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Examination would likely reveal a short neck, low posterior hairline and limited neck motion.
2%
127/5727
Serum human leukocyte antigen B27 is likely to be positive.
76%
4335/5727
He is likely to be of Japanese descent.
86/5727
The disease is defined by flowing ossification of the anterior longitudinal ligament at 4 consecutive levels.
18%
1019/5727
Rheumatoid factor is likely to be positive.
112/5727
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This patient has ankylosing spondylitis (AS). HLA-B27 is positive in 90% of patients with this disease. This tends to occur in younger patients (as opposed to DISH, which happens in older male patients). Cervical spine fractures are not uncommon in ankylosing spondylitis because of osteoporosis and the long lever arm from fused vertebrae. They commonly occur because of hyperextension of the cervical spine (usually C5-7) and have a high rate of neurologic injury. AS fractures have a higher rate of neurologic injury than DISH fractures. Posterior decompression and stabilization with long constructs is necessary Whang et al. reviewed spine injuries in 12 patients with AS and 18 patients with DISH. Most injuries involved C5-C7. Patients with AS were more likely to have severe neurologic injury (41% ASIA A) than DISH (44% ASIA E). There was 81% good-excellent outcome and 4 deaths related to halo vest use. Caron et al. reviewed spine fractures in patients with ankylosing spine disorders (AS and DISH). AS patients were younger than DISH patients. Spinal cord injury was present in 58%. Surgery was performed on 67% and comprised instrumentation 3 levels above/below the injury. Mortality correlated with age. Mortality was 32%. Westerveld et al. performed a systematic review on spine injuries in ankylosing spinal disorders. Most patients had sustained low energy trauma (fall from sitting/standing). In DISH, most fractures were through the vertebral body. In AS, vertebral body fractures equaled those through the disc. Surgery was performed for neurological deterioration, unstable fracture and the presence of an epidural hematoma. Figure A shows a hyperextension injury at C6-7 (Type I, disc or Type IV,anterior disc, posterior body) cervical spine fracture in ankylosis spondylitis. Visible radiographic characteristics include osteopenia, bamboo spine, marginal syndesmophytes and ossfication of the disc space. Figure B is a chest radiograph showing thoracic syndesmophytes consistent with ankylosing spondylitis. Figure C shows bilateral sacroilitis and right SI joint fusion with hip joint space narrowing typical of ankylosing spondylitis. Illustration A shows the Caron classification of spine fractures in ankylosing spondylitis (Type A, disc injury; Type B, body injury; Type C, anterior body, posterior disc injury; Type D, anterior disc, posterior body injury). Illustration B shows the difference between the marginal osteophytes of AS and nonmarginal osteophytes of DISH in the cervical spine. If you have osteophytes that are building up, and project out anterior to the anterior cortex of the vertebral bodies, like "flowing wax" it is DISH. Incorrect Answers: Answer 1: This is characteristic of Klippel-Feil syndrome Answer 3: This is characteristic of ossfication of the posterior longitudinal ligament (OPLL), which occurs in up to 2% of the Japanese population. Answer 4: This is characteristic of diffuse idiopathic skeletal hyperostosis (DISH, Forrestier's disease). Answer 5: Ankylosing spondylitis is a seronegative spondyloarthropathy and rheumatoid factor is usually negative.
3.7
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