Complications corner: Quadriplegia after a minor hyperextension injury with severe OPLL teaching case and illustrative images

BACKGROUND: A previously healthy and asymptomatic male surviving well into his ninth decade (86 years of age) was rendered immediately and completely quadriplegic after a minor fall associated with cervical hyperextension. METHODS: Since he was unable to undergo a magnetic resonance (MR) scan due to the presence of a cardiac pacemaker, a non-contrast computed tomography (CT) was performed. This study demonstrated extremely severe cervical spinal canal stenosis secondary to previously undiagnosed ossification of the posterior longitudinal ligament (OPLL) resulting in marked spinal cord compression between C5 and C6. RESULTS: Secondary to his severe and irreversible quadriplegia, the patient elected not to undergo any intervention; he expired 4 days later. Had his deficit not been so severe, and had he been diagnosed earlier and undergone prophylactic/preventive posterior decompression (e.g. laminectomy C4-C7) sufficient to allow his cord to migrate dorsally, his irreversible quadriplegic deficit might have been avoided. CONCLUSIONS: Older patients with symptoms of progressive myelopathy should undergo early cervical MR (or CT if they have a pacemaker) screening looking for “silent” cord compression due to stenosis, spondyloarthrosis, and/or OPLL. This case highlights the devastating consequences of even a mild hyperextension injury in a patient harboring extremely severe but previously undiagnosed OPLL. Devastating life-threatening or life-ending injuries may be avoided by maintaining a low threshold for performing screening” cervical studies in elderly patients with vague complaints that might signal the onset of myelopathy.