A Pain in the Neck, on Ice with a Twist... Dr Darren Lillis A Pain in the Neck, on Ice with a Twist...

The Case Mr HS 52 yrs old Shopkeeper Normally fit and well GP referral with neck and upper back pain

HxPC Fell on the ice 4 weeks previously Stepping down off a foot bridge, his two feet went out from under him Landed on his sacrum Felt a “shudder” transmitted from his sacrum to his neck on impact

HxPC continued No loss of power or sensation in limbs Got himself off the ground, walked home. Went to work over the following 2 weeks Ongoing lower cervical and upper thoracic pain Went to his GP Emergency Dept

PMHx etc Appendectomy as child No other relevant history No medications or allergies Lives with wife, non smoker, no alcohol Full time employment

On examination Kyphotic posture Fixed flexion deformity in his C spine Chin- chest distance= 5cm Unable to flex his neck laterally Only able to rotate approx 10 degrees R+L Stated this was normal for him- no recent change associated with the fall

Examination condt Tender over the lower cervical and upper thoracic regions- bone and muscular tenderness Neuro examination was entirely normal

ED Management Soft tissue injury Analgesia Physio Discharge Call from radiology- C spine fracture

Correct Diagnosis C Spine fracture- C 6/7 fracture X rays and posture in keeping undiagnosed Ankylosing Spondylitis

Admitted under Orthopedics Further investigation

Treatment No Miami J Cervical collar No spinal precautions Transferred to the Mater Spinal Unit once a bed became available Reviewed by Rheumatology- Likely Ank Spond but inflammatory markers normal... burnt out

Ankylosing Spondylitis and C Spine fractures Inflammatory arthropathy Ligaments and discs become calicified- characteristic flexed posture, loss of flexibility Incidence of spinal fractures is 4 times that of the normal population (1) 75% of these occur in the lower C Spine region (2) Multi level fractures associated with minor trauma (3)

References 1. Amamilo SC (1989) Fractures of the cervical spine in patients with ankylosing spondylitis. Orthop Rev 18:339–344 2. Hunter T, Dubo HIC (1983) Spinal fractures complicating ankylosing spondylitis. A long-term follow up study. Arthritis Rheum 26:751–759 3. J. Mountney, A. J. Murphy, J. L. Fowler Lessons learned from cervical pseudoarthrosis in ankylosing spondylitis. Eur Spine J (2005) 14: 689–693

Take home message C7 on T1, Peg and clear AP C Spine views should be attained Further images should be attained using arm pull, swimmers views or CT