Injuries of the cervical spine in patients with ankylosing spondylitis: experience at two trauma centers

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Object

The cervical spine in a patient with ankylosing spondylitis (AS) (Bechterew disease) is exposed to maximal risk due to physical load. Even minor trauma can cause fractures because of the spine’s poor elasticity (so-called bamboo spine). The authors conducted a study to determine the characteristics of cervical fractures in patients with AS to describe the standard procedures in the treatment of this condition at two trauma centers and to discuss complications of and outcomes after treatment.

Methods

Between 1990 and 2006, 37 patients were surgically treated at two institutions. All patients were examined preoperatively and when being discharged from the hospital for rehabilitation. Single-session (11 cases) and two-session anterior–posterior (13 cases), anterior (11 cases), posterior (two cases), and laminectomy (one case) procedures were performed. The injury pattern, segments involved, the pre- and postoperative neurological status, and complications were analyzed.

Preoperative neurological deficits were present in 36 patients. All patients experienced improvement postoperatively, and there was no case of surgery-related neurological deterioration. In patients in whom treatment was delayed because of late diagnosis, preoperative neurological deficits were more severe and improvement worse than those treated earlier. The causes of three deaths were respiratory distress syndrome due to a rigid thorax and cerebral ischemia due to rupture of the vertebral arteries. There were 12 perioperative complications (32%), three infections, one deep venous thrombosis, five early implant failures, and the three aforementioned fatalities. There were no cases of epidural hematoma. In all five cases in which early implant failure required revision surgery, the initial stabilization procedure had been anterior only. A comparison of complications and the outcomes at the two centers revealed no significant differences.

Conclusions

The standard intervention for these injuries is open reduction, anterior decompression and fusion, and anterior–posterior stabilization; these procedures may be conducted in one or two stages. Based on the early implant failures that occurred exclusively after single-session anterior stabilizations (five of 10—a failure rate of 50%), the authors have performed only posterior and anterior procedures since 1997 at both centers. Diagnostic investigations include computed tomography scanning or magnetic resonance imaging of the whole spine, because additional injuries are common. The causative trauma may be very slight, and diagnosis may be delayed because plain radiographs can be initially misinterpreted. In cases in which diagnosis is delayed, patients present with more severe neurological deficits, and postoperative improvement is less pronounced than that in patients in whom a prompt diagnosis is established. Because of postoperative pulmonary and ischemic complications, the mortality rate is high. In the present series the mortality rate was lower than the mean rate reported in the literature.

Abbreviations used in this paper:AS = ankylosing spondylitis; CT = computed tomography; DVT = deep vein thrombosis; MR = magnetic resonance; VA = vertebral artery; VB = vertebral body.

Article Information

Address reprint requests to: Thomas Einsiedel, M.D., Department of Trauma, Hand, and Reconstructive Surgery, University of Ulm, Steinhövelstrasse 9, 89075 Ulm, Germany. email: thomas.einsiedel@uniklinik-ulm.de.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Bar graph showing postoperative Frankel grade–based improvement in all patients.

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    Case 13. Lateral radiograph revealing severe C5–6 instability and so-called bamboo spine resulting from Bechterew-induced changes.

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    Case 13. Anteroposterior (left) and lateral (right) radiographs demonstrating outcome after a two-session anterior–posterior stabilization. The anterior procedure involved placement of a Morscher plate system from C-5 to C-7. The posterior procedure involved C5–7 stabilization without a graft.

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    Case 13. Postoperative MR images obtained after the two-session anterior–posterior C5–7 procedure.

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    Case 17. Plain radiographs (A and B) and MR images (C and D) obtained in a patient with primary sensori-motor paraplegia due to a C6–7 fracture. Note the considerable changes in the anatomy of the cervical spine on the plain radiographs; the fracture is practically undetectable.

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    Case 17. Postoperative plain radiographs (A and B) and CT reconstruction (C).

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    Case 7. Lateral (left) and anteroposterior (right) plain radiographs acquired in a patient with a C5–6 fracture–dislocation that is difficult to detect because of the Bechterew disease–induced changes.

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    Case 7. A–C: Reconstructed CT scans revealing an anterior to posterior fracture (arrows). D: Reconstructed CT scan showing the first step of surgery in which anterior fusion was performed with iliac graft and Morscher plate.

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    Case 7. Postoperative images demonstrating the definitive stabilization after the posterior procedure in which we implanted the Cervifix system. The long C4–7 posterior fusion was chosen when, intraoperatively, we observed complete posterior instability due to rupture of the ligaments.

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    Case 12. Plain radiograph (A) and conventional tomogram (B) revealing a C5–6 dislocation. Lateral (C) and anteroposterior (D) radographs showing bamboo lumbar spine.

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    Case 12. Sagittal MR image confirming the C5–6 fracture–dislocation and the presence of an intraspinal fragment.

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    Case 12. Left and Right: Postoperative radiographs showing implant failure with redislocation after isolated anterior graft and Morscher plate fusion.

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    Case 12. Radiograph demonstrating the failure of additional dorsal wire fixation performed as a salvage procedure; spinal instability remains.

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    Case 12. Left and Right: All implants were removed after the wire caused infection; a longer (C4–6) anterior fusion stabilization was undertaken.

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    Case 12. After the wound infection subsided, the NEON system was implanted from C–7.

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    Case 20. Radiographs (A and B) and CT scan reconstruction (C) demonstrating early implant loosening and failure after the patient (who presented with AS and osteoporosis) underwent anterior stabilization of a C6–7 fracture-dislocation. A graft and four-hole plate were placed, but the system did not encompass enough of the spine.

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    Case 20. Radiographs obtained after the patient underwent a revision procedure: anterior plates were placed, this time with cement augmentation; posterior stabilization was achieved by placing a plate and bone chips removed from the explanted graft. Note again loosening of screws (no clinical significance). Angle-stable locking screw implants would have helped in this case, but they were not yet available in 1991.

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