In a small town in Indiana a man collapses, and EMS is summoned. When paramedics arrive, they find the man in cardiac arrest. So, based on their education and experience, they begin resuscitative measures. Per protocol, they elect to place an endotracheal (ET) tube. During the process of intubation, they extend the head to properly visualize the airway. Unfortunately, they hear a "crack". The patient's cervical spine is fractured and the spinal cord injured. The paramedics did not do anything wrong; they followed established protocols. But the patient suffered from a condition called ankylosing spondylitis (AS), a condition that requires care modifications.

An estimated 500,000 people in the United States have AS, a form of inflammatory arthritis that primarily affects the spine. The disease causes inflammation of the joints between the vertebrae of the spine and the sacroiliac joints in the pelvis. It can also cause inflammation and pain in other parts of the body. As the condition worsens and the inflammation persists, new bone forms as a part of the healing process. The bone may grow from the edge of the vertebra across the disc space between two vertebra, resulting in a bony bridge. This may occur throughout the spine so that the spine may become stiff and inflexible, effectively fusing the spine. On spinal X-rays, this phenomenon is referred to as bamboo spine. This fusion can also affect the rib cage, restricting lung capacity and function.

X-ray of a fused spine

As the disease progresses, the spine can become fused into a single unit incapable of flexion, extension or lateral movement. Usually, the fusion progresses with the spine assuming a flexed position and the patient forced to walk bent over.

EMS providers called to care for a victim of AS must remember that their patient's spine is inflexible and cannot be moved. Further, the fused spine can be extremely fragile and subject to fracture with resultant spinal cord injury. Numerous EMS techniques must be modified to accommodate patients with AS. These include airway management techniques, splinting techniques and transport considerations. Because most AS patients have spinal flexion, it's important to adequately pad underneath the patient's head, neck and upper back with a pillow or pillows. Likewise, airway management techniques must be applied without extending the neck. Airway devices that do not require visualization (e.g. CombiTube, LMA) should be considered instead of ET intubation, with cricothyrotomy used as a last resort.

Although AS is not common, improper EMS care of patients with the disease can be devastating. Learn to identify the signs and symptoms of AS, and protect the spine accordingly.

For more information on ankylosing spondylitis (AS), please click here, or you can browse our educational materials.

Acknowledgements: Thank you to Bryan E. Bledsoe, DO, FACEP, for writing this article. It originally appeared in the Journal of Emergency Medical Services (JEMS); July 2006 • Volume 31 • Number 7