Disclosures: George R. Malik, MD: No financial relationships or conflicts of interest

Case Diagnosis: Incomplete Spastic Paraplegia

Case Description: 27-year-old male with a PMH significant for developmental delay, diabetes, and morbid obesity (525 lbs, BMI 60) presented to acute care with progressive bilateral lower extremity weakness and functional decline. Patient was unable to undergo a CT/MRI given size limitations; electromyography demonstrated “presumed chronic inflammatory demyelinating polyneuropathy (CIDP)” and he was subsequently treated with IVIG. Patient reported minor improvement in strength, however was still limited by lower extremity weakness, decreased sensation in all extremities, and spasticity/hyperreflexia in lower extremities upon admission to inpatient rehab facility (IRF). An MRI facility that could manage patient’s BMI/girth was located. The MRI demonstrated moderate-severe central canal stenosis throughout the spine. Neurosurgery recommended surgical decompression once patient weighed 400 lbs.

Setting: IRFAssessment/

Results: With careful physical exam, the correct diagnosis was established and allowed the treatment team to develop a plan for confirmatory imaging in a morbidly obese patient. Appreciable gains were made with self-care (doubled FIM scores) and transfer/walking FIM scores increased from 0-1 to 4-5. Additionally, an optimal nutrition plan was developed, decreasing the patient’s weight by 40 lbs during admission.

Discussion: This patient had spastic hyperreflexia, not typically found in CIDP and prompted the care team to suspect more central processes. A PVC-pipe shower chair was found to support the patient’s body weight for transit from the ambulance directly to the MRI machine (wheel chairs were not large enough and contained metallic materials). Imaging confirmed the diagnosis of an incomplete spinal cord injury and allowed for necessary therapy and weight loss in preparation for spinal cord decompression.

Conclusion: Increasing prevalence of morbid obesity corresponds with prolonged hospitalizations and increasing caregiver burden/injuries. Standard imaging is often unavailable for the morbidly obese and can lead to misdiagnosis. Thorough physical exams are essential in guiding treatment plans and providers should advocate for appropriate confirmatory testing.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/go-big-or-go-home-a-case-of-undetected-sci-in-a-morbidly-obese-patient/