1254 - Detection of Alcohol Withdrawal Syndrome in Spinal Cord Injury

Case Diagnosis: alcohol withdrawal syndrome

Case Description: A 63-year-old male with a history of alcohol use disorder presented after a fall with a C4 cord contusion, C6-7 disc disruption, and blood alcohol level of 260. He underwent surgical decompression and fusion and was found to have a C1 AIS D injury, with strength 0/5 in the majority of the upper limbs. He had multiple visitors. On hospital day 6, he became altered with confusion, agitation, and visual hallucinations. Infectious workup was unremarkable. Gabapentin was discontinued as a possible contributor. He then became hypertensive, tachycardic, and more confused with notable head and tongue tremors. When Librium was started for alcohol withdrawal and gabapentin restarted, vital signs normalized and his confusion, hallucinations, and tremors resolved.

Discussions: Alcohol withdrawal syndrome (AWS) can occur in patients with alcohol use disorder who abruptly stop or significantly reduce their alcohol consumption and can be seen inpatient where alcohol is not accessible. Although rare, delirium tremens can occur within 48 to 72 hours after alcohol cessation which is characterized by tremor, agitation, fever, tachycardia, confusion, delusions, and hallucinations. In people with spinal cord injury (SCI) with profound extremity weakness, hand tremors may be missed and close observation for subtle tremors of the tongue or head movements are critical. In addition, gabapentin and benzodiazepines prescribed for neuropathic pain or spasticity may also help treat alcohol withdrawal, which if still undiagnosed can make the diagnostic process more opaque.

Conclusions: Signs of AWS may be decreased in SCI patients with profound weakness and medications given for SCI-related pain or spasticity may treat aspects of withdrawal and complicate diagnosis. Close observation for tremors of the head or tongue can be helpful in diagnosing AWS and consideration should be given for possible masking effects of medication.