Bilateral Lower Extremity Pain Research Articles

0987 Asking the Right Questions: A Case of Restless Legs Syndrome and Spinal Muscular Atrophy

Abstract Introduction The association between iron deficiency and restless legs syndrome (RLS) is well established. However, there is limited data on the association between motor neuron diseases such as spinal muscular atrophy (SMA) and RLS. A forty-three-year-old with Type 2 SMA presented to clinic for management of chronic respiratory failure. She had recently undergone surgery and chemotherapy for newly diagnosed anal cancer. However, she reported persistent abdominal pain, anorexia, weight loss, and rectal bleeding. She reported “muscle twitching” and bilateral lower extremity pain and tingling that was worse at night. Her husband would awaken every 2 hours to massage her legs. She assumed these symptoms had emerged as a result of an increase in motor function due to risdiplam, a survival motor neuron 2 splicing modifier drug. Further questioning led to the diagnosis of RLS. Bloodwork revealed severe iron deficiency anemia (hemoglobin of 6.0 g/dL, iron 13 mcg/dL, and ferritin 3 ng/ml). She received a blood transfusion and underwent sigmoidoscopy for evaluation of cancer recurrence given the report of bleeding. Fortunately, her cancer remained in remission. Her symptoms of RLS significantly improved after blood transfusions and iron supplementation. Report of case(s) n/a Conclusion RLS is a complex sensorimotor syndrome. The diagnosis of RLS is clinical, relying on diagnostic criteria that requires lower extremity movement. The case is a reminder of the variable presentation of RLS in individuals with neuromuscular disorders, including SMA. How are symptoms of restless legs disclosed in patients with the inability to move and with potentially altered sensorium? The focus of the patient encounter could have anchored on the common and expected sequalae of SMA, chronic respiratory failure. Unfortunately, anchoring bias would have delayed the diagnosis and treatment of what could have been a potentially fatal disease – metastatic cancer. Ironically, the patient’s longing for motor function repressed her ability to lament. To the patient, symptoms of frequent nighttime awakenings and limb discomfort were perceived as a desired side effect of a medication that would increase movement. This case emphasizes the importance of the patient interview and its value of uncovering subtle complaints that may broaden the differential diagnosis and guide further work-up. Support (if any)

45-year-old Male with Bilateral Lower Extremity Wounds, Swelling, and Rash.

A 45-year-old male presented to the emergency department (ED) with bilateral lower extremity pain, swelling, and associated atypical rash in the setting of polysubstance use and unstable housing. Laboratory tests showed an elevated white blood cell count and inflammatory markers.

S2772 Subcutaneous Sweet Syndrome Successfully Treated With Ustekinumab in Patient With Ulcerative Colitis

