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osttraumatic syringomyelia is a rare complication of mild P spinal injury. We describe a case in which the diagnosis was made 20 years after a minor cervical injury. CASE REPORTA 77-year-old woman was referred to the geriatric day hospital with neck pain and increasing disability from claw hands. She had fallen from a ladder 20 years previously and had injured her thoracic and cervical spine. A few weeks after her fall she began to develop sensory symptoms and weakness in her hands. Soon after this she was referred to a hospital where she received radiotherapy. Unfortunately, no notes exist from this time. During the first year after her injury, she developed "claw hands," but remained independent in all activities of daily living. On presentation to the day hospital, she had a 2-month history of pain on neck extension and increasing difficulty in manual tasks.Examination revealed marked kyphoscoliosis with a limited range of neck movements. She had bilateral wasting of the small muscles of the hands, with a claw-type flexion deformity (Figure l), no upper limb reflexes, and wasting of the forearm muscles with fasciculation. Pinprick sensation was impaired in both forearms and hands, with a definite level on the left at the elbow. The lower limbs were normal in power and tone, reflexes were present, and the plantar responses were flexor. Sensation in the lower limbs was normal.Plain radiographs of the neck show right-side flexion deformity with gross degenerative change, especially in the facet joints. There was evidence of an old injury to the T1 spinous process. The clinical signs were not explained purely by the degenerative disease in the cervical spine; syringomyelia was suspected, and a magnetic resonance (MRI) scan was performed. The T1 weighted section is shown in Figure 2. This demonstrates a syrinx (arrowed), which extends from the first cervical vertebra to the upper thoracic segments. The cervical cord is deviated by disc bars at C4/5 and (2516, but not significantly compressed. The etiology of the syringomyelia was presumed to be posttraumatic following spinal injury 20 years ago. DISCUSSIONThis case is noteworthy for several reasons. The development of neurological signs and symptoms was fairly rapid (2-3 months) after the accident. The neurological deficit then remained stable over the next 20 years. Although the finding