Neck Pain After a Fall in an Anticoagulated Patient
A 72-year-old man with atrial fibrillation takes apixaban 5 mg twice daily. Two days ago he fell approximately 6 feet from a ladder while cleaning gutters, landing on his buttocks, and he now has midline neck pain and occipital headache. He did not lose consciousness, vomit, or have focal weakness, but he feels 'shaky.' Examination shows midline tenderness at C2, limited cervical rotation, and normal upper-extremity strength, sensation, and reflexes. Blood pressure is 148/86 mm Hg; heart rate is 78 and irregular. He asks for an adjustment because 'the chiropractor helped my neighbor's neck.' He has no prior imaging. You are the covering clinician in a community clinic without on-site MRI. He denies fever, weight loss, and prior neck surgery. He takes no other medications.
1. What serious diagnoses must you exclude, and what findings drive that concern?
Read the worked answer
The main concern is a cervical fracture, especially at C2, given the fall mechanism and midline tenderness. I must also consider spinal epidural hematoma, vertebral artery injury, and cord contusion because the patient is anticoagulated. Normal strength, sensation, and reflexes do not exclude fracture or evolving bleeding; midline tenderness and occipital headache are the key warning findings. The absence of loss of consciousness and vomiting is reassuring but not sufficient. In a clinic without MRI, the next step is same-day emergency department referral for CT of the cervical spine and further vascular imaging if indicated. I would not treat this as a simple mechanical neck pain presentation until imaging and medical evaluation are complete.
2. Would you perform cervical manipulation today? What alternative management and referral would you choose?
Read the worked answer
No. High-velocity cervical manipulation is contraindicated when fracture, bleeding, or vertebral artery injury is being considered. The anticoagulant plus fall mechanism raises the risk of serious harm from even a subtle fracture or vascular injury. I would place the patient in a stable collar if trained and available, avoid deep tissue work over the midline neck, and arrange immediate transfer to the emergency department. I would document the mechanism, anticoagulant, midline tenderness, limited rotation, normal neurologic examination, and the reason for referral. I would not provide a benign reassurance that this is just a stiff neck; the time course and medication make urgent imaging the safer choice.
3. What informed-consent and documentation steps are needed if the patient insists on treatment?
Read the worked answer
I would explain in plain language that manipulation could worsen a possible fracture or bleed and that I cannot provide it safely before imaging. I would offer only comfort measures within scope and continue the emergency referral. If the patient insists, I would document his request, my explanation of risk, his understanding, and the fact that manipulation was declined. I would not perform a technique simply because the patient asks; consent does not make an unsafe procedure appropriate. The record should show that the decision was based on the anticoagulant, trauma history, midline findings, and unavailable on-site imaging. I would also send a referral note and arrange follow-up communication.