Cervical flexion myelopathy after valproic acid overdose

Case report and literature review of cervical flexion myelopathies.

To increase awareness that prolonged extreme neck flexion, in association with profound muscular relaxation, can produce a severe cervical myelopathy.

Similar case reports of cervical myelopathies have been documented in the neurosurgical literature after intraoperative prolonged neck flexion, and after forcible prolonged neck flexion during a robbery. To the authors' best knowledge, this is the first report of a cervical flexion myelopathy after a medication overdose, and the only clinical-pathologic correlation.

Retrospective case report with clinical, radiographic, and postmortem data available for analysis.

A transverse myelopathy at the sixth cervical level developed in a 25-year-old woman after an overdose of valproic acid in a suicide attempt. She was found in the sitting position, with her neck in extreme flexion, where she had been for an estimated 18 hours. Magnetic resonance imaging showed that her cervical cord was enlarged, maximally at C6, with prominent paraspinal soft tissue swelling. The patient died of pulmonary embolism and pneumonia. Pathologic findings included transverse spinal cord necrosis at C6; central gray matter necrosis extended to several segments below this.

Prolonged extreme neck flexion, in association with profound muscular relaxation, can produce a severe myelopathy that is at least partly related to compromise of the spinal cord's microcirculation.