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

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

3. 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

4. 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

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

6. 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

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

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

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

16. Admitted under Orthopedics
Further investigation

18. 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

19. 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)

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

21. 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