Left shoulder pain from spinal epidural haematoma: BMJ case
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A 66-year-old man with medical history of old myocardial infarction and on daily aspirin presented to the emergency department with sudden onset of severe left shoulder pain. He reported no prior trauma and denied cold sweat, vomiting, chest or back pains. At the time of initial evaluation, cardiac and neurological examinations were normal and there was no tenderness over the shoulder joints or the spine.

A diagnosis of acute myocardial infraction or aorta dissection was first suspected. However, ECG, serum troponin T concentration and contrast-enhanced CT of the chest showed negative results.

The patient was admitted to the emergency department under the diagnosis of possible acute coronary syndrome. But, several hours later, he suddenly developed mild weakness of the left upper and lower extremities without facial muscle involvement. Urgent MRI revealed cervical spinal epidural haematoma (SEH) with spinal cord compression mainly to the left side.

The patient underwent decompression laminectomy. Aspirin was considered as a contributing factor to the development of haematoma and thus it was discontinued for a week. The patient was restarted with aspirin 1 week after the operation since we considered it was important to prevent myocardial infarction and the patient agreed with our plan. He was discharged home free from neurological symptoms after a course of rehabilitation.

Learning points
• Shoulder pain without tenderness could be a referred pain or a neuropathic pain.

• Left shoulder pain could be a symptom suggestive of spontaneous epidural haematoma of the cervical spine in patients on daily aspirin.

Read more here: http://casereports.bmj.com/content/2018/bcr-2018-226159.full
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