Resident Physician Cleveland Clinic Findlay, Ohio, United States
Case Diagnosis: A 24-year-old Caucasian male with a C5 AIS C Incomplete spinal cord injury.
Case Description: Patient presented to an acute care hospital for acute onset cervical neck pain progressing to upper extremity paresthesias, upper and lower extremity weakness with flaccid left lower extremity, and urinary retention over the course of minutes to hours. He first reported hearing a pop in his cervical neck and felt a “squishing” sensation while overhead pressing 145 pounds, prior to the onset of symptoms.
Discussions: MRI revealed cervical cord myelopathy with acute edema and T2 signal hyperintensity from C4-5 to T1. No evidence of hematoma, disc, or other compressive disease. MRA and CTA noncontributory. Likely acute to subacute cord infarct from fibrocartilaginous embolism from weightlifting. Hypercoagulable work-up and labs were negative except a low serum copper. He was initially treated with a short course of IV Decadron, and a foley was placed for urinary retention. He was discharged to inpatient rehabilitation, where he progressed rapidly and significantly with his functional gains, including use of robotic gait device. Ultimately discharged home, modified independent in all ADLs except min assist in lower body dressing, ambulating with a left ankle foot orthosis and walker, and voiding spontaneously. Repeat exam revealed C4 AIS D incomplete level of spinal cord injury.
Conclusions: Fibrocartilaginous embolisms are rare, with most cases affecting the cervical spine. Typically, there is preceding neck injury, often minor such as lifting, causing neck pain and intervertebral disc herniation, and possible spinal cord infarction. If the cervical spine is involved, fatality rates are typically high. The pathogenesis is hypothesized that axial loading forces on the spinal column and disc, may cause disc material to eject into the vasculature and spread retrograde to spinal cord blood vessels. While devastating, this case demonstrates the role of inpatient rehabilitation in regaining function.
