Handle With Care: The Dangers of Cervical Spine Fracture in Patients With Ankylosing Spondylitis

Patients with ankylosing spondylitis are at increased risk for fractures (particularly extension fractures of the cervical and thoracolumbar spine) and spinal cord injury. Fractures in these patients are extremely unstable; in fact, they are among the most complication-prone of all cervical spine injuries likely to be seen in the primary care setting. Ankylosing spondylitis is more common in men than in women. Many patients have a pronounced kyphotic or flexed deformity of the cervical spine. Any minor injury to these fragile spines can result in significant neurologic deficit or other major sequelae, including death. Assume a patient with ankylosing spondylitis who sustains trauma to the head or neck has a fracture and a potentially serious spinal cord injury until you rule out these conditions. Plain radiographs may not visualize the fracture, and further evaluation with CT or MRI is often indicated. The mortality may exceed 30% in patients with ankylosing spondylolysis and fracture. The following cases illustrate some of the pitfalls in the care of these patients.

CASE 1:AN ELDERLY MAN WITH DYSPHAGIA AND NECK PAINInitial evaluation. An 86-year-old man with long-standing cervical spine ankylosis presented for evaluation because of dysphagia and neck pain. He reported that he had fallen the night before while walking to the bathroom. On initial evaluation, he was ambulatory and had no neurologic deficits. Because of persistent pain and dysphagia, a cervical spine radiograph was ordered. The film showed massive retropharyngeal swelling (Figure 1), but no fracture was seen or even suspected at this point.

Hospital course. The patient was admitted to the hospital. Shortly after admission, stridor and cyanosis developed, and the patient underwent emergent indirect laryngoscopy and nasotracheal intubation. Two days later, a tracheostomy was performed. Approximately 2 weeks after admission, the patient displayed marked weakness of the upper extremities. Follow-up cervical radiographs demonstrated fracture through the ossified C5-6 disk space (Figure 2). The neck was immobilized in a cervicothoracic orthosis, but there was no neurologic improvement. Pneumonia developed, and the patient died 11 weeks after admission.

Discussion. Most fractures in patients with a kyphotic ankylosed cervical spine result from minor trauma. In many cases, neither the patient nor the physician suspects fracture. Moreover, a number of these injuries occur in the lower cervical spine, which can be difficult to visualize with standard radiography. Because of their chalk-like, highly vascularized nature, the bones in ankylosed spines are susceptible to bleeding after a fracture. This can occur hours or days after the injury and produce extraspinal or intraspinal hematomas. Neurologic deficits can occur hours or days after the original injury as an intraspinal hematoma compresses the cord.

CASE 2:A MAN WITH WORSENING NECK PAINInitial evaluation. A 64-year-old man with kyphosis of the cervical spine was involved in a motor vehicle accident in which he experienced a transient loss of consciousness. He was taken to the emergency department, where he complained of severe neck pain. Cervical spine radiographs were initially interpreted as negative for fracture (Figure 3). The patient was fitted with a Philadelphia collar for presumed soft tissue injury, but he asked that it be removed immediately because it worsened his neck pain. He was discharged and advised that it was not necessary to use the collar. Follow-up. Two weeks later, while turning over in bed, he experienced sudden severe neck pain and weakness of the upper extremities. He was reevaluated at the same hospital and once again fitted with a Philadelphia collar for suspected occult fracture or subluxation. Once again, he reported increased neck pain and arm weakness and paresthesias. Emergency tomograms, obtained with the patient in his collar, demonstrated a fracture through the ossified C7-T1 disk space, with marked hyperextension displacement (Figure 4). The patient was placed in a halo brace, which maintained his neck in a kyphotic position (Figure 5). The fracture healed and the patient experienced partial neurologic recovery, with resolution of motor deficits but residual sensory loss in his hands.

Discussion. Hard collars and standard immobilization techniques are best avoided in patients with preexisting kyphosis of the cervical spine. No attempt should be made to correct a kyphotic deformity of the cervical spine associated with a fracture because such attempts may aggravate the neurologic deficit.¹ The fracture should be immobilized in a halo vest as soon as possible, with the patient’s head and neck maintained in the fixed kyphotic position during traction or bracing. Pin-site infection following halo application occurs occasionally, but this small risk is far outweighed by the prevention of neurologic complications.

TIPS FOR PREVENTING INJURY

• Educate patients with ankylosing spondylitis about the fragility of their spine and encourage them to report any head or neck trauma promptly.

• Advise patients with advanced disease to install preventive devices such as night-lights and handrails. Remind them to use supports or headrests when driving and to avoid walking on slippery surfaces or loose carpets. In a recent study, more than half of the spinal cord injuries in patients with ankylosing spondylitis resulted from a fall.²

• Counsel patients to avoid excessive consumption of alcohol and activities such as contact sports that involve the risk of injury.

References:

REFERENCES:

1.

Connolly J.

Fractures and Dislocations: ClosedManagement

. Philadelphia: WB Saunders Company;1995.

2.

Alaranta H, Luoto S, Konttinen YT. Traumaticspinal cord injury as a complication to ankylosingspondylitis. An extended report.

Clin Exp Rheumatol

.2002;20:66-68.

FOR MORE INFORMATION:

• Broom M, Raycroft J. Complications of fracturesof the cervical spine in ankylosing spondylitis.Spine. 1988;13:763-766.

• Yacyshyn EA, Cohen MD. Ankylosing spondylitis:early detection and management. J Musculoskel Med.1999;16:703-711.