Painful and weak shoulder following a generalized seizure: a missed odontoid fracture causing central cord...

Spinal fractures following seizures are reported but can be easily missed, as symptoms may be misinterpreted. Most seizure-induced spinal fractures occur in the thoracic and lumbar spine. Of all cervical spinal fractures, only 10% are odontoid fractures, making odontoid fractures following generalized convulsive seizures even rarer. Most odontoid fractures are unrecognized at the time of injury, as almost none are associated with neurological deficit at presentation. However, with time, it may result in incomplete or complete cervical cord compression owing to spinal instability, resulting in devastating neurological complications. Therefore, a high index of suspicion for early recognition and intervention is vital to prevent such sequelae.

We report a previously healthy, independent, right-handed, 72-year-old South Asian man who presented with painful, weak shoulders with the inability to raise his arms above shoulder level following three generalized tonic-clonic convulsions. He did not have signs of lower limb or respiratory muscle weakness and had no difficulty in walking. His symptoms were attributed to postconvulsive muscle pain and spasm, for which he was managed conservatively. His shoulder pain and arm weakness resolved slowly over a month, but the restriction of neck movements persisted. Therefore, he was re-investigated 1 year later and was found to have a nonunited odontoid fracture with American Spinal Injury Association E impairment. Despite nonsurgical management, including neck immobilization with a soft cervical collar, he progressed to have impaired dexterity and diminished pain sensation in his hands, with sparing of legs (American Spinal Injury Association D impairment). He was diagnosed with central cord syndrome. He eventually underwent cranio-cervical fixation, after which he made a significant neurological recovery within 2 weeks.

Odontoid fracture without direct trauma, although uncommon, must be suspected when a patient complains of severe pain in the neck and shoulder following a generalized tonic-clonic convulsion. A high index of suspicion and anticipated cervical immobilization are required to avoid devastating neurological complications.