Hong Kong Journal of Emergency Medicine
A lady with alarming neck swelling after minor head injury
, WB Wong
KF Chan
, MK Ho
, CH Chung
A 52-year-old woman with hidden ankylosing spondylitis for years attended the emergency department
after a minor head injury. Rapid and alarming neck swelling appeared shortly after the initial consultation.
Although the physical examination and the lateral cervical spine X-ray did not suggest fracture, a later CT
scan revealed a fracture line. A high index of suspicion and early use of the halo device are needed in order
to prevent irreversible neurological damage in such patients. (Hong Kong j.emerg.med. 2007;14:45-47)
52
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Keywords: Ankylosing spondylitis, cervical vertebrae, spinal fractures, spinal cord injuries, traction
Case report
A 52-year-old woman attended the emergency
department (ED) after head injury in July 2006, one
hour after a fall on level ground. It was a rainy day and
her forehead hit the ground directly. There was no loss
of consciousness and no vomiting was noted after the
injury. She could walk in the ED unaided. She was
triaged into the urgent category due to an elevated
Correspondence to:
Chan Kin Fai, MRCP(UK), FRCSEd, FHKAM(Emergency Medicine)
North District Hospital, Accident & Emergency Department,
9 Po Kin Road, Sheung Shui, N.T., Hong Kong
Email: [email protected]
Ho Man Kam, MRCSEd, FHKAM(Emergency Medicine)
Chung Chin Hung, FRCS(Glasg), FHKAM(Surgery), FHKAM(Emergency
Medicine)
North District Hospital, Department of Orthopaedics and
Traumatology, 9 Po Kin Road, Sheung Shui, N.T., Hong Kong
Wong Wah Bong, FRCSEd, FHKAM(Orthopaedic Surgery)
blood pressure of 210/110 mmHg and the presence of
a 4-cm haematoma over the right side of her forehead.
She had some mild low back pain which had lingered
on for years. She had consulted private practitioners
and was diagnosed as 'rheumatism', but no
investigation was done. Otherwise, she enjoyed good
health and was working as a school bus assistant.
On physical examination, there was a 4-cm oval-shaped
haematoma over the right side of her forehead. The
cervical spine was not tender and no focal neurological
deficit was detected. X-ray of the skull bone showed
no vault fracture. She was advised to stay in the
observation room for further evaluation of possible
complications of the head injury, partly because of the
alarming forehead swelling and partly because of the
raised blood pressure. Within one hour of admission
to the observation ward, she developed massive neck
swelling. The whole neck was swollen, but there was
no stridor and the patient was not in respiratory
46
Hong Kong j. emerg. med. „ Vol. 14(1) „ Jan 2007
distress. X-ray of the cervical spine showed marked
prevertebral soft tissue swelling but no cervical spine
fracture was detected. Evidence of ankylosing
spondylitis (AS) was suggested by the fused 'bamboo'
spine (Figure 1). X-ray of the pelvis at the same time
showed fused bilateral sacroiliac joints.
to the intensive care unit and she was transferred to
the orthopaedic ward on Day 2 after the injury. A halo
jacket for immobilisation of her cervical spine fracture
was arranged on Day 3. She was discharged
uneventfully 19 days after admission.
The orthopaedic surgeon repeated the examination of
the cervical spine and confirmed no tenderness, and
no myelopathic or radiculopathic signs. Urgent CT
scan of the brain and cervical spine were performed.
There was a transverse fracture of the C6 body on the
plain and 3-dimensional reconstruction CT films
(Figure 2). A Philadelphia neck collar was then applied.
The blood result, coming back after the CT scan,
showed no clotting or platelet disorder. She was
transferred to the intensive care unit for the
management of potential airway compromise. MRI was
done on the day of admission and no spinal cord lesion
was found. Her neck swelling stabilised after admission
Discussion
The presence of bilateral sacroiliitis and the long
duration of low back pain in our patient satisfy the
diagnostic criteria for ankylosing spondylitis in the
Rome criteria.1 Ankylosing spondylitis is a seronegative
inflammatory condition affecting predominantly the
enthesis (i.e. the tendons and ligaments) of the axial
skeleton. The disease is more common in male and
tends to run a more benign course in female. With an
estimated prevalence of 0.2% in the Chinese
population,2 it may not be uncommon in seeing trauma
patients with hidden AS.