Introduction: Extraintestinal manifestations (EIMs) of inflammatory bowel disease (IBD) are well-established. Sweet syndrome (SS), or acute febrile neutrophilic dermatosis, is a reactive mucocutaneous manifestation of IBD presenting as erythematous papules/plauqes with associated fever and arthomyalgias. There is limited evidence regarding efficacy of Ustekinumab in management of EIMs of UC, particularly SS. Case Description/Methods: The patient is a 50-year-old woman with left-sided UC (Montreal classification E2) that previously failed several therapies, including mesalamine, azathioprine, infliximab, adalimumab, vedolizumab, and a fecal microbiota transplant trial. She presented with worsening abdominal pain, diarrhea/hematochezia, and bilateral lower extremity pain. She was febrile and tachycardic with tender, violaceous, and ulcerated subcutaneous nodules on the bilateral ankles with hemorrhagic bullae (FigureA). Labs revealed negative C. diff, elevated ESR/CRP, thrombocytosis, and borderline leukocytosis with neutrophilic predominance. Lower extremity MR imaging and bone biopsy revealed multifocal sterile osteomyelitis with adjacent abscess; skin biopsy demonstrated dense granulomatous/neutrophilic infiltrate in the deep dermis/subcutis without microorganisms, consistent with subcutaneous SS (FigureB). A restaging colonoscopy demonstrated severe proctosigmoid ulcerative colitis (FigureC). Given that the patient had failed several immunomodulators and biologic therapies, she was started on prednisone and Ustekinumab. Four months later, she reported complete resolution of her cutaneous SS off steroids and improving UC symptoms (less frequent and more formed stools, minimal hematochezia). Repeat MRI demonstrated resolution of the sterile osteomyelitis and abscess. Discussion: Our case highlights the novel use of Ustekinumab in the treatment of subcutaneous SS with sterile osteomyelitis in a patient with flaring UC. SS is a neutrophilic dermatosis that is a rare EIM of IBD, classically characterized by tender cutaneous lesions. There is limited evidence supporting the use of Ustekinumab in treating EIMs of CD, and a lack of data regarding its efficacy in treating EIMs of UC. Our case fills a major gap in the literature and highlights the clinical efficacy of Ustekinumab for SS and UC especially in patients that have a contraindication to, failed previous treatment with, or otherwise cannot tolerate corticosteroids and TNF-alpha antagonists.Figure 1.: 1A. Right lateral malleolus with 2.5 cm shallow erosion with slightly violaceous borders and central bright yellow fibrinous debris. There was slight atrophy of surrounding skin with mild edema and hyperpigmentation (left image). Left medial malleolus/dorsal foot with grouped irregular shallow ulcers with surrounding mild violaceous erythema (middle and right image). 1B. Left ankle biopsies showed mixed septal and lobular panniculitis with granulomatous and neutrophilic inflammation. Histologic sections show a mildly spongiotic epidermis with dense granulomatous and neutrophilic inflammatory infiltrate in the deep dermis and subcutis (left image). The inflammatory infiltrate, which consists of prominent neutrophils, histiocytes, and scattered lymphocytes, surrounds vascular and adnexal structures, as well as adipocyte lobules. Definitive features of vasculitis are not seen. PASd (periodic acid-Schiff-diastase), GMS (Grocott’s methenamine silver), Gram, and Fite staining fail to highlight microorganisms (right image). 1C. Colonoscopy demonstrated severe (Mayo Endoscopy Score 3) proctosigmoid ulcerative colitis to 30 cm (left image). Sigmoid biopsies showed significant immune cell infiltration with crypt architectural distortion concerning for severe chronic active colitis. No evidence of granulomas, dysplasia or cytomegalovirus (right image).

Large Free-Floating Right Atrial Thrombus

We present the images of a 67-year-old man who came to the emergency department with bilateral lower extremity pain and shortness of breath. Our images include an intraoperative transesophageal echocardiogram that shows a large, continuous free-floating right atrial mass and a large 31 cm × 1 cm thrombus that was successfully extracted. The thrombus likely could not embolize because of the patient's severe heart failure.

ID:15744 Atypical Complex Regional Pain Syndrome or Functional Neurologic Disorder: A Case Report

A 41 year-old, male was referred by neurology to the outpatient pain clinic with an initial tentative diagnosis of a functional neurologic disorder. Upon interview the patient endorsed an approx. 3 year history of progressive, ascending numbness and neuropathic pain in bilateral lower extremities that was precipitated following a ligamentous injury involving the right ankle. He also reported temperature sensitivity and noted delayed healing of on an ulcer on his 5th digit. On physical examination the patient was neurologically intact and did not display allodynia. EMG/NCS revealed no evidence of a pathologic process. Given the post traumatic onset of his pain and possible trophic symptoms it was hypothesized that his neurologic symptoms could be related to a sympathetically mediated process. He subsequently underwent a fluoroscopic guided unilateral lumbar sympathetic block using local anaesthetic and dexamethasone. Pre-procedurally he rated his pain as 8/10. Within two days the patient reported complete resolution of his pain with lasting benefit at 2 weeks’ follow up.

Post-COVID-19 vaccination inflammatory syndrome: A case report.

