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AS Spinal Fracture Emergency — SCE Rheumatology MCQ

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ModerateRheumatology EmergenciesAS Spinal Fracture EmergencySCE Rheumatology

A 30-year-old man with radiographic axial spondyloarthritis and a rigid, completely ankylosed spine trips on a kerb and falls. He develops sudden severe neck pain but has no neurological deficit. Cervical spine radiographs show no definite fracture. What is the most appropriate immediate next step?

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Correct answer: D — Maintain spinal precautions and obtain urgent thin-slice CT of the entire spine with multiplanar reconstructions

The correct answer is D. A completely ankylosed spine behaves mechanically like a long bone: even low-energy trauma can cause a highly unstable, three-column fracture. Plain radiographs may miss nondisplaced fractures because of deformity, osteoporosis and superimposed ossified structures. Spinal motion restriction in the patient’s pre-injury alignment should therefore be maintained while urgent thin-slice CT of the whole spine is obtained, including multiplanar reconstructions because non-contiguous injuries may occur. MRI is additional rather than the sole routine first study; it is particularly indicated after CT if there is a neurological deficit, suspected cord or epidural pathology, or persistent suspicion despite negative CT. Repeat radiography, delayed outpatient imaging, discharge and physiotherapy risk displacement, secondary neurological injury and death.

Reference: Ren C, Zhu Q, Yuan H. Imaging features of spinal fractures in ankylosing spondylitis and the diagnostic value of different imaging methods. Quantitative Imaging in Medicine and Surgery. 2021;11:2499–2508. https://pubmed.ncbi.nlm.nih.gov/34079719/