Figure 2. Three dimensional reconstruction of the CT neck,
Figure 1. Lateral cervical spine X-ray, showing gross prevertebral
showing fractured C6 involving both the anterior and posterior
soft tissue swelling and the "bamboo" spine appearance.
elements.
Chan et al./Neck swelling after minor head injury
Because of the rigidity of the spine and the osteoporosis
as a result of prolonged disuse, fracture usually presents
with or after minor trauma.3-6 The cervical spine is the
most common region involved, with C5-7 being the
most likely fracture sites.3-5,7 Spinal cord injury is more
common in AS patients than in the general population
with spinal fracture.3,4,8 The spinal fracture can occur
in different levels with the same injury, particularly
when previous surgical immobilisation of the spine has
been done. 7 We cannot depend solely on the initial
X-ray to rule out spinal fracture in patients with AS.9
The distorted anatomy of the cervical spine, a flexed/
kyphotic posture with fused annulus fibrosis may mask
the initially undisplaced fracture as in our patient. It
is also not uncommon that neck pain may become
prominent only after the fracture starts to displace,
leading to irreversible neurological damage. 8,10 We
should have a high index of suspicion of spinal fracture
in all AS patients, even when the mechanism of trauma
is trivial.
We should be cautious in the use of neck collar to
immobilise the cervical spine in AS patients. Their preexisting cervical spine deformity is flexion and
kyphosis. The neutral neck position in normal persons
for the application of neck collar may actually
hyperextend the cervical spine in AS patients and
neurological damage may occur. Also, as the two sides
of the fracture are fused vertebrae functioning in effect
as two pieces of long and straight bones, it is difficult
to immobilise with a neck collar.11,12 Vigilance during
patient transfer and the early use of immobilisation
devices such as halo cast/jacket are needed to prevent
displacement of the cer vical fracture and the
subsequent neurological damage.
47
References
1. Peh CGW. Ankylosing spondylitis. eMedicine. [cited
2005 May 5]. Available from: http://www.emedicine.
com/radio/topic41/htm.
2. Wigley RD, Zhang NZ, Zeng QY, Shi CS, Hu DW,
Couchman K, et al. Rheumatic diseases in China: ILARChina study comparing the prevalence of rheumatic
symptoms in northern and southern rural populations.
J Rheumatol 1994;21(8):1484-90.
3. Hunter T, Dubo H. Spinal fractures complicating
ankylosing spondylitis. Ann Intern Med 1978;88(4):
546-9.
4. Graham B, Van Peteghem PK. Fractures of the spine in
ankylosing spondylitis. Diagnosis, treatment, and
complications. Spine 1989;14(8):803-7.
5. Samartzis D, Anderson DG, Shen FH. Multiple and
simultaneous spine fractures in ankylosing spondylitis:
case report. Spine 2005;30(23):E711-5.
6. Cooper C, Carbone L, Michet CJ, Atkinson EJ,
O'Fallon WM, Melton LJ 3rd. Fracture risk in patients
with ankylosing spondylitis: a population based study.
J Rheumatol 1994;21(10):1877-82.
7. Weinstein PR, Karpman RR, Gall EP, Pitt M. Spinal cord
injury, spinal fracture, and spinal stenosis in ankylosing
spondylitis. J Neurosurg 1982;57(5):609-16.
8. Broom MJ, Raycroft JF. Complications of fractures of
the cervical spine in ankylosing spondylitis. Spine 1988;
13(7):763-6.
9. Harrop JS, Sharan A, Anderson G, Hillibrand AS,
Albert TJ, Flanders A, et al. Failure of standard imaging
to detect a cervical fracture in a patient with ankylosing
spondylitis. Spine 2005;30(14):E417-9.
10. Mu r r a y G C , Pe r s e l l i n R H . C e r v i c a l f r a c t u r e
complicating ankylosing spondylitis: a report of eight
cases and review of the literature. Am J Med 1981;70
(5):1033-41.
11. Cooper PR, Maravilla KR, Sklar FH, Moody SF, Clark
WK. Halo immobilization of cervical spine fractures.
Indications and results. J Neurosurg 1979;50(5):603-10.
12. Rowed DW. Management of cervical spinal cord injury
in ankylosing spondylitis: the intervertebral disc as a
cause of cord compression. J Neurosurg 1992;77(2):
241-6.