The current study reports a patient who complained of right neck-to-shoulder pain, which seems to be referred pain from PE. First, we thought that the patient's pain was neuropathic pain or musculoskeletal pain, such as myofascial pain syndrome, rotator cuff syndrome, or cervical facet joint syndrome. The pain was not reduced after the administration of pain medication; however, it was completely relieved after the treatment of the PE. Furthermore, the dermatome corresponding to the location of the patient's pain was at C2–4 (Fig. 1). Because the patient's last intact level was C5, his pain was not neuropathic pain from SCI. Considering the responses to the treatment and the clinical symptoms, the patient's pain on the right side from the neck to shoulder was referred pain from PE in the right lower lobe pulmonary artery.
PE is the potentially life-threatening condition causing morbidity and mortality in patients with acute SCI. Venous stasis and alterations of various regulatory proteins following paralysis increase the incidence of thromboembolic disorders, DVT, and PE. In the acute phase of SCI, the incidence of PE has been reported as 4.5% with a mortality rate of 3.5%. If patients present high suspicious clinical presentation of PE, a thorough examination for diagnosing PE is necessary. CT pulmonary angiography is the first-line imaging test for acute PE. If patients show symptoms that indicate PE, CT pulmonary angiography should be conducted for the diagnosis of PE. Usually, clinical symptoms of PE manifest as dyspnea, tachypnea, syncope, or chest pain; however, these symptoms are indistinctive from the symptoms that typically present after cervical SCI. The symptoms from PE can be easily misjudged as the symptoms from weakness of respiratory muscles, orthostatic hypotension, or neuropathic pain. Therefore, diagnosis of PE in patients with cervical SCI is challenging. This report suggests that pain in the neck-to-shoulder area in patients with SCI can be a potential clue for the diagnosis of PE. Additionally, in the case of complete cervical spinal cord injury, patients cannot receive sensory inputs from the dermatomes below the level of injury to the spinal cord. Considering that the vagus nerve carries nociceptive afferent input from the viscera of thorax and abdomen, the referred pain in the neck-to-shoulder area is not limited to PE. The refractory pain in the neck-to-shoulder area (the dermatome of upper cervical nerve distribution) may be an important sign of internal organ diseases.
Our patient did not receive prophylactic treatment for DVT and PE. Previous studies reported that Asian patients have a significantly lower incidence of DVT as compared with western patients.[19,20] Therefore, pharmacologic thromboprophylaxis with either warfarin or heparin is not routinely provided to Asian patients with SCI. However, recently, several studies have reported that the incidence of DVT after SCI in Asian patients is comparable with that in western populations.[21–23] On the basis of the results of these recent studies, we think Asian clinicians should consider the routine use of pharmacologic thromboprophylaxis during the acute stage after SCI.
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