Surgical Treatment of Spinal Fracture in a Patient With Ankylosing Spondylitis
By Admin | March 01, 2022
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.
Advanced cases of ankylosing spondylitis (AS) are usually associated with restriction of mobility and debilitating deformity of the spine and other joints. There is an elevated fracture risk in AS due to pathological spinal remodeling and osteoporosis [1-2]. Ectopic bone forms with unusual osteoproliferative processes leading to a ligamentous ossification progressively bridging the whole spine and simultaneously develops osteopenia - in part resulting from a stress shielding of the cancellous vertebral parts . The fractures are usually associated with low-energy trauma. Patients with AS have often a disturbed line of vision and they are prone to falls; 40% of fractures are caused by simple ground-level falls . Due to deformity with altered spinal balance, the fracture may have a mechanism of fatigue fracture. It is often an expression of patients’ effort to properly align the head and/or compensate spinal balance. The fractures are frequently recognized with delay, which increases the risk of secondary neurologic injury due to high instability and potential displacement; the spine acts as a long bone. The timing may also add to deformity development or, more likely, a deterioration of the present one. The diagnostic issues are driven by the often uncertain mechanism of trauma (low-energy) and are asymptomatic. Thus, the sooner the treatment begins the better.
The treatment strategies for patients with AS have to be different from patients with non-rigid spines. Conservative treatment is rarely an option and is chosen only in uncommon cases of stable fractures ; however, nonoperative treatment is associated with the risks of healing problems and pseudarthrosis . Longer immobilization and bed rest may result in general medical complications (pulmonary, urinary infections, thromboembolism, etc.). Moreover, the selection and fitting of the proper external immobilization may be extremely difficult due to deformity. Since spinal fractures in AS are usually highly unstable, with three columns involved, and the risk of primary and secondary spinal cord injury, the majority of patients require surgery .
The surgery itself presents several issues. Besides the fact that AS patients commonly present comorbidities, the number of complications related to surgery remains high [5-7]. Especially, these patients require long constructs, extensive surgery with decompression, and, at least, realignment of the spine, if not deformity correction .
A 58-year-old male was treated for ankylosing spondylitis for many years with anti-inflammatory drugs (steroids and non-steroidal anti-inflammatory drugs (NSAIDs)). Due to his medical history, he has never been offered biologic therapy. He was a patient with multiple comorbidities, with a history of myocardial infarction treated with a percutaneous coronary intervention (PCI) of the left anterior descending (LAD) artery and insertion of...(More)
For more info please read, Surgical Treatment of Spinal Fracture in a Patient With Ankylosing Spondylitis, by Cureus