Postoperative redislocation of the hip in a patient with congenital insensitivity to pain with anhidrosis: A case report and review of literature

Pelvic osteotomy is commonly used to adjust acetabula dysplasia for congenital dislocation of the hip, whereas congenital insensitivity to pain with anhidrosis (CIPA) is a rare hereditary disease that often has the characteristics of joint development deformity and easy fracture. This article reports the case involving a CIPA patient who was surgically treated by Chiari pelvic osteotomy and proximal femoral rotation osteotomy for congenital dislocation of the left hip joint and was provided long-term follow-up for redislocation and bilateral femoral head absorption.     

An unusual cause of S1 radicular pain presenting as early phantom pain in a transfemoral amputee: a case report

Smuck M, Christensen S, Lee SS, Sagher O. An unusual cause of S1 radicular pain presenting as early phantom pain in a transfemoral amputee: a case report.Recent epidemiologic studies have shown back pain to be a significant cause of pain in lower-limb amputees, but only a handful of cases have reported sciatica in amputees. The symptoms are usually described as a phantom pain or neuropathic pain in the residual limb that is often refractory to conventional treatments. These symptoms typically occur with back pain and are distinct from the patient’s usual symptoms. Interestingly, back pain is not a universal finding. We present a patient with presumed phantom limb pain subsequently discovered to be caused by an S1 radiculopathy. This patient’s supposed phantom pain persisted despite multiple medication trials. Initial work-up revealed a sciatic neuroma at the stump. Treatments targeting this neuroma were unsuccessful. Further evaluation found that a sacroiliac joint screw placed to stabilize a pelvic fracture had intruded into the S1 neuroforamen. A diagnostic S1 nerve block temporarily relieved the patient’s pain, and the screw was removed. Pain persisted and a spinal cord stimulator was placed resulting in improvement of his pain. Because conventional diagnostic tests are limited, including physical exam and electromyography, a fluoroscopically guided selective spinal nerve block proved to be a useful diagnostic tool in this patient.     

Retroperitoneal false aneurysm presenting as anterior thigh pain and weakness: a case report

This case highlights the importance of considering retroperitoneal pathology in the differential diagnosis of anterior thigh pain and weakness. We describe a woman in her mid seventies with a history of a left total hip arthroplasty and lumbar decompression who presented with left anterior thigh pain and left lower-extremity weakness. A computed tomography scan of the retroperitoneum revealed a mass along the left iliopsoas muscle. An arteriogram revealed a large false aneurysm that communicated with the left common femoral artery. Surgery to resect the aneurysm revealed exposed parts of the hip replacement that may have contributed to the formation of the aneurysm. We concluded that imaging of the retroperitoneum should be considered in any patient presenting with anterior thigh pain and weakness.     

Monoparesis with complex regional pain syndrome-like symptoms due to brachial plexopathy caused by the varicella zoster virus: a case report

Viral invasion of the motoneurons and the subsequent inflammation in the anterior horn cells by the varicella zoster virus results in a weakness in the area of the cutaneous eruption. The exact mechanism of zoster paresis is uncertain. The occurrence of symptoms resembling complex regional pain syndrome (CRPS) is common in subjects where the herpes zoster (HZ) outbreak affects an extremity, particularly if it is the distal extremity that is involved. We report the case of a 54-year-old man with monoparesis, hyperalgesia, allodynia, edema, and both color and skin-temperature changes in his left arm after a skin eruption. Electrophysiologic examination revealed the partial degeneration of the superior, middle, and inferior truncus in the brachial plexus, with evidence of HZ infection. Magnetic resonance imaging of the cervical spine and brachial plexus showed degenerative changes without any evidence of nerve root compression. Brachial plexopathy may be the direct cause of the reversible upper-limb paresis resulting from HZ with CRPS-like symptoms.     

Twenty-seven years of complication-free life with clean intermittent self-catheterization in a patient with spinal cord injury: A case report

Currently, clean intermittent self-catheterization (CISC) is the most prevalent method of bladder management in patients with spinal cord injury (SCI) at discharge from rehabilitation centers. However, half of the patients discontinue using CISC and change to other methods of bladder management several months postdischarge despite the fact that it the best way to prevent urinary tract complications. Few studies, however, report the long-term consequences of CISC. In this case, we present a woman in her early fifties who had sustained thoracic SCI and had continued using CISC for 27 years without developing any complications. The possible reasons for her success were absence of incontinence because of underactive and normal capacity bladder; normal upper-extremity functions and absence of marked spasticity of lower extremities that facilitated CISC technique; and absence of sociovocational problems, enabling her to keep proper intervals between catheterizations each day. This case indicates that CISC is useful for long-term bladder management in patients with SCI, even for 25 years or more. Long-term outcomes of CISC and factors leading to success need to be delineated in future studies with larger samples.     

