To report a rare etiology of medullary compression by a bizarre vertebral artery, and its overlapping manifestations with spinal cord pathologies.

Vertebral Artery Medulla Compression Syndrome (VAMCS), an extremely rare and under-recognized condition both in literature and clinical practice, occurs after compression of the medulla due to vascular anomaly, presenting with wide spectra of symptomology with varying severity. The etiology is anomalous vertebral artery which becomes tortuous, elongated, or ectatic. Symptoms can be misinterpreted and mismanaged, resulting in worsening of pathology and delay in definite treatment.

Case:

A 48-year-old male presented with complain of moderate neck pain radiating to his left arm with associated numbness for the past 2 years. He had no history of trauma, weightlifting, surgery, or other chronic illness.

Physical examination showed muscle wasting of left upper limb and thenar eminence. Cervical spine X-rays in anteroposterior and lateral projections were unremarkable. MRI and EMG were advised for evaluation of peripheral and central causes.

EMG demonstrated left ulnar nerve lesion given reduced CMAP amplitudes and absent F-waves.

MRI revealed desiccation changes and focal thickening of posterior ligament indenting thecal sac but no nerve compression, disc bulges, or cord pathology. Axial T2-weighted images at the level of medulla showed a prominent and curvilinear course of left vertebral artery causing significant compression on left half of medulla, displacing it towards the right side.