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Abstract: This patient has a history of ankylosing spondylitis. He reported that he fell from bed accidentally 4 days ago and subsequently developed pain, restricted movement, and pins and needles pain in the left neck and shoulder, and was diagnosed with cervical spine fracture and misalignment after coming to our hospital.
Basic information】Male, 58 years old
Disease Type】Cervical fracture
Hospital】The First Hospital of China Medical University
Date of consultation】May 2021
Treatment plan】Surgery (fusion internal fixation surgery) + medication (sodium penicillin for injection, ceftriaxone sodium for injection)
Treatment period】3 months
Treatment effect】Good healing of the neck fracture
I. Initial consultation
The patient was 58 years old and reported a history of ankylosing spondylitis. He fell from bed and injured his neck 4 days ago at home and felt pain in the left side of his neck and shoulder. The outpatient physical examination indicated resistance in the neck, painful skin sensation in the left shoulder joint, and negative cervical ankylosis, suggesting a low genetic possibility. The patient was given an MRI examination of the neck, which showed a transverse fracture and subluxation of the C6 vertebral body and soft tissue edema adjacent to the C2-5 spinous process. The patient was admitted to our department for treatment as “cervical fracture”.
II. Treatment process
After admission, the patient was given peri-collar braking at an early stage, and according to the imaging findings, immediate surgery was required for treatment. The patient was immediately treated with fusion internal fixation surgery. The surgery progressed smoothly and no intraoperative complications occurred. After the operation, in order to avoid secondary injury and promote wound healing, the patient was given a head, neck and chest brace for protection and a drainage tube was left in place. Since the patient did not have much sputum after the operation, he was encouraged to cough and sputum to prevent pulmonary complications and was routinely given sodium penicillin for injection and ceftriaxone sodium for injection to prevent infection. The patient’s sensory condition of the extremities was also closely observed.
III. Treatment effect
The patient recovered well after surgery, and the surgical incision healed in phase 1 without serious postoperative complications, and the mobility of the extremities was good, and the stitches were removed and the patient was discharged 2 weeks after surgery. Physiological function.
IV. Notes
The patient was discharged from the hospital after her condition improved, and I was very happy and excited about the success of the operation and the patient’s improvement. The patient was also instructed to continue wearing the cephalothoracic brace after discharge, and to review the source in the first, third, and sixth months, as well as one year after surgery, until the results of the review indicated healing. In addition, because of the patient’s history of ankylosing spondylitis, and because the risk of cervical fracture dislocation is much higher in patients with ankylosing spondylitis than in the normal population, the patient also needs to adhere to medication for ankylosing spondylitis, continue functional exercises for the spine after the cervical fracture has healed, and follow up every six months.
V. Personal insight
For patients with cervical spine fractures, the first step is to apply immediate brakes and come to the hospital as soon as possible for imaging to clarify the extent of the injury and to choose an appropriate treatment plan according to the specific circumstances of the fracture. This disease can lead to a weakening of the ability to resist shock, which can lead to a fracture of the cervical spine or spine when an external force is applied. Care should be taken in daily life to avoid causing re-injury to the cervical spine.