Breaking the diagnosis: ankylosing spondylitis evidenced by cervical fracture following spine manipulation

Abstract

A 47-year-old Afro-Brazilian woman with long-standing back pain sought chiropractic care for symptomatic relief. Until then, she had never consulted a doctor to treat her axial pain and was not aware of having any specific spinal pathology. Since childhood, she had moderate cognitive deficit, which probably compromised her ability to adequately describe the pain and, thus, lead the family to seek medical advice. During her last session of spinal manipulation, she mentioned a new-onset paresthesia beginning on upper limbs and progressing to lower limbs. Her complaint was disregarded, and the session continued, at the end of which she was unable to stand. Urinary retention ensued a little after. The patient was referred to our service only a week after, completely bedridden. Spine MRI revealed a transdiscal fracture at C5–C6, resulting in critical stenosis and compressive myelopathy. CT angiography revealed traumatic thrombosis of the vertebral arteries emerging on this level. Whole spine-imaging evidenced multiple syndesmophytes giving a characteristic bamboo spine appearance, as well as ankylosis in sacroiliac joints, uncovering the diagnosis of ankylosing spondylitis. She underwent laminectomy from C2 to C6 and arthrodesis from C2 to T2 for spine stabilization, but did not recover mobility. Even though a systematic review did not find an increased risk of significant adverse events related to spine manipulation therapy [1], there have been descriptions of vertebral fracture following a session on patients with ankylosing spondylitis [2] and unsuspected multiple myeloma [3]. (A) Sagittal view of cervical spine CT. (B) Sagittal view of full-length spine CT.