When the Disc Strikes: Rethinking Fibrocartilaginous Embolism

Fibrocartilaginous embolism (FCE) is a rare, under-recognised, and underdiagnosed cause of spinal cord infarction. Its abrupt presentation can mimic transverse myelitis, creating diagnostic uncertainty in the acute setting and leading to potential exposure to inappropriate therapy. We report the case of a 43-year-old woman who presented to the emergency department (ED) with sudden worsening of chronic neck pain while reversing her car, followed by acute-onset bilateral upper limb weakness. On examination, she had marked right-sided weakness, a T1 sensory level, acute urinary retention, preserved dorsal column function, and normal lower limb tone and deep tendon reflexes (including plantar responses). Blood tests and autoimmune screening were normal. Cerebrospinal fluid (CSF) analysis showed mildly elevated protein with a normal white cell count, normal glucose, culture, viral polymerase chain reaction (PCR), and negative oligoclonal bands. MRI of the brain was unremarkable. MRI of the spine demonstrated longitudinal T2 hyperintensity from C5/6 to C7/T1 with adjacent endplate oedema at the left posterior C6/7 disc, without evidence of compressive or demyelinating pathology. Empirical intravenous methylprednisolone was administered while investigations were ongoing. Following multidisciplinary neuroradiology review, the findings were most consistent with anterior spinal cord infarction, with probable FCE as the underlying etiology, as definitive diagnosis requires histological confirmation. The patient was referred for neurorehabilitation. FCE typically presents with sudden-onset neurological deficits that are maximal at onset or within a few hours. Our patient's presentation was consistent with this temporal profile, and her condition improved significantly after just over three weeks of physical rehabilitation. This report highlights the importance of considering vascular causes, particularly when the onset is sudden and cerebrospinal fluid findings are non-inflammatory. Early recognition supports appropriate management, rehabilitation referral, and realistic prognostication.