Cervical Spinal Cord Injury During Prone Position Ventilation in the COVID-19 Pandemic

The prone positioning of patients experiencing acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been proven effective in optimizing oxygenation and lung function. However, such patients may be at risk of developing complications due to the prolonged prone position in intensive critical care. A 45-year-old COVID-19 female, not known with cervical spine disease, presented with progressive severe COVID-19-related hypoxemia that required intensive care unit admission for pulmonary care. She was positioned prone and ventilated for several weeks. She developed a rapidly advanced decreased level of consciousness and flaccid quadriparesis. CT and MRI scans of the cervical spine revealed C4/C5 fracture-dislocation with spinal cord compression in asymptomatic ankylosing spondylitis and focal ossification of a posterior longitudinal ligament. In addition, the patient had severe ARDS-SARS-CoV-2 hemodynamic instability. Surgery was not performed due to her critical condition, and the patient died from multi-organ failure. Patients with underlying cervical spine disease or deformity can be subjected to hyperextension and develop fatigue (stress) spinal fracture, leading to spinal cord compression. To our knowledge, this is the first case of spontaneous cervical spine fracture dislocation in a COVID-19 patient after several weeks in prone position ventilation in ICU. Hence, our case report raises the awareness of the possibility of devastating spinal cord injuries in prone position ventilation during the COVID-19 pandemic and the need for early screening using plain X-rays of these patients for cervical spine disease.