SCIWORA or Functional Paraplegia? An Athlete's Conundrum

Case Diagnosis: Young male athlete develops syndrome similar to a complete thoracic cord injury after fall most consistent with functional paraplegia.

Case Description or Program Description: 25-year-old high-level athlete fell ten feet onto buttocks and had immediate right low back pain and symmetric bilateral lower extremity weakness and anesthesia and self-described urinary retention. At ED, he had difficulty voiding, no strength or sensation below T12 spine level, global hyporeflexia, weak rectal tone. CT and MR imaging found no abnormal cord signal or traumatic spine injury. He was treated non-operatively and admitted for concern of complete spinal cord injury.

Setting: Inpatient medicine.

Assessment/Results: Physiatry was consulted three days later and on initial evaluation, his formal SCI scoring was T11 AIS A though he was normoreflexic bilaterally, able to perform abdominal crunches while engaging hip flexors and maintained upright posture without assistance. Repeat spine imaging demonstrated no cord abnormality and bilateral posterior tibial nerve SSEPs were normal. One week later, he could move toes and void independently with prolonged focus. He later transferred to inpatient rehabilitation for functional paraplegia.

Discussion (relevance): Distinguishing between spinal cord injury and functional paraplegia after trauma without radiographic abnormality requires a comprehensive history and exam that tests a patient’s function based on their expected injury level. We felt he more likely has functional paraplegia given rapid improvement in urinary retention, he demonstrated good core and hip flexor strength during functional testing, his fully returned reflexes three days after injury did not match expected time course of spinal shock, and reassuring follow-up testing.

Conclusions: Incidence of Spinal Cord Injury without Radiographic Abnormality has significantly decreased with widespread use of MRI in emergency departments after trauma. Failure to diagnose spinal cord injury or functional paraplegia may delay needed treatment. Goal of inpatient rehabilitation for functional paraplegia is helping the patient overcome their functional deficits.