Surgical Treatment of Spinal Fracture in a Patient With Ankylosing Spondylitis: An Opportunity To Correct Spinal Deformity Simultaneously With Fracture Fixation?

Abstract

The objective of this case report is to describe the substantial sagittal correction of spinal hyperkyphosis alongside fracture fixation. In advanced ankylosing spondylitis (AS), the spine is usually fused, hyperkyphotic, and due to deformity, as well as improper bone remodeling, predisposed to fractures. These fractures, mostly unstable, require surgical treatment. The authors present fracture management with concomitant deformity correction at the fracture site and pedicle subtraction osteotomy (PSO) below the fracture, showing the benefits of performing the procedures with the patient in a sitting position. A 58-year-old male with AS was diagnosed with a fracture of C6 and referred to the department of neurosurgery, Wroclaw University Hospital. For the last week, he had complained of worsening neck pain and exacerbation of spinal kyphosis, with no neurological deficits. The patient had a fully fused spine, significant hyperkyphosis prior to the injury, and a fracture with an additionally exacerbated deformity. The patient was offered operative treatment - spinal fusion and fracture reduction with hyperkyphosis correction. The procedure consisted of 1) partial, mostly closed correction at the fracture site, 2) PSO of C7 and C2-T3 pedicular fixation and fusion while sitting in the posterior approach. To enable closed reduction at the fracture site and avoid difficulties with positioning a prone patient with very severe hyperkyphosis and an unstable spine, the authors performed surgical procedures with the patient in a sitting position. The authors obtained significant correction during the procedure by 74⁰, from 53.4⁰ of kyphosis to 24.3⁰ of lordosis measured between C2 and T1. The patient had several complications (transient weakness of the upper limb, pleural effusion, and delayed wound healing); however, all resolved and the patient was discharged within two weeks post the operation. In patients with spinal hyperkyphosis with AS who sustain spinal fractures requiring operative treatment, it is worth considering simultaneous correction of the spinal deformity during surgical management of the fracture.

Keywords: ankylosing spondylitis; cervical fracture; hyperkyphosis; pedicle subtraction osteotomy; spinal surgery.

Figure 1. Patient with AS and the chin-on-chest deformity exacerbated by a C5 fracture

A) and B) clinical images. B) CT sagittal MPR showing completely fused spine, displaced fracture, cervical hyperkyphosis AS: ankylosing spondylitis

Figure 2. Positioning of the patient on the operating table in a sitting position

The arm of the Mayfield clamp was mounted on the table with the aid of gravity, which allowed for gradual reduction under carefully controlled neuromonitoring.

Figure 3. A) Preoperative chin-chest distance; B) Chin-chest distance increased after patient positioning and gentle closed reduction; C) Fluoroscopy after closed reduction

Figure 4. A) Wide laminectomy with C7 PSO performed and C7 and C8 roots decompressed before closure; B) Image from intraoperative fluoroscopy after osteotomy closure. Opening of the anterior column at the fracture site attained during primary closed reduction; C) Closing of the osteotomy site along with head repositioning. D) in situ rod bending E) preop CT scan with 53.4 of cervical kyphosis and F) postop CT scans showing 24.3 degrees of lordosis.

Figure 5. Six months after surgery

A) Clinical picture showing satisfactory head position; B) Full spine anteroposterior (AP) and lateral X-rays; C) Significantly unbalanced spine sagittally, significantly positive sagittal vertical alignment (SVA); D) CT scan showing fusion of the anterior column of the spine