Delayed presentation and diagnosis of cervical spine injuries in long-standing ankylosing spondylitis

Abstract

Patients with ankylosing spondylitis (AS) are vulnerable to cervical spine fractures. Long-standing pain may mask the symptoms of the fracture. Radiological imaging of the cervical spine may fail to identify the fracture due to the distorted anatomy, ossified ligaments and artefacts leading to delay in diagnosis and increased risk of neurological complications. The objectives are to identify the incidence and risk factors for delay in presentation of cervical spine fractures in patients with AS. Retrospective case series study of all patients with AS and cervical spine fracture admitted over a 12-year period at Queen Elizabeth National Spinal Injuries Unit, Scotland. Results show that total of 32 patients reviewed with AS and cervical spine fractures. In 19 patients (59.4%), a fracture was not identified on plain radiographs. Only five patients (15.6%) presented immediately after the injury. Of the 15 patients (46.9%) who were initially neurologically intact, three patients had neurological deterioration before admission. Cervical spine fractures in patients with long-standing AS are common and usually under evaluated. Early diagnosis with appropriate radiological investigations may prevent the possible long-term neurological cord damage.

Spine fractures in ankylosing spondylitis: A case report and review of imaging as well as predisposing factors to falls and fractures

“…Standard imaging is not always helpful in diagnosing spine fractures in AS patients. Spine radiographs with their two-dimensional approach are often difficult to read given the distorted anatomy resulting from a kyphotic spine (8,9). Some emphasize the advantage of MRI over CT given that it is more sensitive at detecting soft tissue abnormalities and neurologic manifestations such as spinal cord damage (10).…”

The Michel Benoist and Robert Mulholland Yearly European Spine Journal Review: a survey of the “medical” articles in the European Spine Journal, 2011

“…The study by Anwar et al [3] in the March issue is a good reminder of the difficulty in detecting cervical spine injuries in long-standing ankylosing spondylitis. The authors retrospectively report a case series of 32 patients with AS and cervical fractures.…”

Spinal injury in ankylosing spondylitis

“…8 The annulus fibrosus is a fibrous ring that surrounds the central portion of the intervertebral disc known as the nucleus pulposus. Ossification of the spinal ligaments and calcification of the annulus fibrosus result in a rigid spine with a limited ability to absorb even minimal impact.…”

“…Indeed, one retrospective review showed that 60% of cervical fracture dislocations were undetectable on initial radiographs. 8 Computed tomography is more sensitive than plain radiography in identifying fractures, with a reported sensitivity of 100% and specificity of 99%. 12 Although plain radiography can identify a fracture, computed tomography and magnetic resonance imaging can better define the character of the fracture.…”