ABSTRACTA previously healthy 24-year-old male patient was referred to our clinic with bilateral lower extremity pain and dark urine, which developed two weeks after receiving the second dose of BNT162b2 vaccine against SARS-CoV-2. Laboratory tests indicated rhabdomyolysis. Lower extremity magnetic resonance imaging was compatible with myositis. Myositis-related antibodies were negative. Biopsy taken from gastrocnemius muscle revealed muscle necrosis and striking expression of major histocompatibility complex class I antigen. He was successfully treated, and his complaints resolved. One week later at follow-up, he reported new-onset exertional dyspnea with palpitations. ST-segment depressions were spotted on electrocardiography. Troponin T was found elevated as 0.595 ng/mL (normal <0.014 ng/mL). Echocardiography showed hypokinetic left ventricle with ejection fraction of 40%, and pericardial effusion of 2mm. An appropriate treatment plan was formulated for the diagnosis of myocarditis, eventually the patient recovered within ten days. BNT162b2 mRNA vaccine was felt to cause the aforementioned condition since no other etiology could be identified. Although it is known that BNT162b2 may induce myocarditis, myositis concomitant myocarditis appears to be a very rare adverse effect of this vaccine.

Severe Rhabdomyolysis and Acute Renal Failure Due to Noncompliance to Levothyroxine Therapy

Background: Noncompliance to levothyroxine (LT4) is common however only rarely it leads to severe side effects. We report a case of rhabdomyolysis leading to acute kidney injury (AKI) requiring hemodialysis (HD) due to noncompliance to LT4 therapy for one month. Clinical Case: A 68-year-old Caucasian male presented with a 2-week history of worsening fatigue and generalized weakness, accompanied by pain in bilateral lower extremities. Medical history included coronary artery disease, heart failure with reduced ejection fraction, hypertension, dyslipidemia, hypothyroidism, type 2 diabetes mellitus, CKD. Home medications included LT4 200 mcg daily, metoprolol 25 mg daily, doxazosin 2 mg daily, amlodipine 5 mg daily, fluocinonide 40 mg daily, fosinopril 40 mg twice daily, metformin 500 mg twice daily and rosuvastatin 40 mg daily. Further history revealed the patient to be not taking LT4 as “he ran out of it for a month” and only resumed taking it 3 to 4 days before coming to the hospital. On examination, he had proximal muscle weakness with power 3/5 in bilateral lower extremities and mild tenderness on thigh muscles. Labs revealed creatinine 13.1 mg/dL (0.60-1.10 mg/dL), BUN 101 mg/dL (0-30 ng/dL), eGFR 4.0 ml/min/1.73m2, CK 69,500 U/L (22-198 U/L), TSH 55.8 uIU/ml (0.45-4.5 uIU/ml), and FT4 0.61 ug/dL (0.8-1.8 ug/dL). ABG showed metabolic acidosis. Routine labs three months prior revealed normal thyroid function tests (TSH 1.6 uIU/ml and FT4 1.3 ug/dL) on LT4 200 mcg and baseline CKD stage 3b (EGFR 51 ml/min/1.73m2 with baseline creatinine 1.4 mg/dL). The patient was diagnosed with severe rhabdomyolysis secondary to noncompliance with LT4 therapy in presence of concurrent statin use, leading to AKI. Rosuvastatin was stopped and he was treated with aggressive intravenous hydration, sodium bicarbonate, and LT4 200 mcg daily. Despite two days of aggressive treatment, CK remains elevated and hence HD was initiated. The patient underwent three sessions of HD during the course of his hospitalization. Due to lack of renal recovery, outpatient HD was arranged. At 4 weeks of outpatient follow-up, the patient was oliguric and HD dependent. At 8 weeks outpatient follow up, CK, TSH, and FT4 was normal on LT4 200 mcg daily and became dialysis independent. Conclusion: Noncompliance to LT4 therapy along with concomitant use of statin can result in severe rhabdomyolysis induced AKI in patients with CKD.

