects women with gynecological cancers. Patients typically experience pancerebellar symptoms, including gait ataxia, dysarthria, nystagmus, and truncal and appendicular ataxia. We present the case of a 50-year-old woman with PCD and presumed ovarian cancer who initially complained of ataxia and dysarthria. PCD was diagnosed on the basis of her symptoms, diagnostic imaging, and laboratory work. PCD symptoms may precede the diagnosis of malignancy by months or years. Early diagnosis and treatment of these syndromes, including rehabilitation, may result in improvements in quality of life for this population of patients.

The controversy surrounding sacral insufficiency fractures: to ambulate or not to ambulate?

Sacral insufficiency fractures are an often unsuspected cause of low back pain in elderly women with osteoporosis who have sustained minimal or no trauma. Many of the references in the literature advocate bed rest initially; however, we support early mobilization, because most of these fractures are stable and require no surgical intervention. With good pain control, patients can begin progressive ambulation with assistive devices in a supervised environment and minimize the complications of immobility.

Paraneoplastic cerebellar degeneration as the first evidence of cancer: a case report.

Paraneoplastic cerebellar degeneration (PCD) is the most frequently seen paraneoplastic syndrome affecting the brain. PCD is most commonly associated with cancers of the ovary, breast, and lung. The anti-Purkinje cell antibodies (anti-Yo) that specifically damage the Purkinje cells of the cerebellum are found in the patient's serum and cerebrospinal fluid. The typical presentation of PCD includes limb and truncal ataxia, often along with dysarthria. This report describes the case of a 47-year-old woman without significant medical history who developed new onset of unsteady gait, headache, and vertigo. The imaging studies suggested rhombencephalitis. The patient initially responded to corticosteroid treatment. Unfortunately, her gait ataxia worsened and she developed dysarthria, neither of which responded to increasing dosages of corticosteroids. Extensive imaging studies showed no evidence of tumor, but the patient was found to have positive anti-Yo antibodies and elevated cancer antigen 125 (CA-125). Pathology results from exploratory laparotomy revealed stage III C adenocarcinoma of the ovary. This case demonstrates that PCD may be the presenting symptom of an occult malignancy. The pathogenesis, diagnosis, and treatment of PCD, and its rehabilitation implications, are reviewed.

Gait variables of patients after lower extremity burn injuries.

Functional ambulation is an expected outcome of physical therapy after burn injuries on the lower extremities. The purpose of this study was to document temporal and spatial gait parameters of adult patients with the use of the GAITRite system (CIR Systems Inc, Clifton, NJ) after the patients were burned on their lower extremities and to compare these results with previous data reported for normal subjects. Twenty-five adults with lower extremity burns (19 men and 6 women; mean age, 35.6+/-8.3 years) were evaluated within 5 days of discharge from an acute care facility. The GAITRite system, which consists of an electronic walkway that contains 6 sensor pads encapsulated in a rolled-up carpet, was used to collect temporal and spatial variables. The patients walked at their preferred rate of ambulation and completed 2 passes; the 2 passes were then averaged by the software to determine the patients' gait parameters. A 2-tailed t test was used for comparison of the mean values for the patients and the previously published data. The results indicated that for both men and women, cycle time and base of support were significantly higher (P < or = .01) in the patients with burn injuries than in normal subjects. For men, all of the remaining parameters were significantly lower (P < or = .01) in the patients with burns except stride length, which was not significantly different (P > .05). For women, stance time as a percentage of the gait cycle and cadence, velocity, step length, and stride length, were all significantly lower (P < or = .01) in the patients with burn injuries, whereas double support as a percentage of the gait cycle was not significantly different (P > .05) between the 2 groups. These results indicate that immediately after an acute care hospitalization, patients with lower extremity burns have significantly different gait patterns than gender-and age-matched normal subjects. Future studies are necessary to determine whether these impairments in gait limit the functional abilities of a patient.

The physical, functional, and developmental outcome of pediatric burn survivors from 1 to 12 months postinjury.

Fifty-one children with an average age of 27 months and who had sustained a burn injury were tested at 1, 6, and 12 months postinjury to determine their physical, functional, and developmental outcomes. Most parents were either African-American or Hispanic, lived on public assistance, and had a high school education or less. Most children had normal range of motion and were appropriate for their age in self-care skills. On the basis of the Home Screening Questionnaire, 48% of the children came from suspect home environments. Developmental delays were noted in language acquisition that persisted over the first year postburn. Although the outcomes of these burn injuries were good in physical and functional areas, the developmental findings raised concerns. The results alert clinicians to screen for potential developmental problems during the burned child's recovery phase and to include appropriate developmental activities and parental guidance in the treatment plan.

Sciatic neuropathy secondary to a uterine fibroid: a case report.

