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Leiomyosarcoma (LMS) is a rare but well-recognized malignant soft tissue sarcoma of smooth muscle origin. Metastases commonly occur in the lungs, liver, kidney, brain, and bone. Cases of metastatic osseous lesions or other extradural space–occupying masses secondary to LMS leading to neurologic compromise are relatively commonplace in the literature. Conversely, cases of intramedullary spinal cord metastasis (ISCM), an unusual entity as a sequela of any cancer, are exceedingly rare as a consequence of LMS. Only 2 cases of an ISCM from LMS are currently documented in the literature, and to the best of our knowledge, no case is described in the rehabilitation literature. This case report presents a patient with a history of longstanding metastatic LMS presenting with incomplete paraplegia, neurogenic bowel and bladder, and neuropathic pain. The patient was found to have an ISCM of the thoracic spinal cord. She made functional gains with concurrent inpatient rehabilitation and radiation but was unable to perform her own intermittent catheterization program, bowel program, or transfers and was unable to discharge home independently. Intramedullary spinal cord metastasis is a rare and potentially devastating consequence of LMS or any primary cancer, but can be amenable to common interventions in the acute inpatient rehabilitation setting.