Fatal Isolated Cervical Spine Injury in a Patient with Ankylosing Spondylitis: A Case Report.

Study Design Case report. Objective The purpose of the present case report was to present a patient with a history of ankylosing spondylitis who sustained a dislocation of C6 on C7 and died soon after his presentation in the emergency room (ER). Methods An 88-year-old man was brought to the ER due to a neck injury secondary to a fall. Imaging of the cervical spine revealed anterior dislocation of C6 on C7 and the characteristic "bamboo" spine of ankylosing spondylitis. Results The patient died within 30 minutes due to respiratory insufficiency. Conclusion Isolated cervical spine injuries in patients with ankylosing spondylitis can be fatal. A high degree of clinical suspicion, thorough imaging with computed tomography, and meticulous handling are required in this patient population.

Introduction

Isolated cervical spine trauma is rare in elderly people. These injuries are usually combined with other injuries (e.g., brain and thoracic injuries) as a result of motor vehicle accidents or falls. The clinical and/or radiographic findings vary after a cervical spine injury depending on many factors, such as the severity of the injury, the presence of spinal cord injury, the age of the patient, the time of arrival in the emergency room (ER), and the presence of comorbidities.

Cervical spine injuries in patients with ankylosing spondylitis are associated with greater mortality and morbidity regardless of the treatment used. The purpose of this report is to present a rare case of an 88-year-old man with ankylosing spondylitis who sustained a dislocation of C6 on C7 and died minutes after his presentation in the ER.

The study was approved by the University Hospital of Ioannina ethics committee.

Case Report

An 88-year-old man was brought to the ER due to a neck injury secondary to a fall. The patient was transferred without a neck collar to the hospital by his relatives in a car. Upon his arrival in the ER, he was conscious with muscle strength of 2 of 5 in the upper extremities and 2 of 5 in the lower extremities, according to the Medical Research Council muscle grading scale. No Achilles and no patella reflexes could be obtained, and the Babinski sign was positive bilaterally. In the upper extremities, the triceps reflex was present and symmetric but not the biceps bilaterally. Sensitivity was absent below the level of the nipples.

The patient was on warfarin due to chronic atrial fibrillation and his international normalized ratio was 5. Immediately after the arrival of the patient in the ER, he was started on intravenous steroids. Imaging of the cervical spine revealed anterior dislocation of C6 on C7 and the characteristic “bamboo” spine of ankylosing spondylitis (Figs. 1 and 2). The patient died within 30 minutes due to respiratory insufficiency.

Fig. 1

Lateral film of the cervical spine showing the dislocation of C6 on C7.

Fig. 2

Sagittal view of the cervical spine on computed tomography (CT) scan showing the anterior dislocation of C6 on C7. The ankylotic vertebras C7, T1, and T2 are clearly shown on CT.

Discussion

Isolated cervical spine injury in elderly people is a rare condition. The data from the literature is limited because of the combination of cervical spine trauma with other injuries as a result of major accidents. Older patients with comorbidities tend to have increased injury severity status compared with younger patients with cervical spine trauma, regardless of the fact that younger patients are more commonly involved in higher-energy injuries than the elderly.1 2 3 4 5 6 7

Ankylosing spondylitis involves chronic inflammation, which leads to disorders mainly in the spine and the sacroiliac joints.8 One of the main findings of the disease in the spine is the ossification of the soft tissues, mainly the ligaments and the disks. This abnormal ossification leads to biomechanical alterations in patients with ankylosing spondylitis, and these patients tend to suffer from spinal fractures even with low-energy injuries.9 10 11 After trauma in these patients, a fixed kyphotic disorder is commonly observed; the most common injury in the spinal column is observed around the C5 and C7 segments, with neurologic deficits for the patients.12 13

Immobilization of the injured patient with ankylotic spondylitis must be done with great care. Neurologic deterioration can have a rapid onset or can develop gradually in the first few hours. Etgen and Rieder reported on a patient with ankylotic spine who presented with a C4 fracture without any neurologic deficits after a minor fall.14 During regular X-ray positioning, he developed severe bradycardia and had to be resuscitated. The early manifestation of neurogenic shock with bradycardia and hypotension is unusual in cervical cord injury, as <20% of patients display classical neurogenic shock upon arrival in the ER. The authors suggest that the bone fragments compressing the spinal column triggered the early bradyarrhythmia.

Spinal cord injury on the level of the cervical spine is not only associated with motor and sensory deficits but also goes hand in hand with respiratory disorders.15 The deficits in the respiratory system after trauma in the spinal cord have been well reported and reviewed by Mansel and Norman,16 who emphasize the different innervations of the inspiratory (higher cervical spinal cord C4 and above) and expiratory (innervations below C5) muscles. From electromyographic findings, it is suggested that a great part of the active expiration in patients with cervical spinal cord trauma is provided by the clavicular portion of the pectoralis major muscle. In another study, Roth et al reported that in patients with trauma in cervical and high thoracic spinal cord, a decrease in the strength of the muscles of the chest is documented with simultaneous increase in the muscle tone for these patients.17 These factors are implicated in the diminished function of the respiratory system observed in patients with cervical and high thoracic spinal cord injuries.

Conclusion

Isolated cervical spine injuries in patients with ankylosing spondylitis can be fatal. A high degree of clinical suspicion, thorough imaging with computed tomography, and meticulous handling are required in this patient population.

Commentary on: “Fatal Isolated Cervical Spine Injury in a Patient with Ankylosing Spondylitis: A Case Report”