We present a case of an unusual course of the vertebral artery (VA) with intra-foraminal entrance at C4. A patient with traumatic fracture of C3 and C4 with dislocation C3/C4, spinal cord compression and ensuing quadriplegia presented with unilateral entrance of the VA at C4 detected on preoperative magnetic resonance imaging (MRI). The patient was surgically decompressed and stabilized by an anterior-posterior approach without intraoperative complications. Apart from anatomical findings no clinical case of entrance of the VA at C4 had been described in recent clinical literature. A physiologic high entrance of the VA is very rare but must be diagnosed preoperatively to avoid potential life threatening complications.Many variations of vertebral artery (VA) anatomy have been reported in the literature. Most commonly vertebral arteries arise from the superoposterior aspect of the first part of subclavian artery and than take a posterior cephalad course to enter the transverse foramen at C6, but other entry levels have been described. Anomalies have been reported with an entry level of C2 [5] and C3 [7,9]. The entry of the VA into the transverse foramen at C4 has been seen in anatomical studies with an incidence of 1-1,4% [1,11]. To our knowledge there is no clinical case report in the literature describing the VA entry at C4.The following case report describes a young man who suffered quadriplegia from a traumatic fracture of C3/C4 with an anomalous entry of the artery into the transverse foramen at C4 on the left in contrast to the usual entry at C6 on the right. Case reportA 52-year-old construction worker fell from a trestle from a height of 2 meters. He was found prone with his head in anteflexion. On initial examination he presented with bradycardia, somnolence and quadriplegia. During rescue he suffered from apnoea and hypotension and required intubation and cardiopulmonary resuscitation (CPR). After cardiopulmonary stabilization he was transferred to our hospital.On initial clinical examination we found an intubated and vitally stable patient with his head still in modest anteflexion. Apart from the supposed cervical lesion no other injury was detected. Initial helical (spiral) CT scan revealed a fracture of C3 including articular processes and the left vertebral arch, a dislocation between C3/C4 and a comminuted fracture of C4 with inclusion of articular processes, the vertebral arch and the left transverse foramen. Close scrutiny of the CT scans demonstrated an unusual course of the left VA. The right VA showed a normal course with entrance into the transverse foramen at C6 but the left VA entered the vertebra at C4 (Figs. 1, 2).