Successful Treatment of Chronic Back and Leg Pain With Lower Than Usual Placement of High-Frequency Spinal Cord Stimulation in a Patient With Uncorrected Tethered Cord: Case Report

ABSTRACT BACKGROUND AND IMPORTANCE Tethered cord syndrome (TCS) often leads to severe back and leg pain. The typical treatment to stall disease progression is untethering surgery, but this is not always effective for pain. Spinal cord stimulation (SCS) is an efficacious treatment for neuropathic pain. However, it has seldom been utilized in TCS cases. Moreover, with cord elongation, ideal paddle placement is not certain. CLINICAL PRESENTATION We present the case of a 77-yr-old male with severe chronic lower-back and lower-extremity pain. Magnetic resonance imaging (MRI) showed severe lumbar spine degenerative changes, along with a previously undiagnosed spina bifida and conus medullaris termination at L5. We felt that SCS would be the best treatment avenue for his chief complaint of pain. Due to cord elongation, we trialed lower placement of the high-frequency (HF)-SCS system at T11-T12, which led to 80% improvement in pain symptoms within 1 wk and ability to walk for the first time in a year. At his first follow-up appointment, the patient endorsed 80% to 90% relief of his lower-back and bilateral lower-extremity pain, which improved to 100% relief at 12 mo at last visit. CONCLUSION Only 4 other reports were identified in the literature utilizing SCS in TCS cases. Our case adds to the limited body of literature that SCS is an effective therapy for pain in TCS and degenerative spine disease. Only 2 other reports employed lower than usual lead placement. Our case demonstrates that lead placement may need to be changed to accommodate the elongated cord.

A case of statin-associated immune-mediated necrotizing myopathy with atypical biopsy features.

Statin-associated immune-mediated necrotizing myopathy (IMNM) is a rare presentation of a statin-associated myopathy. Patients usually present with muscle weakness and pain in the setting of statin use with elevated creatine kinase (CK) levels and a positive anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (anti-HMGCR) antibody. Muscle biopsies typically show necrosis, CD68+ macrophages, and minimal lymphocytes. We present a case of a 67-year-old woman who had 2 months of progressive weakness and bilateral lower extremity pain after initiating atorvastatin therapy with symptoms persisting after statin cessation. She was found to have high anti-HMGCR antibody titers, and the biopsy of the rectus femoris muscle showed a prominent endomysial inflammatory cell infiltrate with necrotic and regenerative fibers and an atypical extensive inflammatory infiltrate composed of both CD4+ helper T cells and CD8+ cytotoxic T cells. She showed symptom resolution and normalization of CK levels and inflammatory markers with treatment involving a prolonged prednisone taper and a brief course of azathioprine, which was stopped because of the adverse effects.

Persistent Toe-Walking in a Developmentally Normal 7-year-old Girl

1. Ngoc Thien T. Nguyen, MD, MPH* 2. Eyal Ben-Isaac, MD*,† 3. Mikako Warren, MD‡ 1. *Department of Pediatrics, Children’s Hospital Los Angeles, California 2. †Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California 3. ‡Department of Pathology and Laboratory Medicine, Children’s Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California A 7-year-old, developmentally normal girl with a history of toe-walking presents to an emergency room with complaints of worsening back and leg pain with limp. She has walked on her toes since she learned to ambulate at 18 months. However, in the past she was able to correct her gait when reminded. Family was reassured that these symptoms were most likely benign as the child continued to otherwise do well and had symptom-free periods. In the past 2 years, she developed bilateral lower extremity pain, which was more frequent at night and improved with massaging of the extremities. Initially her symptoms were attributed to growing pains. However, in the past month, massage no longer relieved the pain. In addition, she now has been having back and bilateral knee pain. Her symptoms are more prominent on the right side. Most recently she has been hunching to the right when walking and having extended periods of toe-walking. On examination, she has a right-sided lower thoracic prominence and levoscoliosis of the thoracic region. She exhibits an antalgic gait with toe-walking more prominent on the left side along with a left-sided foot drop. Strength is decreased in the left lower extremity, and sensation is intact throughout. She does not demonstrate clonus or any appreciable cranial nerve abnormalities. Further workup with imaging and pathology revealed the diagnosis. A common benign etiology for lower extremity pain in school-aged children is “growing pains.” There is no …