Treatment of testicular pain using conservative management of the thoracolumbar spine: a case report

Unsuccessful recognition of the origin of testicular pain and a high failure rate of surgical interventions lead to poor outcomes, psychologic distress, and increased costs of care. A frequently overlooked cause of testicular and buttock pain is irritation of the T10-L1 sensory nerve roots, the genitofemoral nerve, and the ilioinguinal nerve. We present the case of a 36-year-old policeman with a 5-year history of back pain and testicular pain of unknown origin. Physical examination of the thoracolumbar region revealed that active movement provoked the patient's buttock symptoms, and local mobility restrictions were present in the thoracolumbar region. A central disk protrusion at T12-L1 was noted on upper lumbar spine magnetic resonance imaging, which supports dysfunction of this region. The diagnosis of thoracolumbar stiffness led to implementation of passive and active mobilization of that region and to specific hip stretching and strengthening exercises. After a course of direct and guided physical therapy, the patient attained complete symptom resolution. The patient returned to full work duties as a police officer and resumed his full recreational activity. The excellent outcome achieved in managing this patient was attributed to identifying the origin of referred pain from the thoracolumbar junction.     

Synovial chondromatosis in an elite cyclist: a case report

Primary synovial chondromatosis is a rare disorder that can present as chronic hip and groin pain. It is characterized by formation of osteocartilaginous nodules arising from the synovium. We report the first case, to our knowledge, of an Olympic-caliber cyclist, in her mid thirties, with primary synovial chondromatosis of the left hip. Clinical examination showed decreased internal rotation, external rotation, forward flexion, and abduction of the left hip. A radiograph of the left hip showed slight hip-joint narrowing centrally. A magnetic resonance imaging arthrogram showed a small anterior labral tear and innumerable small intermediate-intensity filling defects situated diffusely within the joint fluid. Fluoroscopically guided injection of the left hip with local anesthetic and cortisone produced temporary pain relief. Conservative treatment was marginally helpful. Results of a rheumatology workup were unremarkable. Arthroscopic removal of loose bodies and synovectomy were performed. The diagnosis of primary synovial chondromatosis was confirmed by histologic examination. At the 17-month follow-up, our patient was essentially pain free and had returned to her previous athletic activities.     

先天性痛觉不敏感并夏科关节1例

病例 男，12岁。反复双踝关节胀痛5年，再发加重1周。近5年来剧烈活动后出现双踝关节红肿、胀痛，休息后缓解，曾多次到多家医院就诊，以化脓性踝关节炎、缺血坏死、类风湿性关节炎等疾病治疗，效果不佳，且病情缓慢进展。父母述，患儿婴幼儿时期打针从未哭过，平时喜欢活动，动作粗暴，皮肤经常带有伤痕，未曾诉疼痛，但恐惧冰冷物体。父母健康，非近亲结婚，家族中无类似病例。     

Intracerebral hemorrhage secondary to autonomic dysreflexia in a young person with incomplete C8 tetraplegia: A case report

Intracerebral hemorrhage is an unusual complication of autonomic dysreflexia and can be fatal if massive bleeding occurs with brain herniation. We report the case of a man in his midthirties with incomplete tetraplegia who suffered right putaminal hemorrhage during an episode of autonomic dysreflexia. Prompt recognition and removal of the triggering factors of autonomic dysreflexia quickly brought his blood pressure under control and the patient had a favorable functional outcome after rehabilitation. A review of the literature suggests that the location of hemorrhage in autonomic dysreflexia-induced cases is similar to that in the general population. The most common triggering factors are bladder distension in men and labor induction in women. Hemorrhagic stroke can also occur in patients with incomplete spinal cord injury (SCI) who develop autonomic dysreflexia. The role of sympathetic skin response examination is also discussed. This life-threatening complication should be kept in mind in the case of people with SCI.     

