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Endgames Picture Quiz

Spinal injury in ankylosing spondylitis

BMJ 2014; 348 doi: (Published 16 June 2014) Cite this as: BMJ 2014;348:g3849
  1. G Stenhouse, specialist registrar, radiology,
  2. C Ulbricht, consultant spinal neurosurgeon,
  3. M Khanna, consultant, musculoskeletal radiology
  1. 1Department of Radiology, Imperial College Healthcare NHS Trust, London W2 1NY, UK
  1. Correspondence to: G Stenhouse gregors45{at}

A 51 year old man attended the emergency department because of a painful neck after falling from standing height while climbing out of the bath. He slipped backwards in the bath and landed heavily on his back. He didn’t remember hitting his head. He lived alone and was previously independent, although his activities had become increasingly difficult in recent years owing to ankylosing spondylitis. The neck pain worsened during the day and he attended hospital. On initial clinical examination, he was alert and communicative. He had paravertebral soft tissue discomfort at the level of the mid-cervical spine but no midline bony tenderness. His range of neck movement was limited, although this was not unusual for him. No neurological deficits were noted and he was discharged with analgesia.

He came back to the hospital five days later because of ongoing neck pain. Despite the seemingly innocuous injury at the time, the attending doctor recognised the greater risk of spinal injury in patients with ankylosing spondylitis and urgently requested cervical spine imaging (fig 1).

Fig 1 Lateral radiograph of the cervical spine


  • 1. What acute abnormality does the radiograph show?

  • 2. What factors should be considered high risk for potential cervical spine injury in alert adult patients with neck pain?

  • 3. What radiological features might lead you to suspect an underlying disease?

  • 4. What further imaging could be considered and how would you manage this patient in the acute setting?


1. What acute abnormality does the radiograph show?

Short answer

Unstable fracture dislocation at the level of C5/6 with fracture extension into the posterior elements.

Long answer

When reviewing a cervical spine radiograph, the C7-T1 junction should always be analysed. Alignment on a lateral film should be assessed using four anatomical lines—the anterior and posterior spinal lines, the spinolaminar and the spinous process lines (fig 2). In this case they are …

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