Chest Pain and Paraplegia – an uncommon presentation, a diagnostic challenge.

Abstract

Chest pain is a common scenario at the Emergency Department. However, presentation of acute chest pain with sudden onset bilateral lower limb weakness is rare and usually is a diagnostic challenge.

48-year-old male with no premorbid presented with acute onset left sided chest pain radiating to the neck and left upper limb lasting for an hour associated with nausea. No profuse sweating, palpitation or shortness of breath. He also complained of weakness and loss of sensation over bilateral lower limb. No recent history of fall or spinal trauma.

Patient alert upon arrival, not tachypnoiec with normal vital signs. Physical examination revealed normal lungs, heart and abdomen. Neurology examination revealed bilateral upper limb power was normal 5/5 with normal tone and reflexes. However bilateral lower limb power was absent 0/5 with arreflexia and absent sensation. Anal tone was absent, however bulbocavernous reflex was still present.

ECG sinus rhythm, bedside echo and abdominal ultrasound showed no abnormality. An urgent CTA of the thorax and abdomen was done and no evidence of aortic dissection or aneurysm. An MRI revealed a spinal cord stenosis involving the C5/C6 level.

The suspicion of a possible aortic dissection or aneurysm is usually of concern if a patient presented with chest pain and acute onset paraplegia. This patient had normal ECG and cardiac biomarkers, with no hypokinetic segments on echo. Hence a CTA of the thorax was done which was normal. This raised a diagnostic challenge and hence an MRI was done which revealed the cause of his symptoms.

We report an uncommon case of spinal cord injury with atypical presentation. This case suggests the need to increase awareness among emergency doctors who may encouter similar cases of chest pain with atypical paraplegia. The CT Thorax and MRI spine was critical for timely diagnosis for this patients.