Case 3, presented by Stelios Koutsoumbelis, MD, and Han Jo Kim, MD describes a 49-year-old female who presented with acute quadriparesis. The patient had a history of long standing rheumatoid arthritis for which she had not had medical treatment. In the weeks preceding presentation she had an evolving neurologic decline; at the time of first evaluation she had been quadriplegic for three weeks. On physical exam, the patient was markedly short in stature; she had obvious gross deformity in all extremities, and diffuse muscle wasting. Her muscle grade was 0/5 in all extremities and she was unable to shrug her shoulders.
The patient was initially placed in halo traction, gradually increased over 4 days to 40lbs. After traction, the patient’s physical exam improved. Eventually, bilateral deltoid and biceps muscle strength improved to 2-3/5. She was able to shrug her shoulders, and sensation was completely restored. However, this interval of traction did not restore the patient’s lower extremity motor function. After approximately one week of traction the patient’s condition stabilized, and she was medically cleared for surgery. The patient was taken to the operating room and underwent an occiput to T5 posterior spinal fusion. Laminectomy of C1 and C3 to C6 was performed, utilizing a posterior distraction technique, originally described by Goel  (Figure 3). Post-operatively the patient was placed in a rigid cervical orthosis and closely monitored. During her three week post-operative hospitalization she had dramatic improvement in motor strength, as well as return of lower extremity function. Post-operative imaging confirmed reduction of the basilar invagination and decompression of the brainstem and cervical spine (Figure 4). With physical therapy, the patient was able to perform assisted transfers and was discharged to a regional spinal cord injury rehab facility. At two month follow up the patient was able to stand with a walker with one person assistance and had marked neurologic improvement. She was very pleased with her recovery and felt she was continuing to improve. X-rays were taken at this visit (Figure 5).
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