No bones about it: a case of infected intradural dermoid cyst mimicking primary orthopedic pathology

Introduction Dermoid cysts are benign developmental tumors that arise from the inclusion of ectodermal and mesenchymal components within the neural groove during embryonic development. Infection is rare and can lead to profound neurologic sequelae that closely mimic orthopedic or rheumatologic pathology. Case Report A previously healthy 2 year old male presented with 4 month history of progressive pain and refusal to ambulate or bear weight in his lower extremities. His initial decline began with falls while walking or running, followed by unilateral lower extremity pain, then bilateral lower extremity pain, and eventually refusal to ambulate. He also had …

SAT-362 A Bone to Pick with FGF23

A 48 yo M with a past medical history of bilateral femoral neck stress fractures at age 44 status post closed reduction percutaneous pinning (CRPP) presented to the emergency room with bilateral lower extremity pain after a ground level fall. Plain films were notable for a right intertrochanteric fracture and left hip nonunion. The patient underwent removal of right CRPP hardware and revision fixation with a short TFN-Advanced Femoral Nailing System (TFNA) and fixation of the left femoral neck nonunion. Given his injuries following a ground level fall, endocrinology was consulted for recommendations. Labs during his hospital course were notable for hypophosphatemia as well as normal levels of alkaline phosphatase, serum calcium, and PTH. Serum protein electrophoresis and urine protein electrophoresis were within normal limits. A 24-hour urine calcium and phosphorous were done and the patient was found to have a low calculated renal phosphate threshold (TmP04/GFR), concerning for hypophosphatemic osteomalacia. An FGF23 level was drawn and was elevated, suggestive of an FGF23-induced hypophosphatemic osteomalacia. A low vitamin D 1,25-OH was also found consistent with this process, given interference of alpha-hydroxylation of vitamin D 25-OH from FGF23. The patient therefore underwent a PET scan to rule out a mesenchymal tumor-induced osteomalacia but his PET scan was largely unremarkable. Given that there were no issues with bone development or fractures during childhood, the suspicion for X-linked hypophosphatemia or autosomal recessive hypophosphatemia was low. The patient was believed to have either a small mesenchymal tumor not seen on PET scan or an autosomal dominant hypophosphatemia, which can manifest clinically during adulthood, and so was treated with daily Calcitriol and phosphate with subsequent correction of his serum phosphorous. Such a delayed presentation of hereditary hypophosphatemic osteomalacia, however, has been reported only in women either soon after puberty, during pregnancy, or after delivery (1). This case thus represents a possible autosomal dominant hypophosphatemia in a male patient or a rare case of tumor-induced hypophosphatemic osteomalacia.Reference: (1) Drezner MK, Whyte MP. Heritable renal phosphate wasting disorders. Genetics of bone biology and skeletal disease, 2nd ed. 2018; 761–782.

Acute Lyme Arthritis Presenting in Bilateral Hips of an Elderly Patient: A Case Report

A 70-year-old male presented with a chief complaint of 10 days of lower back and bilateral lower extremity pain. He described sudden onset of intense, sharp bilateral anterior thigh pain radiating to the medial calves intermittently and without paresthesia, bowel or bladder incontinence, fevers, rashes or weight change.

