Study Design: Case report and review of the literature. Objectives: Discuss a case of cruciate paralysis, a review of the literature and the hypotheses regarding the pathogenesis and recovery in spinal cord injuries that cause disproportionate weakness of the upper extremities. Setting: Thomas Je erson University Hospital, Philadelphia, PA, USA. Methods: Case report. Results: A case of cruciate paralysis is presented involving a 59-year-old female who experienced a gunshot wound to the face. Initial motor exams revealed mild lower limb weakness and absent upper limb function with an upper limb modi®ed American Spinal Injury Association motor score of 0/50 (a modi®ed impairment scale using half point muscle grades). Spinal imaging revealed fractures of the C1 anterior ring and the odontoid process, both associated with multiple bullet fragments. No spinal surgery was performed and she was placed in halo ®xation. By 3 weeks she had regained enough upper limb function to manipulate large objects with her left hand and move her right hand. At that time, her upper limb ASIA score was 16/50. By 5 weeks, her upper limb modi®ed ASIA motor score had improved to 31.5/50 and she began manipulating feeding utensils, writing legibly, and brushing her teeth with her left hand. Conclusions: In this case report we present a patient's motor and functional recovery. We also discuss the hypothesis that the acute central cord syndrome and cruciate paralysis are a likely result of similar pathologic mechanisms and that good functional outcome resulted from an initially disabling trauma. Spinal Cord (2000) 38, 120 ± 125