Posttraumatic cystic myelopathy in motor incomplete quadriplegia presenting as progressive orthostasis

A 20-year-old man sustained a C7 burst fracture in a motor vehicle accident. Initial neurologic examination showed sensory incomplete C7 quadriplegia. Seventeen days postinjury anterior C7 body excision with bony fusion was performed. Postoperatively, his sensation improved. He first voluntarily moved the lower extremities at seven weeks. Eight months postinjury he could ambulate independently with forearm crutches for 500 feet. Eleven months postinjury he complained of headache and fatigability. Examination demonstrated orthostatic hypotension which became severe after walking 40 feet. In spite of salt loading, ephedrine, fludrocortisone, and compression garments, he became increasingly disabled by fatigability and orthostatic hypotension. Consequently, he could not ambulate regularly. Twenty-two months postinjury metrizamide myelogram showed widening of the spinal cord at C7. Following the myelogram CT showed a small cyst filled with contrast material. The patient underwent surgical decompression of the spinal cord cyst with placement of a drain from the cyst to the subarachnoid space. Postoperatively, he noted improvement of fatigability and was able to ambulate 500 feet without symptomatic orthostasis. Posttraumatic cystic myelopathy is increasingly recognized as a late complication of traumatic spinal cord injury. Presenting symptoms are usually pain and neurologic deterioration. Progressive loss of sympathetic nervous system function with severely symptomatic orthostatic hypotension should also alert physicians to consider this diagnosis.