The First Case Report of Tazobactam Induced Thrombocytopenia

Drug-induced immune thrombocytopenia (DITP) is a rare and often overlooked cause for thrombocytopenia. It is a particularly difficult diagnosis given its rarity and because at least 100 different medication have been implicated. Cases of piperacillin-tazobactam-induced DITP have sparked growing interest given how common this antibiotic is used. Few studies, however, have defined the specific moiety causing the suspected DITP by serologic testing. When this has been done, only piperacillin has been implicated. Here, we describe the first case of DITP in which tazobactam was implicated by serologic studies. Case A 62 year-old-male with a past medical history of Crohn's disease, alcohol use disorder and chronic obstructive pulmonary disease (COPD) presented to the hospital with bilateral lower extremity pain and redness, and diffuse abdominal pain for 1 week. His home medications included pravastatin, meloxicam, pantoprazole and adalimumab. Physical exam, lab testing and imaging studies provided evidence for lower extremity cellulitis, multifocal pneumonia and possible colitis. In the Intensive care unit the patient was started on broad-spectrum antibiotics (vancomycin and piperacillin-tazobactam). He developed new onset thrombocytopenia to &lt;20 K/UL (&gt;50% drop within 72 hours) by hospital day 3, and vancomycin was discontinued. A peripheral smear showed no evidence of schistocytes or platelet clumps. Subcutaneous heparin was discontinued and supportive care with vasopressors, antibiotics and RRT was continued. Patient's septic shock improved, and he was eventually weaned off the vasopressor support. However, his thrombocytopenia persisted which prompted further workup as shown in Table 2. After initial workup remained unrevealing, piperacillin-tazobactam was discontinued and he was started on cefepime on hospital day 11. On day 12, his thrombocytopenia started to improve and showed an upward trend over next 48 hours. At this point antibiotic associated thrombocytopenia was highly suspected so antibiotic specific antibodies to piperacillin-tazobactam were requested. Platelet count on the day of discharge (hospital day 18) was 72 K/UL (Figure 1). IgM antibodies that reacted with normal platelets only when tazobactam was present in the reaction mixture were identified in laboratory testing performed by the Platelet and Neutrophil Immunology Laboratory of Versiti-BloodCenter of Wisconsin. Discussion Serologic findings made in this very complex case indicate that severe thrombocytopenia was caused by an IgM antibody that recognized normal platelets only in the presence of tazobactam. Tazobactam is almost invariably given with piperacillin to inhibit bacteria-derived penicillinase and prolong the lifespan of piperacillin in vivo but, although numerous cases of piperacillin-induced thrombocytopenia have been described, this is the first report in which tazobactam has been documented as the trigger for immune thrombocytopenia. While tazobactam, like piperacillin, contains a beta-lactam structure, tazobactam-specific antibiotic testing may have implications on choosing future antibiotic therapies (particularly penicillins) for a patient. DITP occurring in the ICU can often be over-looked because patients tend to be critically ill and there may be many other reasons for a low platelet count. It is important to keep this diagnosis in mind whenever severe thrombocytopenia develops. Additionally, further work may seek to understand whether a patient's penicillin allergy may be specific to a moiety such as tazobactam, allowing continued use of other types penicillin-class drugs. Disclosures No relevant conflicts of interest to declare.

PERSISTENT GENITAL AROUSAL DISORDER INTERVENTION WITH MANUAL PHYSIOTHERAPY - A CASE STUDY

A 36-year-old female patient came with an bilateral lower extremity pain and altered sensation, physical evaluation and radiological finding are normal, and there was presence of myofascial trigger points in both lower extremities diagnosed as a myofascial pain syndrome (MPS) and had been treated for it. The failure of treatment for MPS is followed by reevaluation, and on subjective evaluation, her genital symptoms such as unresolving genital arousal, fullness, engorgement, and restless leg syndrome were revealed, and on the objective evaluation, there was an overactive pelvic floor muscles; with subjective and objective findings, the problem was diagnosed as persistent genital arousal disorder (PGAD), the problem causing pathoanatomic structure and pathomechanism was discovered and addressed with manual physiotherapy, and the patient got complete solution from the PGAD. The informed consent was obtained from the patient.