Irreversible spinal nerve injury from dorsal ramus radiofrequency neurotomy: a case report

Radiofrequency neurotomy (RFN) of the medial branches of the dorsal rami is a successful method of treating facet joint pain. Documented serious complications are rare. We discuss the case of a 33-year-old woman with low back pain (LBP) who sustained a right L5 nerve root injury during RFN. The patient had several months of axial LBP after a motor vehicle collision. She had no relief after anti-inflammatory medications, physical therapy, L5-S1 interlaminar epidural corticosteroid injections, and a right sacroiliac joint injection. She then received bilateral L3 and L4 medial branch and bilateral L5 dorsal ramus blocks with excellent temporary pain relief. Subsequently she underwent bilateral L3 and L4 medial branch and bilateral L5 dorsal ramus RFN. Afterward, she noticed new right leg pain and paresthesias extending throughout the L5 dermatome. Electromyography and magnetic resonance imaging were normal and she was diagnosed with a right L5 sensory radiculopathy. The right leg symptoms were unresponsive to multiple medications. After a successful trial with a spinal cord stimulator, she underwent permanent stimulator placement. Afterward, she had 90% relief of her right leg pain and discontinued all analgesics. Irreversible injury of nontarget nerves is a possible complication of RFN, and can be avoided by following proper procedural protocol.     

Septic sternoclavicular joint: a case report

Crisostomo RA, Laskowski ER, Bond JR, Agerter DC. Septic sternoclavicular joint: a case report.A 23-year-old man presented to our sports medicine clinic with a history of nontraumatic left anterior chest pain. Prior to presentation, a magnetic resonance image (MRI) had been performed that showed increased signal in the soft tissues around the sternoclavicular joint, primarily in the pectoralis major, and a small amount of fluid in the joint, thought possibly consistent with sympathetic effusion from a muscle tear. On examination, the patient was toxic appearing and had severe pain with virtually any left upper-extremity movement and with walking. There was swelling, redness, warmth, and tenderness over the left sternoclavicular joint. Vital signs were normal, but due to concerns of possible septic arthritis, he was admitted to the hospital. After discontinuation of prednisone and hydrocodone-acetaminophen that he had been receiving, the patient became febrile. Blood and sternoclavicular joint aspirate cultures grew methicillin-sensitive Staphylococcus aureus. On re-review of the MRI, subtle abnormal signal compatible with the patient's joint infection was seen. The patient was treated with intravenous antibiotics and, eventually, surgical resection of the left sternoclavicular joint, proximal clavicle, and lateral manubrium with subsequent muscle flap. No predisposing factor for this infection was found. Septic sternoclavicular joint is rare, accounting for 1% of all septic joints. Infection or other unusual pathology should be suspected when clinical findings are not consistent with simple musculoskeletal injury.     

Transitional cell carcinoma of the urethra [correction of ureter] in a patient with buttock pain: a case report

Murphy DR, Morris NJ. Transitional cell carcinoma of the ureter in a patient with buttock pain: a case report.This case reports on a patient with an unusual presentation of a rare tumor: urethral transitional cell carcinoma (TCC). Urethral TCC occurs in approximately 0.7% to 4.0% of patients who have had primary bladder cancer. The initial symptoms usually involve hematuria, with approximately a third of patients reporting flank area pain. Buttock pain and the absence of hematuria are uncommon with this disorder. The patient was initially suspected to have piriformis syndrome, but when he did not respond as expected to treatment, and because of his history of primary bladder cancer, further evaluation was undertaken and the diagnosis was made. The patient responded well to radiation and chemotherapy. Musculoskeletal physicians should be particularly suspicious of the presence of urethral TCC in a patient with a history of primary bladder cancer who reports low back or buttock pain, particularly if the patient does not respond quickly to treatment.     

One rare side effect of zolpidem--sleepwalking: a case report

Zolpidem is an imidazopyridine agent indicated for the short-term treatment of insomnia. Sleepwalking is a rare side effect of zolpidem. A review of the literature produced only 2 cases. We report a case of a male rehabilitation inpatient in his mid fifties with a history of alcoholism and traumatic brain injury who had undergone a right hip hemiarthroplasty. He had no history of somnambulism or insomnia but walked in his sleep on 2 nonconsecutive nights after taking zolpidem. He had exhibited no such behavior before taking zolpidem, on the intervening night that was he was not given medication, and after the medication was discontinued. We conclude that zolpidem can cause sleepwalking, and patients who have suffered a brain injury may be more susceptible to this side effect. Here we describe the clinical presentation and review the relevant literature on zolpidem and sleepwalking.     

