Deb Kumar Mojumder MD PhDa, Chuang-Kuo Wu MD PhDa,
Ragesh Panikkath, MDb, Nabeel S. Dar MD
c
Correspondence to Deb Kumar Mojumder MD PhD
Email: dkmj7@yahoo.com
SWRCCC 2014;2(8):40-41
doi:10.12746/swrccc2014.0208.103
Figures Top panel: A: Sagittal T2 image of the cervical spine, dotted lines marked D, E, and F indicate the horizontal sections shown in the bottom panel; B: Sagittal T1 image of the cervical spine; C: Sagittal T1 post-gadolinium image of the cervical spine. Arrows indicates the location of the thickened transverse atlanto-axial ligament causing deformity of the cervico-medullary junction anteriorly. This ligament is isointense to the neural tissue on T1-weighted sequence, is hypo-intense on T2-sequence, and is non-enhancing (2). There are postsurgical changes of cervical spine reconstruction/fusion from the C3 to the C6 level.
Bottom panel: D, E, and F represent horizontal sections indicated by the corresponding three dotted horizontal lines shown in A. The double arrowheads indicate the presence of T2 hyper-intense cerebrospinal fluid surrounding the cord that is missing at the region of the spinal block (E).
A 77-year-old man with underlying dementia was admitted with confusion, limited movement of his upper and lower extremities, low grade fever (101.2°F), stiff neck, depressed deep tendon reflexes, and flexion plantar responses. Laboratory data were significant for leukocytosis, an elevated CK, and an elevated CRP. The patient was initially scheduled for a lumbar puncture procedure to evaluate him for meningitis pending imaging study results. His MRI of the cervical spine showed marked compression on the cervico-medullary junction by thickened transverse atlanto-axial ligament along with features suggesting complete spinal block (Figure 1). The patient was treated for meningitis without the lumbar puncture due to complete spinal block. This case illustrates that a thickened transverse atlanto-axial ligament can present as quadriparesis. One should be cautious in performing lumbar puncture in cases of spinal block as this can aggravate signs of spinal cord disease.1 Surgical decompression via subtotal resection of the thickened transverse atlanto-axial ligament is the usual management of these cases.2 The patient’s family deferred surgery. Over the next few days patient’s confusion improved, but he continued to show limited movement in his extremities. He was subsequently discharged to a long term care facility. Two months after admission the patient showed improvement in both upper extremity and lower extremity weakness without surgery.
Habermann TM, editor. Mayo Clinic Internal Medicine Review 7ed: Page 703. CRC Press; 2006.
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