Image Quiz
Delayed Onset of Neurologic Deficit Following High-Energy Trauma to the Head and Neck1
A thirty-nine-year-old man was involved in a high-speed snowmobile accident in which he was thrown off his vehicle and landed on his head. The main symptom in the emergency room was pain in the upper part of the neck. Radiographs of the cervical spine showed no fracture or dislocation. The workup included a computed tomographic scan of the head and chest, which revealed normal findings. The patient was treated with a soft cervical collar, narcotic analgesics, anti-inflammatory agents, and muscle relaxants. He was discharged with the diagnoses of cervical sprain, a stable compression fracture of the fourth thoracic vertebra, a fracture of the fifth metacarpal of the right hand, a chip fracture of the right acromion, and acute alcohol intoxication.
Acute hoarseness developed four weeks later, while the patient was swinging an ax to cut wood. After undergoing an evaluation by an otolaryngologist, the patient was treated with antibiotics for a probable infection. No improvement was noted during the next seven days, and an examination by a second otolaryngologist revealed paralysis of the vocal cords. A magnetic resonance imaging scan of the neck suggested rotatory subluxation of the left occipital condyle in relation to the left lateral mass of the atlas. The patient was then sent to our facility for additional evaluation.
When we evaluated the patient, he was alert and oriented. He reported hoarseness and soreness in the upper part of the neck. He had been experiencing voice changes and dysphagia that had become progressively worse; at the time of our evaluation, he was able to swallow only liquids. On physical examination, the patient had wasting of the left trapezius muscle, and the tongue deviated to the right on protrusion. He had weakness of shoulder elevation on the left and a weak left sternocleidomastoid muscle. There was no myelopathy or upper or lower-extremity radiculopathy.
Anteroposterior and lateral radiographs of the cervical spine showed no obvious abnormality. An open-mouth radiograph showed mild asymmetry of the lateral masses (Fig. 1).
Fig. 1 |
Fig. 1 Open-mouth radiograph of the upper cervical spine showing no obvious fracture; however, there is mild asymmetry in the interval between the dens and the lateral masses of the atlas.
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A computed tomography scan was performed.
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Fig. 2-A |
Fig. 2-B |
Fig. 2-C |
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