eMedicine Specialties > Physical Medicine and Rehabilitation > Plexopathy

Neoplastic Lumbosacral Plexopathy

Rajesh R Yadav, MD, Assistant Professor, Section of Physical Medicine and Rehabilitation, MD Anderson Cancer Center, University of Texas at Houston

Updated: Dec 4, 2008

Introduction

Background

Neoplastic lumbosacral plexopathy (NLP) is an infrequent complication associated with advanced systemic cancer due to local or regional progression of the primary tumor. NLP is characterized by significant pain and sensorimotor deficits.

Anatomically, the lumbosacral plexus consists of lumbar (L1-L4) and sacral (L5-S5) portions, which are connected by the lumbosacral trunk (L4-L5).The L1-L4 nerve roots transverse through psoas muscle and then coalesce into the lumbar plexus, which then divides into anterior and posterior divisions. The first 3 nerves (iliohypogastric, ilioinguinal, femoral) of the 7 major branches of lumbar plexus provide motor and sensory innervation to the abdominal wall. The next 3 nerves (lateral femoral cutaneous, femoral, obturator) innervate the anteromedial thigh. The femoral nerve terminates into the saphenous nerve, providing sensation along the medial aspect of the leg.

The sacral plexus also divides into anterior and posterior divisions, which further divide into various peripheral nerves that provide sensory motor innervation to the posterior hip girdle, thigh, and anterior and posterior leg. The 5 main nerves are the superior gluteal, inferior gluteal, posterior femoral cutaneous, sciatic, and pudendal nerves. The sciatic nerve divides into the common peroneal and tibial nerves in the thigh.

NLP associated with pelvic, abdominal, and retroperitoneal tumors often results in significant pain, sensory disturbance, weakness, and disability. Plexus involvement occurs as a result of tumor extension or invasion and heralds a progressive disease course. Plexopathy is part of the initial presentation of cancer in 15% of patients.

Related eMedicine topics:
Diabetic Lumbosacral Plexopathy
Radiation-Induced Lumbosacral Plexopathy

Pathophysiology

Lumbosacral plexus involvement occurs most commonly due to intra-abdominal tumor extension (73% of cases); it occurs less commonly with growth from metastases, lymph nodes, or bone structures. A tumor can invade the plexus directly or track along the connective tissue or epineurium of nerve trunks.

The most prevalent types of tumors are colorectal tumors (20%), sarcomas (16%), breast tumors (11%), lymphoma (9%), and cervical tumors (9%). Other tumors, including multiple myeloma, account for another 37% of cases. The most common distant metastatic lesions are caused by breast cancer. In one study, the lumbosacral plexus was involved in 50 of 2261 cases of cervical cancer; however, it was involved in 38 of the 74 patients (51%) in the subgroup with proven retroperitoneal metastatic disease.

The lower (sacral) plexus is involved most frequently (approximately 50%), followed by upper plexus involvement (more than 30%) and panplexopathy (18%).^{[1 ]}Bilateral plexopathy occurs in 25% of cases and is usually caused by breast cancer metastases. Lower plexus involvement occurs generally with colorectal and cervical neoplasms. Involvement of the sacral sympathetic nerves is less common (10%).

Malignant psoas syndrome (MPS) was first described in 1990 by Stevens and refers to severe and difficult pain due to proximal lumbosacral plexopathy, painful fixed flexion of the ipsilateral hip, and radiologic or pathologic evidence of malignant involvement of the ipsilateral psoas major muscle.^{[2 ]}

Frequency

United States

The incidence of neoplastic lumbosacral plexopathy is 0.71%.

Mortality/Morbidity

Significant morbidity from neoplastic lumbosacral plexopathy occurs due to associated pain, weakness, and sensory deficits.^{[3 ]}One study noted median survival of 5.5 months after diagnosis. In patients with prostate cancer,^{[4 ]}symptoms may persist for years and survival may be longer.

Race

No known correlation is recognized between the incidence of neoplastic lumbosacral plexopathy and race.

