200 Section - A Heave and a Hematoma: Sudden Paraplegia After GLP-1–Related Emesis

Acute Spinal Cord Injury secondary to thoracic and lumbar spinal subdural hematomas (SDH) in the setting of non-physician-prescribed escalation of GLP-1 therapy. Postoperative complications included persistent cord edema and paraplegia below the waist.

Case Description:

Patient is a 71-year-old female with hypertension, rheumatoid arthritis, GERD, obesity, chronic back and hip pain, and bilateral knee and hip arthroplasties. She had been on GLP-1 therapy for three weeks and trialed a non-prescribed dose escalation on the day she presented with abdominal and lower back pain, nausea, vomiting, and elevated blood pressure. Imaging ruled out aortic dissection. She acutely developed bilateral lower-extremity numbness and paralysis. MRI revealed thoracic and lumbar subdural hematomas. Emergent T12–L1 laminectomy with evacuation was performed; repeat T8–T10 laminectomy was required for recurrent collections. An arteriovenous fistula (AVF) was identified and resected. Postoperative imaging showed resolving collections but persistent cord edema. She was stabilized medically, and PT/OT were initiated. Previously independent, she is now paraplegic with minimal lower extremity movement or sensation.

Discussions:

This case highlights the risk of severe neurologic complications in older adults with comorbidities undergoing unsupervised GLP-1 dose changes. Rapid recognition, imaging, and surgical intervention were essential to prevent further deterioration. Despite extensive interventions, residual cord edema resulted in paraplegia, emphasizing the importance of early rehabilitation. Multidisciplinary management, including neurosurgery, PM&R, and skilled PT/OT, is crucial for functional recovery, secondary complication prevention, and patient adaptation to new neurologic deficits.

Conclusions:

Acute spinal hematomas in the context of unsupervised GLP-1 escalation can cause catastrophic neurologic injury. Early identification and surgical management, followed by structured inpatient rehabilitation, are critical. While paraplegia persists, ongoing PT/OT aims to maximize independence and quality of life. This case underscores the role of PM&R in optimizing outcomes after acute spinal cord injury and complex postoperative neurologic events.