Life-threatening spinal cord injury and occult intercostal artery rupture following low-energy trauma in a patient with ankylosing spondylitis: a case report.

backgroundAnkylosing spondylitis (AS) significantly increases vulnerability to severe spinal injuries from minor trauma due to rigid "bamboo spine" morphology and secondary osteoporosis. Isolated intercostal artery rupture without rib fractures is extremely rare in general trauma populations. The concurrent occurrence of multilevel spinal fractures with complete spinal cord injury and occult intercostal artery hemorrhage following low-energy blunt trauma in AS patients has rarely been documented, and the underlying pathophysiological mechanisms remain unclear. CASE PRESENTATION: A 43-year-old male with previously undiagnosed AS sustained a low-velocity bicycle collision, resulting in cervical and thoracic fracture-dislocation (C6-C7 and T11 bilateral laminae fractures) with complete spinal cord injury (ASIA Grade A, complete paraplegia), massive hemothorax, and active intercostal artery bleeding without significant rib fractures. Due to the patient's hemodynamic instability and altered consciousness on admission (hemorrhagic shock with SBP 63/40 mmHg), formal assessment of the bulbocavernosus reflex was not performed initially. The ASIA Grade A classification was based on complete absence of motor function (lower limbs 0/5) and sensory function below the T3 level, including absence of sacral sparing. Computed tomography angiography revealed active contrast extravasation from the right T10-level intercostal artery. Emergency transcatheter arterial angiography and embolization using coils and gelatin sponge particles successfully controlled the hemorrhage and stabilized the patient's hemodynamics. Following stabilization, staged posterior cervical (C5-C7) and thoracolumbar (T9-T12, L3-S1) pedicle screw-rod internal fixation with anterior cervical discectomy and fusion were performed. Despite postoperative complications including hospital-acquired pneumonia, pulmonary fungal infection (Candida albicans isolated from bronchoalveolar lavage, treated with intravenous fluconazole), and deep vein thrombosis, the patient demonstrated partial neurological recovery, with ASIA grade improving from Grade A (complete paraplegia) on admission to Grade C (incomplete paraplegia) at discharge on day 59. Serial neurological examinations documented the evolution from complete to incomplete injury (Table 1). The patient was subsequently transferred to a specialized rehabilitation center for long-term functional training.

conclusionsThis case illustrates the heightened and often unrecognized risk of complex, multisystem injuries in AS patients following seemingly minor trauma. Early recognition of hemothorax without rib fractures should raise high suspicion for intercostal artery injury, necessitating a lowered diagnostic threshold for computed tomography angiography. Transcatheter arterial embolization should be considered the first-line treatment for confirmed intercostal artery bleeding rather than a last resort. Prompt diagnosis, individualized multidisciplinary management, and early referral to specialized centers with interventional and spine surgical capabilities are essential for optimizing outcomes in these high-risk patients.