Sex

One study noted a male-to-female ratio for neoplastic lumbosacral plexopathy of 1.3:1, although the investigation involved just a small number of patients.

Age

In one study, age at the time of presentation of neoplastic lumbosacral plexopathy ranged from 19-80 years, with a median age of 65.5 years.

Clinical

History

• Patients with neoplastic lumbosacral plexopathy (NLP) present most frequently (93%) with pain located in regional areas, such as the low back, buttock, hip, and thigh. Features of this pain include the following:
  • The pain may be of unilateral onset, being confined to one side, in 90% of cases.
  • The pain is usually constant, dull, aching, or pressurelike, but it is rarely burning. Cramping may be present in a radicular pattern.
  • The pain may worsen at night, and patients generally have difficulty finding a comfortable position.
  • Involvement of the iliopsoas muscle leads patients to rest with their legs and hips in flexion.
  • Pain exacerbation may occur with prolonged ambulation or sitting.
  • The pain may also radiate down the leg as a result of epidural involvement from the tumor.
  • Eventually, such pain manifests in all patients with NLP and is the most prominent symptom. An absence of pain should prompt consideration of other diagnoses.
  • The presence of autonomic symptoms is less frequent; one of these, the "hot and dry foot," occurs because of the involvement of the sympathetic components of the plexus.^{[5 ]}A clear difference in temperature of the affected limb may be reported.
  • When the disease process manifests first with pain, it lasts from 1 week to 13 months, with a median duration of 3 months, before other neurologic symptoms appear.
• Weakness and sensory loss complaints eventually develop in most patients.^{[3 ]}Sensory loss occurs in 50-75% of patients and is more severe with greater motor impairment, potentially adding significantly to the degree of disability for the patient.
• Muscle weakness occurs in most patients and is progressive and diffuse. Unilateral weakness and gait abnormalities are common.
• Incontinence and impotence generally imply bilateral plexus involvement; they occur in about 10% of NLP patients.

Physical

• The most common clinical findings in neoplastic lumbosacral plexopathy include muscle weakness (86%), sensory loss (73%), reflex impairment (64%), and leg edema (47%).
• Diffuse, asymmetrical motor deficits involving more than 1 nerve root develop; associated gait abnormalities are noted.
• With lumbar plexus involvement, weakness usually occurs in the thigh muscles, producing weakness when the patient rises from a seated position or negotiates steps.
• Involvement of the lumbosacral trunk is associated with a foot drop and numbness of the dorsum of the foot.
• In patients with sacral involvement, weakness of foot flexion and hamstrings occurs.
• Sensory deficits are almost exclusively unilateral and can range from mild to severe. The location of sensory deficits in specific dermatomes offers clues to the nerve root or specific nerve involvement.
• Patellar tendon reflex may be impaired with upper plexopathy, and ankle reflex impairment may be noted with lower plexopathy.
• Peripheral edema is seen more commonly with panplexopathy (80%) than with upper (41%) or lower plexopathy (37%).
• Rectal mass is found more often with lower plexopathy (43%) than with upper plexopathy (25%) or panplexopathy (15%).
• A positive straight leg raise test is most common with panplexopathy (83%).
• Pain exacerbation may occur with the Valsalva maneuver.

Causes

Tumor invasion, either local or metastatic, can lead to lumbosacral plexopathy.

Differential Diagnoses

Leptomeningeal Carcinomatosis
Radiation-Induced Lumbosacral Plexopathy

Other Problems to Be Considered

Other causes of lumbosacral radiculopathy
Primary plexus tumors
Epidural cord compression
Chemotherapy toxicity associated with intra-arterial treatment
Aortic aneurysms
Diabetes mellitus
Diabetic amyotrophy
Obstetric procedures
Trauma
Intragluteal injections

Meningeal carcinomatosis or leptomeningeal disease also may cause low back or leg pain with subacute motor or sensory involvement; however, patients with these conditions often demonstrate mental status changes, headaches, cranial nerve palsies, and/or nuchal rigidity.

