Ivy Ren, MD
Resident Physician
Mount Sinai Hospital
New York, New York, United States
Ray Espinosa, MD
Resident Physician
Mount Sinai Hospital
NYC, New York, United States
Amie Kim, MD
Physician
Mount Sinai
New York, New York, United States
40-year-old with a history of paraplegia from a gunshot wound 15 years ago and sacral ulcers presented to the emergency department for new onset right thigh swelling with right knee stiffness. After sleeping on his right side, he noticed that his right knee did not bend to 90 degrees as usual when transferring to his wheelchair. His upper right thigh was indurated and swollen. Exam revealed increased tone in the right anterior thigh compartment and loss of passive range of motion in the right knee. Pain and weakness could not be elicited as the patient is insensate with flaccid paralysis at baseline. Creatinine kinase (CK) was elevated to 1087. The patient was admitted for rhabdomyolysis secondary to severe muscle spasm of the right quadriceps. He was started on fluids and baclofen 10mg TID. Lower extremity dopplers were negative for DVT. He recovered and was discharged with a CK of 413.
Discussions:
Spinal cord injury (SCI) patients are at risk of rhabdomyolysis, a potentially life-threatening syndrome. Patients with SCI can experience immobilization, spasms, mild systemic hypoperfusion, thermal dysregulation, and hemodynamic instability, all of which can increase the risk of rhabdomyolysis. In addition, the sensation and motor physical exam changes suggestive of rhabdomyolysis can be more difficult to identify. Literature review revealed few cases of rhabdomyolysis in SCI patients. One case illustrated rhabdomyolysis secondary to heterotopic ossification, while another was secondary to pressure ulcers causing the muscle breakdown. A few other cases described rhabdomyolysis occurring in the setting of acute SCI. However, no cases have documented rhabdomyolysis in the setting of muscle spasms due to longstanding SCI as in this case.
Conclusions: SCI patients are at increased risk of nontraumatic rhabdomyolysis, and this should be an area of further research. Treatment focuses on hydration to prevent kidney injury and addressing the underlying etiology.