Thoracolumbar spinal neurenteric cyst with tethered cord syndrome and extreme cervical lordosis in a child

Rationale:Neurenteric cysts, are rare benign tumors of the central nervous system that are mostly located in the spinal cord and predominantly seen in male children although adult form of the disorder also occurs. The etiology and treatment of this disorder is still a matter of debate. Our case further throws more light on the pathogenesis and treatment of this disorder.Patient concerns:A 4-year-old boy presented with 5-month history of cervical lordosis and bilateral lower extremity pain that progressed to his abdomen and upper body. The pain was general, recurrent, non-persistent and progressive in nature with no paralysis. The pain was aggravated by trunk stretching and relieved when he assumed opisthotonos position so he preferred sleeping in this position at night.Diagnoses:Magnetic resonance imaging (MRI) revealed a cystic lesion at the thoracolumbar spine with tethering of spinal cord and cervical lordosis.Interventions:He was operated on successfully and the cervical lordosis and pain resolved.Outcomes:The child recovered well with no tumor recurrence and massive improvement of his life.Lessons:The gold standard treatment for this disorder is surgery although the precise surgical approach is still a matter of debate. We are of the view that surgical approach should be individualized and aim at total excision of the cyst.

Acute aortoiliac occlusive disease during percutaneous transluminal angioplasty in the setting of ST-elevation myocardial infarction: a case report

BackgroundAortoiliac occlusive disease, which is also referred to as Leriche syndrome, is a chronic atherosclerotic occlusive disease that occurs at the level of the aortic bifurcation. It is often thought to present with a triad of clinical symptoms: (1) intermittent lower extremity vascular claudication, (2) impotence, and (3) weak/absent femoral pulses.Case presentationWe report a case of a 47-year-old Caucasian woman who presented with an acute inferior ST-elevation myocardial infarction. During percutaneous transluminal angioplasty, our patient suddenly developed severe bilateral lower extremity pain, absent femoral pulses, and cool extremities. Distal aortogram revealed 95% stenosis with an apple core-like lesion in the mid-abdominal aorta. Stent placement resulted in improved blood flow to the distal aortic segment and resolution of symptoms.ConclusionsThe presence of significant peripheral vascular disease, significant cardiac risk factors, and/or difficulty accessing the femoral artery should caution a transfemoral approach during percutaneous transluminal angiography. This approach may precipitate aortoiliac occlusion and/or thromboembolism to the lower extremities. We encourage interventional cardiologists to (1) take extra caution when manipulating the wire and catheter and (2) strongly consider using a transradial approach in such patients.

Sporadic hemangioblastoma of the film terminale with peritumoral cyst

Background:Spinal hemangioblastoma originating from the film terminale are rare tumors. Here, we present a film terminale hemangioblastoma and review the appropriate literature.Case Description:A 37-year-old female presented with bilateral lower extremity pain without a focal neurological deficit. The magnetic resonance (MR) image demonstrated an intradural spinal tumor at the L1 level, which was accompanied by peritumoral cysts. In addition, there were multiple surpentine flow voids (e.g., consistent with torturous and convoluted vessels), which is typical for hemangioblastoma. At surgery, a spinal hemangioblastoma originating from the film terminale with peritumoral cysts at the L1 level was fully excised without producing a focal postoperative neurological deficit. Histological examination revealed stromal cells with vacuolated cytoplasm and small nuclei in a rich capillary network accompanied by several enlarged vessels. These finding were compatible with a hemangioblastoma.Conclusions:We reported a rare case of a hemangioblastoma originating from the conus presenting at the L1 level. Complete surgical resection was accomplished without any motor deficit.

Iatrogenic intradural arachnoid cyst following tethered cord release in a child

Iatrogenic arachnoid cysts represent uncommon complications of intradural spinal procedures. Here we present the case of a 7-year-old girl who was found to have a symptomatic, pathologically proven, intradural arachnoid cyst 3years following tethered cord release. The patient originally presented with abnormal urodynamics testing and was found to have fatty infiltration in her filum terminale. She underwent sectioning of the filum terminale without complications. The patient presented 3years later with pain and neurogenic claudication. The patient was successfully treated with subarachnoid cyst fenestration with resolution of her bilateral lower extremity pain. Spinal intradural arachnoid cysts represent an important, though rare, postoperative complication of dural opening.

Bilateral Lower Extremity Pain in a College Volleyball Player

Bilateral Lower Extremity Pain in a College Volleyball Player