In cancer patients with thrombocytopenia, retroperitoneal bleeding can cause plexopathy accompanied by a rapid onset of pain and neurologic signs that usually are fully developed in 24 hours. Other associated findings include flank, thigh, or low back ecchymoses. A retroperitoneal bleed usually involves the femoral nerve and occasionally will spread to other parts of the plexus.

Other causes of lumbosacral plexopathy to consider are idiopathic in nature, aortic aneurysms, diabetes mellitus, obstetric procedures, trauma, anticoagulation therapy, retroperitoneal hematomas, surgical intervention for mesenteric thrombosis, kidney transplantation, tuberculosis, and intragluteal injections.^{[6,7,8,9,10,11,12 ]}

Acute pain is common with aortic aneurysm, and the resultant weakness typically worsens over 1-2 weeks and then stabilizes. A pulsatile rectal or abdominal mass frequently is observed.

Acute thigh pain with acute or insidious onset weakness can result from diabetic amyotrophy and can be difficult to differentiate from the pain associated with an aortic aneurysm. In diabetic amyotrophy, weakness is more often noted proximally, with relative sparing of distal lower extremity muscles.

Workup

Laboratory Studies

• Results of lab studies depend on the type of cancer and the extent of involvement. Erythrocyte sedimentation rate (ESR), complete blood cell (CBC) count, alkaline phosphatase, protein electrophoresis, prostate specific antigen (PSA), and other cancer-specific labs may be abnormal, depending on the clinical situation. Uremia and hydronephrosis may be an issue with ureter obstruction, especially in patients with gynecologic malignancy.
• Cerebrospinal fluid (CSF) studies may reveal elevated protein with negative cytologic findings.

Imaging Studies

• The clinical diagnosis of neoplastic lumbosacral plexopathy (NLP) is confirmed by magnetic resonance imaging (MRI) or computed tomography (CT) scanning of the affected areas. MRI is preferred, because it is more sensitive and provides better detail than CT scanning.^{[13 ]}
• MRI is more accurate in soft tissues. Hydroureter or hydronephrosis are common findings at the time of diagnosis. Diagnosis can be difficult if the scan does not show a mass lesion, but repeating the study in another 4-6 weeks often reveals pathology that was not initially apparent. Increased T2 intensity within nerve trunks, with or without enhancement, has been shown with NLP.^{[14 ]}
• CT scanning of the abdomen and pelvis is probably the most valuable in diagnosis and gives more information on bony structures. Tumor, bony erosion, and lymphadenopathy are seen in 78% of cases. Clinical findings and CT scan levels do not always demonstrate positive correlation.
• Positron emission tomography (PET) scanning can aid in the detection of active malignancy in the plexus region.^{[15 ]}However, the sensitivity or specificity of PET scanning in the diagnosis of tumor plexopathy is not yet clear.
• Bone scanning reveals pelvic, sacral, or vertebral uptake in 60% of patients with NLP.
• Myelography can be abnormal with malignant plexopathy (in 28-45% of cases).
• Routine spinal and pelvic roentgenograms reveal bone destruction in 50% of patients with NLP.

Other Tests

• Electrodiagnostic testing (electromyography [EMG], nerve conduction studies [NCSs]) reveals abnormalities in almost all patients with neoplastic lumbosacral plexopathy.^{[16 ]}
  • Typical changes include acute and chronic denervation of the lumbosacral plexus. The findings are observed more extensively than would be suspected clinically. Side-to-side comparisons are helpful.
  • Myokymic discharges are not observed.
  • In the segments involved, decreased amplitudes of the evoked motor responses with normal or borderline nerve conduction velocities are noted.

Treatment

Rehabilitation Program

Physical Therapy

For physical rehabilitation, the likely progression of neurologic weakness needs to be considered. If the patient is noted to have associated weakness after acute pain has subsided, one may recommend active range-of-motion (AROM) exercises, with advancement to low resistance exercises. Assistive devices, such as a cane, walker, or wheelchair, may be required for ambulation in patients with weakness of the hip extensors, abductors, or quadriceps, with or without loss of joint position sense. Use of an ankle-foot orthosis (AFO) and, in rare cases, a knee-ankle-foot orthosis (KAFO) may be beneficial for mobility.

