# Spinal Cord Injury Without Radiographic Abnormality Complicated by Acute Cholecystitis: A Case Report Highlighting Diagnostic and Therapeutic Challenges

## TL;DR

An elderly man with a spinal cord injury and no visible spinal damage also developed acute cholecystitis, highlighting the need for thorough diagnosis in such cases.

## Contribution

This case report highlights the diagnostic challenges of acute cholecystitis in patients with spinal cord injury without radiographic abnormality.

## Key findings

- The patient showed elevated inflammatory markers and cholestatic enzymes despite no abdominal symptoms.
- Acute cholecystitis was confirmed and resolved after percutaneous transhepatic gallbladder drainage.
- Physical signs like Murphy's sign may be absent in spinal cord injury patients, requiring comprehensive diagnostic approaches.

## Abstract

A man in his early 90s was brought to our emergency department after a fall in which he struck his left shoulder and subsequently became unable to move his left upper extremity. On arrival, neurological examination revealed muscle weakness and paresthesia predominantly affecting the left upper and lower extremities below the C6 level. Cervical magnetic resonance imaging demonstrated narrowing of the spinal canal at the C4/5 and C5/6 levels, corresponding to the level of neurological deficits, along with multilevel left-sided foraminal stenosis, leading to a diagnosis of spinal cord injury without radiographic abnormality (SCIWORA).

Laboratory tests showed no evidence of trauma-related coagulopathy or anemia; however, inflammatory markers were markedly elevated (C-reactive protein, 18.87 mg/dL), and cholestatic enzymes were increased (alkaline phosphatase, 158 U/L; γ-glutamyl transpeptidase, 232 U/L). Abdominal computed tomography revealed gallbladder distension with increased pericholecystic fat attenuation and a 6-mm gallstone at the gallbladder neck. Although the patient had no abdominal symptoms and Murphy's sign was negative, acute cholecystitis was suspected based on laboratory and imaging findings.

The inflammatory response initially improved with fasting and antibiotic therapy but worsened again on hospital day 15. Based on the clinical course, acute cholecystitis was definitively diagnosed, and percutaneous transhepatic gallbladder drainage was performed, resulting in the resolution of both cholecystitis and systemic inflammation. In patients with spinal cord injury, physical findings such as Murphy's sign may be absent; therefore, serial and comprehensive assessment incorporating physical examination, laboratory data, and imaging findings is essential for accurate diagnosis and appropriate management.