1224 - Complex Regional Pain Syndrome and Heterotrophic Ossification after an Acute Traumatic SCI

Case Diagnosis: Traumatic Spinal Cord Injury, Complex Regional Pain Syndrome, Heterotrophic ossification

Case Description: A 28-year-old male was in a high-speed MVC, resulting in multiple long bone fractures, C3-C7 fractures complicated by incomplete cervical spinal cord injury (SCI), viscous lacerations, and a subarachnoid hemorrhage with brainstem contusion. He presented to inpatient rehabilitation 9 weeks later. Physical exam was notable for severe burning pain of the RUE, with allodynia, pale-purple discoloration, and edema. His extremities had limited passive ROM and he had diffuse whole-body joint pain. X-rays were ordered and evidence of Heterotrophic Ossification (HO) was noted around the right shoulder, right arm, bilateral knees, and right femur. Given the pain, he could not tolerate therapy or assistance with ADLs initially. Indomethacin 25mg TID was started for the HO. He additionally completed a 14-day course of prednisone for presumed complex regional pain syndrome (CRPS). He had improvement of allodynia of RUE and overall pain, leading to functional progression over the course of his IRF stay.

Discussions: Heterotrophic ossification occurs in 10% to 53% of SCI patients, driven by autonomic dysregulation, osseous demineralization, and inflammation promoting peripheral bone deposition. HO signs can appear within three weeks of SCI, and may include pain, autonomic dysreflexia, and limited joint range of motion. Often bone deposition takes time to appear on x-ray, although in this case, it presented fairly quickly. CRPS, characterized by vasomotor dysregulation, is common in extremity fractures and soft tissue injuries following immobilization, frequently co-occurring with SCI injuries.

Conclusions: Pain is a common complaint after traumatic spinal cord injuries and can impact functional outcomes. Swift identification of the source of pain to help tailor management options is crucial in inpatient rehabilitation settings. Treating this patient's pain enabled him to tolerate transfers, use a power chair, regain some upper extremity function, and return home.