Lesions of the sciatic nerve outside the pelvis have been well described. Lesions within the pelvis, however, are far less common. We report the case of a 55-yr-old woman with a history of chronic low back pain who presented with progressive right buttock and posterolateral right lower limb pain associated with right foot numbness and tingling. She denied any associated low back or left lower limb pain. The patient was initially treated for a probable right lumbosacral radiculopathy, without improvement. A subsequent magnetic resonance image of the lumbosacral spine revealed multilevel disc degeneration at L3-4 through L5-S1, without disc herniation or canal stenosis. A magnetic resonance image of the pelvis revealed a markedly enlarged uterus, with a large pedunculated myoma impinging on the right sciatic foramen. The patient underwent a subtotal abdominal hysterectomy, with resolution of her right lower limb pain. This case illustrates the importance of considering intrapelvic causes of sciatic neuropathy. To our knowledge, this is the first reported case of sciatic neuropathy secondary to a uterine fibroid.

Pectoralis major rupture during gait training: case report.

Rupture of the pectoralis major muscle is rare. The majority of cases have been reported in young, healthy athletes during strenuous activities such as weight-lifting, wind surfing, and football. The injury is thought to result from either a forceful contraction of the muscle applied to an immovable object or a sudden stretching force applied to the contracting muscle. This report describes a case of a 79-year-old man with a history of severe degenerative joint disease of the right hip and a recent left transtibial amputation secondary to a failed arterial bypass procedure. During prosthetic training the patient developed acute pain in the left shoulder and left axilla, which prevented him from further ambulation. Physical examination was consistent with a partial rupture of the pectoralis major. The causative factors of pectoralis major rupture in this patient are reviewed. To our knowledge, this is the first such case reported.

Spinal accessory nerve palsy as a cause of pain after whiplash injury: case report.

Spinal accessory nerve injury is most commonly reported following surgery in and around the posterior cervical triangle. Pain, impaired ability to raise the ipsilateral shoulder, and scapular winging on abduction of the arm are the most frequently noted clinical manifestations. We report the case of a collegiate swimmer who developed left-sided neck and shoulder pain secondary to a spinal accessory nerve palsy (SANP) after a "whiplash injury," which we believe to be the first such reported case in the English language literature. We review the clinical manifestations, diagnostic pitfalls, and therapeutic approaches to SANP. A high index of suspicion for SANP following whiplash-type injury will ensure its earlier detection and treatment and improve the chances of a better functional outcome.

Avascular necrosis of bilateral knees secondary to corticosteroid enemas.

Avascular necrosis (AVN) is a devastating adverse effect of corticosteroid therapy rarely reported in the setting of inflammatory bowel disease. We describe a 48-year-old woman with 6 weeks of progressive bilateral knee pain resulting in the inability to ambulate. Her symptoms developed suddenly, 9 months after treatment with hydrocortisone enemas for ulcerative proctitis. On physical examination, the patient had knee tenderness, decreased range of motion, and flexion contractures. Magnetic resonance imaging showed multiple bony infarcts in bilateral distal femora and proximal tibias, consistent with advanced AVN. Initial therapy included pain management, serial casting, gentle flexibility and strengthening, and limited mobility training. The rehabilitation efforts led to functional improvement. Ultimately, bilateral total knee arthroplasties were recommended to treat her advanced AVN. This is the first reported case of AVN secondary to hydrocortisone enemas. We review the literature and discuss the pathophysiology and management of corticosteroid-induced AVN.

Transient osteoporosis of the hip during pregnancy: a case report.

Transient osteoporosis associated with pregnancy is a rare, self-limiting skeletal disorder, the origin of which remains unclear. We report the case of a 36-year-old Japanese woman who developed pain in the left hip, groin, and knee in the seventh month of pregnancy. The pain gradually worsened and prevented weight-bearing. The hip and knee pain progressed to bilateral involvement and persisted after an emergent cesarean section at 35 weeks. Radiographs after delivery revealed gross osteopenia of both the femoral heads, left distal femur, and proximal tibia, consistent with transient osteoporosis associated with pregnancy. The patient remained mostly wheelchair-dependent because of severe hip and knee pain. Several weeks later, the patient was started on alendronate, a biphosphonate, which provided dramatic relief of hip and knee pain. The patient's ambulatory function subsequently improved dramatically as a result of pain relief and assistance with gait training. This case is unique for several reasons. First, it is rare for transient osteoporosis associated with pregnancy to involve both hip joints, and it rarely involves the knee. Second, this is the first reported case of pain management of transient osteoporosis associated with pregnancy being successfully treated with an antiresorptive agent. Finally, the use of alendronate in transient osteoporosis associated with pregnancy may help shorten disability by providing pain relief and decreasing the fracture risk associated with this disease.

Recurrent spontaneous hemarthrosis associated with reflex sympathetic dystrophy.

Reflex sympathetic dystrophy is a mysterious entity with unclear pathogenesis. The diagnosis is largely clinical and based on signs and symptoms of pain and vasomotor dysfunction. Treatment is a challenge because the underlying mechanism remains unknown. Our patient is a 75-year-old woman 2 years after left total knee replacement who presented with her second spontaneous hemarthrosis in 3 months. After arthrocentesis, dusky discoloration, edema, hyperesthesia, and decreased range of motion of the left knee and entire distal extremity were noted. Despite analgesia and physical therapy her symptoms worsened. Radiographs of her left knee showed severe periprosthetic osteopenia and a triple phase bone scan was negative. Clinically, reflex sympathetic dystrophy was considered likely and a lumbar sympathetic block was performed. The patient improved and continued to do well after a series of blocks. This is the first reported case of recurrent atraumatic hemarthrosis associated with reflex sympathetic dystrophy.

