1138 - A Case Report: Social factors leading to needed neurosurgical intervention in setting of homicide vs suicide attempt.

A 60-year-old female with a history of major depressive disorder, COPD, and cocaine/marijuana use was admitted to the ICU after being found hanging by a cord around her neck. Following extubation and seizure management, she exhibited generalized weakness, upper extremity hyperreflexia, and a positive Hoffman sign. Cervical MRI revealed C4–C5 spondylolisthesis with cord edema, and she underwent C4–C5 anterior cervical discectomy and fusion (ACDF). 

Her social history included significant stressors such as homelessness after a house fire, prior substance use, and suspected domestic abuse. The etiology of the hanging—suicide attempt versus assault—remained unclear. 

Upon admission to inpatient rehabilitation as a C3 ASIA D, she presented with left greater than right weakness and decreased sensation throughout. Initially requiring minimal assistance for mobility and ADLs, she progressed to supervision to minimal assistance for most tasks within 10 days. 


Discussions:

Cervical spondylolisthesis is often degenerative but may remain clinically silent until exacerbated by trauma. In this patient, the hanging drew attention to generalized weakness from preexisting cervical spinal pathology. The case also highlights how psychosocial factors—such as domestic violence and psychiatric illness—can obscure or reveal serious medical conditions. 

Notably, the patient presented to the ED two weeks earlier for bilateral back pain and weakness. Lumbar MRI showed extensive multilevel spondylosis with substantial progression since 2020. Admission was discussed, but the patient declined treatment and discharged against medical advice. 


Conclusions: This case underscores the need for thorough evaluation after trauma, which can reveal underlying spinal pathology requiring urgent intervention. It also highlights psychosocial factors—mental health, substance use, housing instability—can pose as significant barriers to essential care. Early interdisciplinary rehabilitation after surgical stabilization can significantly improve outcomes despite these challenges.