Occupational Therapy

The occupational therapist should assess activities of daily living (ADL) and prescribe appropriate adaptive equipment. In particular, be aware that standing-transfer safety may be impaired in cases in which involvement is more distal than proximal. With more proximal involvement, sit-to-stand transfers also may be affected. Equipment may be used specifically to facilitate dressing and bathing activities involving the lower extremity.

Medical Issues/Complications

• Medical or surgical treatment of the carcinoma when possible is the first treatment of choice.
• Intra-arterial chemotherapy regionally has limited use in patients with pelvic pain and intractable pain due to plexopathy.
• The most commonly used treatment with such plexopathy involves radiation treatment. Subjective improvement has been noted in 85% of patients with regard to symptoms. Objective improvement, including neurologic improvement and reduction in measurable tumor size, has been noted in 48% of patients. However, the average response duration has been found to be only 4 months.
• Pain management is an important issue and may require an analgesic ladder approach, including agents specifically for the management of neuropathic pain.
• Neuropathic pain may respond to nerve stimulation, antidepressants, and antiepileptics.
• Plexopathy-associated complications, such as contractures, deep venous thrombosis, immobility, and compressive neuropathies, should be anticipated, and early treatment should be provided.
• Lymphedema in the lower extremities may be an issue and can be particularly difficult to treat. Treatment should focus on improving the swelling, thus improving pain and function. Initial intervention may include wrapping with nonelastic wrapping, elevation, appropriate retrograde massage techniques, ROM exercises, and education. With improvement in edema, compressive garments should be considered, although these may have to be of a custom type.

Surgical Intervention

Patients with more severe and recalcitrant pain may respond to the use of epidural catheter drug delivery and/or neurostimulatory/neuroablative surgical approaches. Cordotomies have been reported to have good outcomes in Europe. However, pain relief has been noted to be transient. Such ablative procedures carry the risk of sensory and motor deficits. The mortality rate has been significant at 5%.

Occasional relief of chronic pain has been achieved with plexus dissection and neurolysis.

Consultations

Pain is a significant issue in most patients and studies have shown that pain is often poorly controlled in these patients. A multidisciplinary approach is needed. Consider early consultation with pain service, given the patient's short life expectancy following diagnosis. These patients may benefit from opiate analgesics, continuous infusion pumps, and procedures such as local and regional blocks, sympathectomy, and rhizotomy.

Other Treatment

Nonpharmacologic measures, such as transcutaneous electrical nerve stimulation (TENS) or Anodyne therapy, may be used for neuropathic pain.

Medication

Tricyclic antidepressants, such as amitriptyline (10-100 mg qhs), may be helpful at low doses. Antiepileptics, such as gabapentin (300-3600 mg/d in 3-4 divided doses) also can be tried. Opiates, especially methadone and steroids, can be considered as well. Mexiletine, a class 1b antiarrhythmic, at 200 mg bid, has been used for the management of significant neuropathic pain due to neoplastic plexus infiltration.^{[17 ]}Low- (0.1 g/kg/d) and higher-dose (0.2-2 g/kg/d) intravenous immunoglobulin therapy has, in limited cases, been successfully used for idiopathic brachial and lumbosacral plexopathy. However, its effectiveness in neoplastic plexopathy is unproven. A single dose (500 mg or 1 g) of intravenous magnesium sulfate has been used with success in a small sample of patients with neuropathic pain due to neoplastic plexopathy.^{[18 ]}

Tricyclic antidepressants

These agents have central and peripheral anticholinergic effects, as well as sedative effects, and block the active reuptake of norepinephrine and serotonin.

Amitriptyline (Elavil)

Analgesic for certain chronic and neuropathic pain.

