Locked-in syndrome following elective cervical foraminotomy: a case report

• Published in: Spinal cord series and cases Vol. 10; no. 1; p. 32
• Main Authors: Wrenn, Sean P., Song, Junho, Billington, Leslie, Czerwein, John K.
• Format: Journal Article
• Language: English
• Published: London Nature Publishing Group UK 26-04-2024; Nature Publishing Group
• Subjects: 59/57; 59/78; 692/1807/1693/2610; 692/699/375/1345; 692/699/375/1824; Anatomy; Back surgery; Biomedical and Life Sciences; Biomedicine; Case Report; Case reports; Cervical Vertebrae - surgery; Dissection; Foraminotomy - adverse effects; Head & neck cancer; Hemorrhage; Human Physiology; Humans; Infections; Locked-In Syndrome - etiology; Magnetic resonance imaging; Male; Medical imaging; Middle Aged; Neck pain; Neurochemistry; Neuropsychology; Neurosciences; Ostomy; Postoperative Complications - etiology; Radiation; Spectrum analysis; Stroke; Thrombosis; Trauma; Vehicles
• DOI: 10.1038/s41394-024-00643-4
• EISSN: 2058-6124

Introduction
There are no previously reported cases of locked-in syndrome occurring following cervical spinal surgery. We describe a case of locked-in syndrome following an elective cervical foraminotomy and discuss potential etiologies and contributing factors to our patient’s presentation.
Case presentation
A 54-year-old male with a history of head and neck cancer and prior anterior cervical discectomy and fusion presented with neck pain following a motor vehicle accident. The patient underwent C4-C7 left-sided cervical posterior foraminotomy with no intraoperative complications. On postoperative day 1, the patient suddenly developed rapidly progressing weakness of the extremities and soon became non-verbal. CT angiography and near-infrared spectroscopy confirmed a basilar artery occlusion and left vertebral artery dissection. On MRI, infarcts involving the bilateral pons, left cerebral hemisphere, and left cerebellar infarct were identified.
Conclusion
The etiology of locked-in syndrome in our patient remains unclear, but it is likely multifactorial. It is possible that the patient was predisposed to vascular injury from prior radiation therapy to the head and neck. In addition, intraoperative vascular insult may have occurred from vibrational shear stress, in turn leading to a vertebral artery dissection, basilar artery occlusion, and pontine infarct, ultimately resulting in our patient’s locked-in state.