Spinal cord injury in unconscious ankylosing spondylitis patients: decision-making

INTRODUCTION Spinal cord injury (SCI) in unconscious patients with ankylosing spondylitis (AS) is associated with higher mortality and complications rates when vertebral fractures are present compared to the general population. Diagnostic delays are commonly observed in AS patients, as most show symptoms of neurologic deterioration only after minor trauma. Lack of awareness of these factors delays the prompt diagnosis of AS in unconscious patients, emphasizing the importance of imaging in guiding medical decisions. OBJECTIVES To identify unconscious patients with undiagnosed AS when spine trauma is present and to recognize that SCI is prevalent in the presence of vertebral fractures. METHODS This study includes a literature review on the medical management of unconscious AS patients observed in an emergency room setting, alongside a case report for illustrative purposes. RESULTS A 70-year-old man was admitted to the emergency room in an unconscious state following a minor trauma (fall from standing height). The patient presented with sudden flaccid tetraplegia, sensory anesthesia at the C4 level, spinal shock, and reversed asystole rhythm cardiac arrest. A cervical spine computed tomography (CT) scan revealed an AOSpine type C C5–C6 vertebrae fracture dislocation resulting in spinal cord compression (Figures 1, 2, and 3). Other findings were consistent with the characteristic "bamboo" degenerative discopathy associated with AS. Due to the patient’s frail clinical condition, surgical treatment for cervical spine was unfeasible, and the patient passed away 5 days after admission. Diagnostic criteria for AS patients include CT axial bone imaging screening for sacroiliitis, costovertebral joint ankylosis, osteoporosis, and vertebral ossifications affecting facets, intervertebral discs, and spinal ligaments. A positive HLA-B27 antigen test is unnecessary, as only 5% of positive cases develop AS. CONCLUSION CT axial diagnostic imaging identifies unconscious patients with undiagnosed AS who have spinal fractures and SCI in an emergency room setting. This knowledge aids in treatment decision-making.