Dosing

Adult

10-100 mg PO qhs

Pediatric

Not established

Interactions

Phenobarbital may decrease effects; coadministration with CYP2D6 enzyme system inhibitors (eg, cimetidine and quinidine) may increase amitriptyline levels; amitriptyline inhibits hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram

Contraindications

Documented hypersensitivity; patient has taken MAO inhibitors in past 14 d; has history of seizures, cardiac arrhythmias, glaucoma, and urinary retention

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in cardiac conduction disturbances and history of hyperthyroidism, renal or hepatic impairment; avoid using in elderly patients

Analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who experience pain.

Morphine sulfate (Astramorph, MS Contin, MSIR)

Generally used for short-term, acute pain, moderate to severe in nature, as well as for chronic pain (eg, that associated with cancer). Morphine sulfate is available in immediate (3-4 h duration) and extended-release preparation (12 h). Switch over to long-acting preparations (MS Contin) once the pain is controlled with short-acting preparation (MS IR). Morphine can produce drug dependence and has the potential to be abused. Tolerance may develop with repeat exposure. Abrupt cessation of the drug or a sudden reduction in dose with prolonged use may result in withdrawal symptoms. Physical dependence is not of paramount importance in terminally ill patients.

Dosing

Adult

30 mg PO q3-4h initial dose in opiate-naive patients (no exposure to opiates) or in those with limited opiate exposure; may be titrated upward by 50% if pain control inadequate after first 24 h; balance between analgesia and adverse effects

Pediatric

Not established

Interactions

Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants, MAOIs, and other CNS depressants may potentiate adverse effects of morphine

Contraindications

Documented hypersensitivity; hypotension; potentially compromised airway where establishing rapid airway control would be difficult

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hypotension, respiratory depression, nausea, emesis, constipation, urinary retention, atrial flutter, and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate

Methadone (Dolophine)

Used in the management of severe pain. Methadone inhibits ascending pain pathways, diminishing the perception of and response to pain.

Dosing

Adult

2.5-10 mg PO/IM/SC q3-8h prn; increase to maintenance dose of 5-20 mg q6-8h

Pediatric

Not established

Interactions

Phenytoin, rifampin, and pentazocine may decrease blood levels of methadone; phenothiazines, tricyclic antidepressants, MAOIs, and CNS depressants may increase toxicity of methadone

Contraindications

Documented hypersensitivity; bronchial asthma or increased intracranial pressure

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in severe liver disease; due to its relatively long half-life, titrate dose slowly

Muscle relaxants

These agents inhibit events involved in muscle contraction.

Methocarbamol (Robaxin)

Reduces nerve impulse transmission from the spinal cord to skeletal muscle.

Dosing

Adult

1.5 g PO qid for 2-3 d and decrease to 4-4.5 g/d in 3-6 divided doses

Pediatric

Administer as in adults

Interactions

Increases toxicity of CNS depressants

Contraindications

Documented hypersensitivity; renal impairment

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in history of seizures

Antiepileptics

Antiepileptics are used to manage severe muscle spasms and to provide sedation in neuralgia.

Pregabalin (Lyrica)

Structural derivative of GABA. The mechanism of action is unknown. Pregabalin binds with high affinity to the alpha₂ -delta site (a calcium channel subunit). In vitro, it reduces the calcium-dependent release of several neurotransmitters, possibly by modulating calcium channel function. Pregabalin is FDA approved for neuropathic pain associated with diabetic peripheral neuropathy or postherpetic neuralgia and as an adjunctive therapy in partial-onset seizures.

Dosing

Adult

50 mg PO tid initially; if needed, may increase to 100 mg tid within 1 wk

Pediatric

Not established

Interactions

May cause additive effects on cognitive and gross motor functioning when coadministered with drugs that cause dizziness or somnolence

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Discontinue gradually (over a minimum of 1 wk) to minimize increased seizure frequency in patients with seizure disorders; may cause insomnia, nausea, headache, or diarrhea with abrupt withdrawal; common adverse effects include dizziness, somnolence, blurred vision, weight gain, and peripheral edema; may elevate creatinine kinase level, decrease platelet count, and increase PR interval; doses >300 mg/d associated with higher rate of adverse effects and treatment discontinuation; decrease dose with renal impairment (ie, CrCl <60 mL/min)

Gabapentin (Neurontin)

Has anticonvulsant properties and antineuralgic effects; however, the exact mechanism of action is unknown. Gabapentin is structurally related to GABA but does not interact with GABA receptors.

