A 34-year-old woman. History: perinatal anoxic encephalopathy; atloaxoid subluxation with critical canal stenosis (Fig. 1A) – neurosurgery being discarded in 2008 due to surgical risk. Seizure episode with head injury (head in cervical hyperflexion). The patient was assisted by out-hospital emergency care (112), initially in asystolia. Resuscitation was started, with recovery of pulse after lung isolation. In hospital: blood pressure 80/50mmHg, heart rate 45bpm, SatO2 100% and temperature 33°C. The full body CT scan revealed no acute lesions and confirmed the already known atloaxoid subluxation (Fig. 1B and C). In the Intensive Care Unit: tetraplegia, areflexia, anal sphincter atonia and absence of respiratory effort in pressure support ventilation. The MRI scan revealed lesions consistent with acute cervical myelopathy (Fig. 1D). With a diagnosis of spinal cord injury without radiographic abnormality (SCIWORA), under noradrenaline perfusion and the administration of dexamethasone, the patient failed to recovery respiratory activity.

Figure 1.

(A) Computed tomography scan in 2008: axial acquisition at C1–C2 level showing spinal cord canal stenosis (6mm) (grey asterisk). (B) Computed tomography scan in 2018: axial acquisition at C1 level showing spinal cord canal stenosis (6mm) (grey asterisk). (C) Computed tomography scan: sagittal acquisition showing the already known canal stenosis at the craniocervical junction, with no apparent soft tissue lesions (vacant grey arrow). (D) Magnetic resonance imaging: T1-weighted acquisition showing canal stenosis with diffuse dural thickening and signal alteration in lower bulbar zone, together with cervical intramedullary image consistent with traumatic myelopathy (solid grey arrow).

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