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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

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

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  1. 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

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

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

  10. Admitted under Orthopedics • Further investigation

  11. 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

  12. AnkylosingSpondylitis 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)

  13. 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 ankylosingspondylitis. 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 ankylosingspondylitis. EurSpine J (2005) 14: 689–693

  14. 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

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