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Flexion extension radiographs of the cervical spine
10%
253/2488
CT cervical, thoracic and lumbar spines
85%
2108/2488
Soft cervical collar
1%
35/2488
Outpatient follow up with repeat radiographs in 7-10 days
28/2488
NSAIDs and physical therapy evaluation
2%
45/2488
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Patients with ankylosing spondylitis (AS) are at high-risk for having spinal fractures (and spinal cord injuries), even after lower energy accidents. Advanced imaging of the entire spine is recommended, as up to 50% of these fractures are missed on plain films. Patients with AS are at an increased risk for developing spinal fractures, even without a history of trauma. The creation of bridging syndesmophytes, which give the spine its characteristic “bamboo appearance” leads to increased rigidity and longer lever arms, making them more susceptible to fracture. Given the abnormal appearance of the spine, these injuries are often missed on plain radiographs. Thus, patients with AS, who present with neck or back pain, should undergo complete evaluation utilizing CT imaging. Lastly, in patients with progressive neurologic deficits, an MRI is warranted, as patients with AS are at a higher risk for epidural hemorrhage. Taurog et al. review the diagnosis and treatment of AS and axial spondyloarthritis. They report a spinal fracture rate of 10% in patients with AS given the combination of osteoporosis and spinal rigidity. Furthermore, they outline the high association of spinal fractures and devastating spinal cord injuries in this subset of patients. They conclude, that even in the absence of trauma, the spine should be fully evaluated using CT scans in the setting of new-onset neck or back pain. Caron et al. specifically review spinal fractures in patients with ankylosing spinal disorders. They report that of 122 consecutive spinal fractures in patients with AS, most were extension type injuries affecting C6-7. Concomitant spinal cord injuries were present in 58% of patients in this study. They conclude that patients with AS have a high rate of complications and neurologic compromise following spinal fractures and should be counseled accordingly. Incorrect Answers: Answer 1: Flexion/Extension radiographs in the setting of a likely fracture should not be performed. This patient has an undiagnosed, unstable cervical spine fracture and flex/ex films could have devastating complications. Answer 3: While patients with suspected cervical spine injuries should be immobilized, a rigid cervical orthosis should be used. Answer 4 and 5: Conservative management and outpatient follow up are not appropriate prior to ruling out a spinal fracture.
4.0
(9)
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