Atypical Presentation of Pulmonary Embolism Through Visceral and Referred Pain: A Case Report

Case Diagnosis: 66 year old female with cervical stenosis and myelopathy.

Case Description or Program Description: Patient underwent posterior cervical laminectomy and fusion (PLIF) from C2-T2. Post-operative day 3, she was transferred to acute rehabilitation unit.
Prior to admission, diagnostic screening for potential pulmonary embolism was requested due to patient's vital signs demonstrating intermittent hypoxia and mild tachycardia. Patient was otherwise asymptomatic. Chest X-ray (CXR) and bilateral lower extremity (BLE) Duplex study were negative.

On admission the patient participated in therapy for first two days, at a contact guard to minimum assist level of mobility. On the third day, she was evaluated by pain management for complaints of severe bilateral proximal shoulder pain, left greater than right. She was started on pain medication regimen for complex regional pain, muscle spasms and neuropathic pain. Despite some improvement of her pain at rest, she was unable to participate in therapy due to worsening pain on left shoulder blade area. On the 6th day, Medicine was consulted for persistent hypoxia. Diagnostic work-up including Transthoracic Echocardiogram (TTE), repeat BLE Duplex and CXR were unremarkable.

Setting: Acute Inpatient Rehabilitation Unit

Assessment/Results: Her debilitating pain and allodynia failed to improve on increased dose of non-opioid and opioid pain medications and therapeutic modalities. She refused to participate in therapy. She was sent for Chest Computer Tomography Angiography (CTA) which revealed bilateral pulmonary emboli with right heart strain. Upon treatment of PE with anticoagulation pain gradually improved and later resolved.

Discussion (relevance): Typically PE presents as pleuritic chest pain. However PE can also cause visceral and referred pain to neck and shoulder areas from the spinal levels C3, C4 and C5. Although neck and shoulder pain are typical in PLIF, these symptoms should also be considered as possible signs of underlying pulmonary pathology when associated with hypoxia, tachycardia, and/or pulmonary symptoms. Furthermore, rehabilitation physicians should not be deterred from evaluating for PE with CTA when duplex study is negative if there is persistent clinical concern.

Conclusions: There should be high index of suspicion for pulmonary embolism in evaluating patients with intractable shoulder and neck pain after high cervical PLIF. CTA should be considered as an essential study in atypical presentations.