title: Epidural hematoma associated with occult fracture in ankylosing spondylitis patient: a case report and review of the literature.
abstract: METHODS
  A case report and review of the literature.
  
  
  OBJECTIVE
  To highlight the risk of occult fracture associated with symptomatic epidural hematoma in patient with ankylosing spondylitis.
  
  
  BACKGROUND
  Hyperextension injuries are common in patients with ankylosed spine. Failure of standard imaging to detect these fractures may result in delayed diagnosis. Ossification of the ligaments in these patients makes even subtle fractures grossly unstable owing to the increased lever arm. Delayed diagnosis of fractures may result in further displacement and increased risk of neurological injury.
  
  
  METHODS
  The clinical findings, roentgenographic appearance, and treatment were presented.
  
  
  RESULTS
  A 69-year-old patient with a history of ankylosing spondylitis fell 9 feet from a ladder. The patient developed pain in his neck and numbness in his hands. Initial computed tomography (CT) scan of spine showed a subtle fracture in the vertebral body of C7. A magnetic resonance imaging scan showed an epidural hematoma extending from C5 to T3. The patient was taken to the operating room urgently for decompression. Laminectomy was performed from C5 to T3 and a large epidural hematoma was evacuated. After decompression the patient had some improvement in his neurological status. A postdecompression repeat CT scan revealed obvious fracture at C6-C7 with anterior distraction indicating a hyperextension injury. The patient was taken back to the operating room within 16 hours of his decompression for C4 to T3 posterior segment instrumentation and fusion.
  
  
  CONCLUSIONS
  Patients with ankylosing spondylitis who sustain low-energy injuries should be considered to have a fracture especially if they develop epidural hematoma. A high index of suspicion is necessary in such a case. Imaging studies including magnetic resonance imaging and CT scans should be reviewed carefully to rule out any occult fracture.
authors.affiliation: Department of Orthopaedic, University of Toledo Medical Center, Toledo, OH 43614-5807, USA. hkelgafy@aol.com
authors.forename: Hossein
authors.initials: H
authors.lastname: Elgafy
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Bransford
authors.forename: Jens R
authors.initials: JR
authors.lastname: Chapman
mesh_terms: D000058:Accidental Falls; D000368:Aged; D005596:Fractures, Closed / Q000000981:diagnostic imaging / Q000209:etiology* / Q000601:surgery; D046748:Hematoma, Epidural, Spinal / Q000000981:diagnostic imaging / Q000209:etiology* / Q000601:surgery; D006801:Humans; D008297:Male; D011859:Radiography; D016103:Spinal Fractures / Q000000981:diagnostic imaging / Q000209:etiology* / Q000601:surgery; D013167:Spondylitis, Ankylosing / Q000150:complications* / Q000000981:diagnostic imaging