Dosing

Adult

300-3600 mg/d PO divided tid/qid

Pediatric

Not established

Interactions

Antacids may significantly reduce bioavailability of gabapentin (administer at least 2 h following antacids); may increase norethindrone levels significantly

Contraindications

Documented hypersensitivity; antacids may significantly reduce bioavailability of gabapentin (administer at least 2 h following antacids); may increase norethindrone levels significantly; caution in severe renal disease

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Antacids may significantly reduce bioavailability of gabapentin (administer at least 2 h following antacids); may increase norethindrone levels significantly; caution in severe renal disease

Follow-up

Prognosis

• Neoplastic lumbosacral plexopathy (NLP) progresses much faster than does radiation-related plexopathy, and the patient survival rate is limited. Median survival is 5.5 months from the time of diagnosis, with a range of 1-34 months. In one study, at 1-month follow-up visit, only 15-17% of patients demonstrated improvement in pain or weakness, and 28% showed improvement in CT scan findings. Over half of the patients (59%) demonstrated gradual worsening of neurologic deficits.
• In another study, 13 patients who underwent palliative irradiation for NLP had median survival of 185 days, with a range of 47-636 days.^{[19 ]}

Miscellaneous

Medicolegal Pitfalls

• If the diagnosis of neoplastic lumbosacral plexopathy is not established in a timely manner and proper treatment pursued, the physician is at risk for medicolegal consequences.

References

1. Jaeckle KA, Young DF, Foley KM. The natural history of lumbosacral plexopathy in cancer. Neurology. 1985;35:8-15. [Medline].

2. Agar M, Broadbent A, Chye R. The management of malignant psoas syndrome: case reports and literature review. J Pain Symptom Manage. Sep 2004;28(3):282-93. [Medline].

3. Jaeckle KA. Neurological manifestations of neoplastic and radiation-induced plexopathies. Semin Neurol. Dec 2004;24(4):385-93. [Medline].

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Keywords

neoplastic lumbosacral plexopathy, plexus, lumbosacral, breast cancer, sciatic nerve, colorectal cancer, psoas, neoplastic, psoas muscle, femoral nerve, iliopsoas, iliopsoas muscle, ilioinguinal nerve, obturator nerve, abdominal cancer, cervical cancer, pelvic tumor, retroperitoneal tumor, NLP, lumbosacral plexus, lumbosacral plexopathy, proximal lumbosacral plexopathy, malignant psoas syndrome, MPS, malignant lumbosacral plexopathy, lumbosacral carcinomatous, neuropathy tumor-induced lumbosacral plexopathy, tumor, lumbar plexus, sacral plexus

Contributor Information and Disclosures

Author

Rajesh R Yadav, MD, Assistant Professor, Section of Physical Medicine and Rehabilitation, MD Anderson Cancer Center, University of Texas at Houston
Rajesh R Yadav, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

Medical Editor

Robert J Kaplan, MD, Associate Professor, Department of Physical Medicine and Rehabilitation, University of Kansas School of Medicine and Medical Center
Robert J Kaplan, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, International Spine Intervention Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Michael T Andary, MD, MS, Residency Program Director, Professor, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine
Michael T Andary, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, and Association of Academic Physiatrists
Disclosure: allergan Honoraria Speaking and teaching

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Robert H Meier III, MD, Director, Amputee Services of America; Active Medical Staff, Presbyterian/St Luke's Hospital, Spalding Rehabilitation Hospital, Select Specialty Hospital; Consulting Staff, Kindred Hospital
Robert H Meier III, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

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