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Retrospective study.To evaluate the clinical and functional outcomes in patients with spinal cord injury (SCI) and preexisting ankylosing spondylitis (AS).AS alters the strength and biomechanical properties of the spine that renders it susceptible to fracture with minimal trauma. Neurologic involvement is common and outcomes largely depend on the early recognition and appropriate management.A 10-year review (1996–2005) was carried out to identify all patients admitted with SCI associated with AS. The cause of injury, prehospital and emergency management, definitive treatment of fracture, final neurology, and functional outcomes were ascertained. Reasons for neurologic deterioration were determined.Eighteen patients were identified. In 15 patients, the injury resulted from trauma (fall 14, road accident 1) and in 3 the SCI followed spinal surgical interventions. Twelve of the 15 patients with traumatic injuries were able to walk immediately after the fall but subsequently deteriorated for various reasons. Spinal epidural hematomas developed in 3 patients (2 traumatic, 1 spinal intervention). The fractures were managed surgically in 3 patients, halo jacket was used in 2, and the remainder were managed expectantly on traction. Four patients died before discharge, 4 were able to walk with an aid at discharge, and the others were wheel chair dependent.Neurologic deficits were often subtle on initial presentation, resulting in many injuries being missed because of a low index of suspicion and poor visualization of lower cervical fractures on conventional radiographs. Extension of the ankylosed kyphotic cervical spine during conventional immobilization or for radiologic procedures resulted in neurologic deficits. Patients with an ankylosed cervical spine are normally unable to see the ceiling lying supine because of cervicothoracic kyphosis and use pillows to support their head. Cervical spine alignment in a similar flexed position is essential during immobilization or imaging. Medical alert cards as for patients with diabetes would be a way forward in correctly identifying patients with AS so that appropriate precautions can be instituted by emergency services.