Name:
FOCUS25824video7
Description:
FOCUS25824video7
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/c4e13812-d6af-4395-826d-364b78d216ff/videoscrubberimages/Scrubber_1.jpg?sv=2019-02-02&sr=c&sig=7k0WqVjTvDO2PREE%2FGwWRvaZmL78kxdrUMRkStmqkIs%3D&st=2026-05-13T19%3A54%3A23Z&se=2026-05-13T23%3A59%3A23Z&sp=r
Duration:
T00H05M56S
Embed URL:
https://stream.cadmore.media/player/c4e13812-d6af-4395-826d-364b78d216ff
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/c4e13812-d6af-4395-826d-364b78d216ff/7. 24-999.mp4?sv=2019-02-02&sr=c&sig=tKtXTj79H9MWMcqnMhaRXAHy6OpWAHM5K5PYWTLz3Z8%3D&st=2026-05-13T19%3A54%3A23Z&se=2026-05-13T21%3A59%3A23Z&sp=r
Upload Date:
2025-12-03T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
SPEAKER: Here we present a case of a 66-year-old male who
SPEAKER: presented to an outside hospital emergency department following a fall down eight steps. He complained initially of severe neck pain. His past medical history was significant for ankylosing spondylitis followed in the outpatient rheumatology clinic. He was neurologically intact on initial examination. A lateral cervical x-ray completed at the outside hospital demonstrated an extension distraction injury at the C4–5 level.
SPEAKER: He was also noted to have extensive changes of ankylosing spondylitis in the cervical spine. A CT scan of the cervical spine was also completed and redemonstrated the C4–5 extension distraction injury. He also was noted to have extensive fusion in the cervical spine. A C4–5 extension distraction injury was diagnosed based on the imaging. Due to the extent of injury, a halo was placed by four people using mild sedation.
SPEAKER: Neurologic examination following the halo placement and tightening was unchanged. Pre– and post–halo placement radiographs demonstrated stable alignment of the fracture. Fifteen minutes following halo placement, decreased movement in the arms and legs was noted. He was noted to have a strength of 3–4/ 5 in the upper extremities and 1–2/5 in the lower extremities on the MRC scale.
SPEAKER: He was then fiber-optically intubated. Radiographs showed no change in alignment of the cervical spine. His mean arterial pressure was elevated with fluid boluses and intravenous vasopressors for a goal MAP of 85. At this point, his neurologic examination returned to baseline. An MRI was then completed.
SPEAKER: The MRI redemonstrated the C4–5 fracture and demonstrated extensive cord compression and injury at the C4–5 level. During the MRI, his oxygen saturation and mean arterial pressure were monitored. His oxygen saturation was between 98% and 100% throughout the MRI, and his MAP was greater than 80 throughout the MRI.
SPEAKER: Following the MRI, he was noted to have developed new weakness. His arms were examined at 0–1/ 5 and legs at 0/5 on the MRC scale. He was graded as having a C4 ASIA A spinal cord injury at this point. Due to the unstable cervical fracture in the setting of an ankylosed spine and dissociated spinal cord injury, plans were made for urgent posterior occipitocervicothoracic decompression and fusion.
SPEAKER: Specific concerns and risks related to the procedure included the reliability of intraoperative neuromonitoring and ensuring immobilization during the flip and positioning at the beginning of the procedure. He was then transferred urgently to the operating room. He was positioned and secured while in the halo frame. Intraoperative neuromonitoring showed no MEP or SSEP signals. Surgical intervention in the form of a posterior occiput–T2 instrumented fusion, C3–6 laminectomy, and evacuation of the epidural hematoma was performed.
SPEAKER: Postoperatively, there were no changes in neuromonitoring. Postoperative clinical examination was unchanged, and he remains at C4 ASIA A. Tracheostomy and gastrostomy were performed 7 days following injury, and he was transferred to a rehabilitation facility 21 days following injury. Postoperative imaging demonstrated occipitocervicothoracic fusion hardware in good position without an overt surgical complication.
SPEAKER: MRI redemonstrated the fracture. In addition, there was adequate decompression of the spinal cord. There was extensive signal change within the spinal cord, thought to be edema. Ankylosing spondylitis–associated spinal fractures are associated with postinjury neurologic decline. Multiple mechanisms have been implicated in the neurological decline, including epidural hematomas, progressive deformity, and vascular compromise.
SPEAKER: Careful immobilization and monitoring are imperative prior to definitive surgical fixation and during any procedures or transfers that occur prior to definitive surgical fixation. Treatment of hypoxia and blood pressure augmentation may improve cord perfusion and decrease the risk of neurologic decline. Halo placement, sedation, repeat x-rays, and multiple assessments delayed definitive surgical intervention in this case.
SPEAKER: An intact neurological examination provides false reassurance in the setting of highly unstable ankylosing spondylitis–associated fractures that are at risk of neurologic decline. Urgent definitive surgical intervention is indicated in these cases. In this case, avoiding halo placement, repeat imaging, and multiple assessments would have facilitated early definitive management and potentially changed the outcome.
SPEAKER:
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