Early onset of syringomyelia presenting with hyperhidrosis and neuropathic pain in upper limbs in a paraplegic patient.

A 21-year-old paraplegic man was seen due to hyperhidrosis and pain in his upper limbs (worse with head extension) for the last few weeks. He stated that the pain was associated with tingling and numbness, and worsened over time. In his medical history, he had a complete T4 level of spinal cord injury (SCI) caused by a fall from height 5 months ago. Physical examination revealed spasticity, weakness (0/5), increased deep tendon reflexes, and anesthesia in his lower extremities; however upper extremities did not reveal any neurologic deficits. X-ray of the spine showed spinal fixation devices. Magnetic resonance images denoted bony fragments compressing the spinal cord and syringomyelia (Fig. 1). Overall, the patient was diagnosed with post-traumatic syringomyelia (PTS) and referred to neurosurgery. Syringomyelia is the presence of a cyst or cavity within the spinal cord. Although PTS is seen in up to 30% of the patients with SCI, they are not always symptomatic. PTS can present with weakness, neuropathic pain, sensory deficits, spasticity, and autonomic dysfunctions (1). Stanworth (2) has reported 8 patients with PTS. Although all of them had excessive sweating, only two of them stated sweating as the main problem. Sweating may occur above or below the level of transection. If it is seen below the injury level, diagnosis can be quite challenging and sweating can be the only indicator. Ko et al (3) reported the mean onset of syringomyelia as 38.8 months after SCI, however early onsets can be seen. Magnetic resonance imaging is the best modality to detect PTS and several surgical procedures have been described for the treatment of PTS (4). In conclusion, by presenting our unusual case we would like to highlight that pain in the upper limbs and sweating in paraplegic patients should alert the examiner to the possibility of PTS even in the early periods of SCI.