Spine Fractures in Ankylosing Diseases: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU)

Abstract

Study design: Review of literature and case series.

Objectives: Update and review of current treatment concepts for spine fractures in patients with ankylosing spinal disorders.

Methods: Case presentation and description of a diagnostic and therapeutic algorithm for unstable spinal injuries with an underlying ankylosing spinal disorder (ASD) of the cervical and thoracolumbar spine.

Results: Nondisplaced fractures can be missed easily using conventional X-rays. Thus, computed tomography (CT) scans are recommended for all trauma patients with ASD. In doubt or presence of any neurologic involvement additional magnetic resonance imaging (MRI) scans should be obtained. Spine precautions should be maintained all times and until definitive treatment (<24 h). Nonoperative fracture treatment is not recommended given the mechanical instability of the most commonly seen fracture patterns (AOSpine B- and C-type, M2) in patients with ASD and inherent high risk of secondary neurologic deterioration. For patients with ankylosing spondylitis (AS) or diffuse idiopathic hyperostosis (DISH) sustaining cervical spine fractures, a combined anterior-posterior instrumentation for fracture fixation is recommended. Closed reduction and patient positioning can be challenging in presence of preexisting kyphotic deformities. In the thoracolumbar (TL) spine, a posterior instrumentation extending 2 to 3 levels above and below the fracture level is recommended to maintain adequate reduction and stability until fracture healing. Minimally invasive percutaneous pedicle screws and cement augmentation can help to minimize the surgical trauma and strengthen the construct stability in patients with diminished minor bone quality (osteopenia, osteoporosis).

Conclusions: Current concepts, treatment options, and recommendations of the German Orthopedic Trauma Society-Spine Section for spinal fractures in the ankylosed spine have been outlined.

Keywords: DISH; Morbus Bechterew; Morbus Forestier; ankylosing spondylitis; cervical spine; complication; diffuse idiopathic skeletal hyperostosis; iatrogenic spine fracture; medical treatment; nonoperative fracture treatment; operative treatment; senile ankylosing hyperostosis; spinal fractures; thoracolumbar spine; trauma.

Figure 1.

Diagnostic and therapeutic algorithm.

Figure 2.

Case 1: Ankylosing spondylitis (AS) patient (AOSpine C4-5 C, F4 BL, N2, M3) with anterior-posterior fixation. (A) Initial lateral c-spine films; (B) Preoperative CT scan; (C) Instability and fracture dislocation following patient intubation and transfer in the supine position before and (D) after closed reduction on the operation table with a halo-reduction device fixed to the operation table; and (E) postoperative results.

Figure 3.

Case 2: Diffuse idiopathic skeletal hyperostosis (DISH) patient (AOSpine C4-5 B2, F4, N0, M3) with 2-level ACDF and anterior angular stable plate fixation. (A) Initial CT scan with (B) C4-5 facet fracture dislocation, (C) fractures and broken off flowing anterior osteophyte; (D) Postoperative CT scans; (E) lateral and AP X-ray films.

Figure 4.

(A) Case 3: 74-year-old female with AS sustaining a multilevel cervical and thoracic spine fracture and intracranial bleeding (SAB) after a trip and fall onto stairways (C1/2 fracture dislocation with AOSpine subaxial classification: C7-Th1 C M3-type injury (a, b, d), and AOSpine TL classification T6-7 B3, M2-type injury) (c). (B) One stage posterior segmental fixation with C1/2 fixation using Harms/Goel technique (a-c), posterior lateral mass screw and pedicle screw/rod construct C5/6-T3-T5/6 and T7/8 (d-f).

Figure 5.

Case 4: DISH patient with iatrogenic T12 hyperextension injury (AOSpine T12 B3, N0, M2) following laparoscopic cholecystectomy. (A) Lateral X-ray of TL spine and (B) sagittal CT image 2 days after laparoscopic cholecystectomy; (C) Repeat sagittal CT image 15 days after laparoscopic cholecystectomy, demonstrating further displacement of the T12 vertebral body fracture dislocation; (D, E) Open reduction internal fixation with monoaxial screws and rods 3 levels above and below.