Working Diagnosis:
Superior articular facet fracture, C6/C7 instability, C6/C7 severe stenosis, C7 radiculopathy, and hairy cell leukemia

Treatment:
The patient underwent a C6-C7 anterior cervical discectomy and fusion which was well-tolerated. Case Photo #8 Case Photo #6 Case Photo #7 He met IADL goals with both physical and occupational therapy with notable return of normal strength in his left arm. However, there was an incidental finding of pancytopenia on pre-op bloodwork which led to a Hematology consult and a diagnosis of Hairy Cell Leukemia. Upon discharge he was given explicit instructions to follow up with an orthopedist and a hematologist in his home state.

Outcome:
Physical therapy worked with the patient on post-op day one. On post-op day two, he was cleared to perform ADL's with minimal assistance while wearing rigid C-collar and discharged home. On discharge, blood counts remained pancytopenic but stable. He was cleared to travel home.

Author's Comments:
Distal, focal pain after a trauma may actually represent radiculopathy from spinal injury. Our patient's complaint of elbow pain, with no midline cervical tenderness, fooled an experienced ski patrol member and physicians into prematurely focusing on extremity trauma. With normal elbow films but difficulty holding arms overhead to text, a functional neurological deficit, more extensive trauma was suspected based on the mechanism of injury despite the lack of midline tenderness normally associated with cervical vertebral injury.

Editor's Comments:
Injuries to the posterior longitudinal ligament are the most common athletic related cervical spine injuries often occurring as a result of substantial axial load on a slightly flexed neck. There is often an associated flexion-compression fragment of the anteroinferior vertebral body. An anterior longitudinal ligament injury is less common, occurring when an athlete's head is subjected to a large and rapid posteriorly directed force. As a result of this rapid hyperextension, there is a failure of the anterior longitudinal ligament and anterior annulus fibrosus. With anterior longitudinal ligament disruption, there is a risk that the superior vertebral body may translate posteriorly compressing the spinal cord. Almost all anterior longitudinal ligament injuries are considered unstable advancing quickly to surgical stabilization.(1)

References:
1. Schroeder, Gregory. et al. "Cervical Spine Injuries in the Athlete." J Am Acad Orthop Surg 2016; 24:9, pg e122-e133.

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