Development of spontaneous intracranial hypotension concurrent with grade IV mobilization of the cervical and thoracic spine: a case report

Donovan JS, Kerber CW, Donovan WH, Marshall LF. Development of spontaneous intracranial hypotension concurrent with grade IV mobilization of the cervical and thoracic spine: a case report.Spontaneous intracranial hypotension (SIH) has been clinically defined as the development of severe orthostatic headaches caused by an acute cerebrospinal fluid (CSF) leak. Typically, intracranial hypotension occurs as a complication of lumbar puncture, but recent reports have identified cases caused by minor trauma. We report a case of SIH secondary to a dural tear caused by a cervical and thoracic spine mobilization. A 32-year-old woman with SIH presented with severe positional headaches with associated hearing loss and C6-8 nerve root distribution weakness. CSF opening pressure was less than 5cmH₂O and showed no abnormalities in white blood cell count. Cranial, cervical, and thoracic magnetic resonance imaging revealed epidural and subdural collections of CSF with associated meningeal enhancement. Repeated computed tomography myelograms localized the leak to multiple levels of the lower cervical and upper thoracic spine. A conservative management approach of bedrest and increased caffeine intake had no effect on the dural tear. The headache, hearing loss, and arm symptoms resolved completely after 2 epidural blood patches were performed. Practitioners performing manual therapy should be aware of this rare, yet potential complication of spinal mobilizations and manipulations.     

Genu recurvatum in hemophilia: a case report

Hemorrhages in the musculoskeletal system of patients with hemophilia give rise to a number of disabilities requiring rehabilitative measures. The knee is the most commonly affected joint. Recurrent hemorrhages in the knee joint can cause arthropathy and flexion deformity. The current literature does not reveal development of genu recurvatum from repeated hemorrhages. This report presents a patient with hemophilia who developed a genu recurvatum deformity. We have discussed the clinical presentation, probable cause, and the management of the patient, and have included a brief review of the epidemiology of this deformity along with management options.     

Two novel mutations of SCN9A (Nav1.7) are associated with partial congenital insensitivity to pain

Insensitivity to pain is a rare disorder that is commonly associated with Hereditary Sensory and Autonomic Neuropathies (HSAN I—V) resulting often in autonomic dysfunction and premature death. Very few individuals have been reported with pain insensitivity lacking such autonomic neuropathies. We performed genetic, neurologic, psychological, and psychophysical evaluations in such an individual (OMIM 243000) and her first degree relatives. Sequence analysis of genomic DNA revealed two novel SCN9A mutations in this index case (IC). One was a non‐conservative missense mutation (C1719R) in exon 26 present only in the IC and one parent. Further sequence analysis of the chilD's DNA revealed a 1‐bp splice donor deletion in intron 17 which was also present in the other parent and one sibling. Detailed psychophysical testing was used to phenotypically characterize the IC, her family members, and 10 matched normal controls. Similar to family members and controls the IC showed normal somatosensory functioning for non‐nociceptive mechanoreception and warmth. However, she demonstrated diminished ability to detect cool temperatures combined with profound deficits in heat and mechanical nociception. Congenital insensitivity to pain in our IC was associated with two novel SCN9A mutations which most likely resulted in a Nav1.7 channelopathy. However, in contrast to individuals with other SCN9A mutations, the observed pain insensitivity was relative and not absolute, which may be consistent with hypomorphic effects of one or both mutations. The ability to sense at least some danger signals may be advantageous and ameliorate the otherwise increased morbidity and mortality of some individuals with congenital insensitivity to pain.     

Spinal cord compression secondary to metastatic non-Hodgkins lymphoma: a case report

Luo CC. Spinal cord compression secondary to metastatic non-Hodgkin’s lymphoma: a case report.Non-Hodgkin’s lymphoma spine metastasis is a rare entity. A woman in her mid fifties with history of non-Hodgkin’s lymphoma was admitted to the hospital with bilateral leg weakness, anesthesia, and incontinence. Magnetic resonance imaging of the spine showed diffuse metastatic disease involving the cervical, thoracic, lumbar, and sacral spine. She was treated with radiation therapy and high doses of corticosteroids. When discharged to home, she could ambulate with a rolling walker independently, was capable of self-catheterization, and could insert suppositories for a bladder and bowel program.     

Myelopathy associated with melorheostosis: a case report

A man in his mid thirties presented with lower-extremity weakness and spasticity because of a myelopathy caused by a rare disorder of bone known as melorheostosis. The primary pathology involved was compression of the cord at the cervicothoracic levels by dystrophic osseous formation within the vertebral bodies. Based on a review of existing literature, it was evident that the spine is an uncommon location to find melorheostosis, making this disease entity a unique cause of myelopathy. The patient's progress was closely observed during his inpatient rehabilitation program, after he underwent spinal decompression surgery. Starting from the level of complete paralysis, he was able to regain functional strength in his legs by the end of his 2-month course. Despite the lack of reported outcomes in cases of myelopathy associated with melorheostosis, our report describes a favorable prognosis with good recovery of both strength and function.