1117 - Chest Pain as a Harbinger of Spinal Cord Injury?

T4 AIS D NTSCI with incomplete paraplegia, secondary to intradural thoracic hematoma. 

Case Description:

A 61-year-old male with CAD (LAD stents in 2020 & 2023), type 2 diabetes, atrial fibrillation on Xarelto, and hypertension presented the the ER with chest pain and elevated troponin. CTA showed coronary atherosclerosis, but cardiac catheterization revealed no obstructive CAD. Ten hours later, a rapid response was called for chest pain with new saddle anesthesia, urinary retention, lower extremity numbness. MRI revealed a hemorrhagic spinal collection (T3–T11) with cord edema. Xarelto was reversed with Kcentra, and he underwent T4–T7 laminectomy. He was transferred to acute inpatient rehabilitation and diagnosed with T4 AIS D incomplete paraplegia by ISNCSCI examination. Course complicated by urinary retention and neuropathic pain.

In therapy his gait progressed from total assistance with a walker or wheelchair to independent with rolling walker and AFO for greater than 150 feet of gait. He regained voluntary bladder function. Neuropathic pain was managed with pregabalin. He was discharged home.

Discussions: Hematoma rupture as an etiology of SCI is quite rare and is estimated to affect only 1 in 100,000 people annually. Neuropathic pain originating in the cervical and upper thoracic spine can present with chest pain, however chest pain as a presenting feature of SCI is exceedingly rare, particularly in lesions below spinal level C7. This so-called pseudo-angina may warrant spinal imaging to evaluate for SCI, particularly in patients with neurologic deficits and a negative cardiac workup.

Conclusions: This case demonstrates both an atypical presentation of SCI and the value of inpatient rehabilitation in the functional outcomes of patients with acute SCIs.