Conservative management of lumbar spinal stenosis. Identifying patients likely to do well without surgery.

Lumbar spinal stenosis is a painful condition that often leads to irreversible neurologic damage and functional disability. Thus, early diagnosis and management are important. Conservative therapy, which is appropriate for many patients, minimizes invasive intervention and decreases the risks of morbidity. As more people live to older ages, the incidence of lumbar spinal stenosis will likely increase. If results of a thorough history and physical examination suggest the disorder, a course of appropriate physical therapy should be started promptly; more expensive tests and treatments are reserved for patients whose pain is refractory to early conservative intervention. However, if pain is severe, if the origin is not clear, or if neurologic deficits quickly become worse, immediate neuroradiologic studies should be considered, including timely EMG. Strong guidance by the primary care physician is of paramount importance because the therapeutic program is lengthy. Additional help from a physiatrist, neurologist, or orthopedic surgeon may be indicated as treatment progresses.

Multiple sclerosis presenting as a spinal cord tumor.

Multiple sclerosis, a disorder of central nervous system demyelination, is a leading cause of disability in young people. Lesions of the spinal cord are usually less than two vertebral body segments long, peripherally located, and found in the cervical region. A 30-year-old woman had a 2-month history of back pain, urinary incontinence, and bilateral lower extremity weakness. Magnetic resonance imaging (MRI) of the spine showed an intramedullary spinal cord tumor from T4 to T8 with an intramedullary cyst from T1 to T4. After thoracic decompressive surgery, findings from biopsy of the cord lesion were consistent with multiple sclerosis. Postoperatively, the patient required an intensive rehabilitation program. This is the first reported case of histopathologically confirmed spinal cord demyelination presenting as an intramedullary thoracic cord tumor. Physiatrists should be alerted that demyelinating disease can mimic a spinal cord tumor, even on MRI, and must be considered in the differential diagnosis of a symptomatic spinal cord mass.

Herpes zoster polyradiculopathy.

Herpes zoster infection, resulting from reactivation of the dormant varicella zoster virus in the dorsal root ganglia, usually causes a painful dermatomal vesicular rash. Rarely, associated peripheral motor weakness is present, the mechanism of which is unclear. Three patients are reported who had focal limb muscle weakness associated with zoster infection. Physical and occupational therapy played a key role in motor function recovery of the patients, yet emphasis on the rehabilitation of postherpetic motor weakness is lacking in the literature. Physiatrists evaluating patients with limb muscle weakness following herpes zoster infection should be alert to this condition. The clinical syndrome of herpes zoster radiculopathy and the rehabilitation of these patients are discussed.

Autonomic dysfunction as the presenting feature of Guillain-Barré syndrome.

Autonomic dysfunction has been demonstrated in various conditions associated with peripheral neuropathy such as acute intermittent porphyria, amyloidosis, and Guillain-Barré syndrome (GBS). In the latter, hypertension is an associated complication that typically occurs after neurological signs are already present. We report a case of a patient with autonomic dysfunction as the presenting feature who was admitted to the coronary unit with chest pain and hypertension. Subsequently, he developed progressive symmetric muscle, weakness, sensory changes, and areflexia. GBS was then diagnosed based on the clinical picture, albuminocytologic dissociation in the cerebrospinal fluid, and electrodiagnostic abnormalities suggestive of demyelinative polyneuropathy with conduction block. Few cases in the literature have reported autonomic dysfunction as the presenting feature of GBS, such as in this case. In a previously asymptomatic patient, acute onset of autonomic dysfunction should alert the physician to the possibility of an acute polyneuropathy, such as GBS.

Cerebral diaschisis following cerebellar hemorrhage.

In 1914, Von Monakow described diaschisis, the recovery of lost cortical function in regions positionally distant from, but linked by neuronal tracts to, the primary site of cortical damage. Cerebellar diaschisis after cortical insult is detailed in the literature; however, cortical diaschisis after cerebellar insult remains a rarely reported occurrence. We describe a 36-year-old woman with rupture of a right-sided cerebellar arteriovenous malformation who developed such expected cerebellar signs as ataxia, dysmetria, and nystagmus. Days later, the patient developed profound impulsivity, disinhibition, and psychomotor agitation. Single photon emission computed tomography (SPECT) showed decreased perfusion of the bilateral frontal and temporal lobes, consistent with regional loss of neural activity. Eventual clinical improvement corresponded with reperfusion of those regions, identified on follow-up SPECT. This case documents cortical diaschisis following cerebellar insult and shows that diaschisis must be considered in patients with cerebral injury manifesting cortical deficits remote from the site of primary pathology.