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CHARACTERISTIC ASPECTS OF CERVICAL SPINE FRACTURES IN ANKYLOSING SPONDYLITIS – CASE REPORT 143 Experimental Medical Surgical RE SEARCH JOURNAL of Correspondence to: Ana-Maria Maxim, e-mail: [email protected] ABSTRACT: Ankylosing spondylitis is a chronic, systemic, inflamatory disease, that affects especially the axial skeleton. In patients with spondylitis, the cervical segment of the spine is the most affected in trauma. The fracture risk appears even after a minor or mild traumatic event and the rigidity of the spine, the kyphosis, the secondary osteoporosis, have a special contribution. The injuries are localized especially on the lower cervical spine, such as segments C5/C6 and C6/C7 and in the cervico-thoracic junction. Traumatic lesions on ankylosing spondylitis spine are commonly succeeded by spine instability and high risk of secondary neurological deficiency, so that surgical intervention is the most indicated. In this article, we reveal some of the special aspects of the spine fractures in ankylosing spondylitis, illustrating a case of a patient with spondylitis, admitted in the department of traumatology „Casa Austria”, University County Hospital Timisoara, with cervical spine trauma, spinal cord injury and tetraplegia, after a medium intensity traumatic event. Patients with ankylosing spondylitis are highly susceptible to cervical fractures, even after a minor or mild trauma. These lesions often lead to secondary neurological deficits, so that CT or/and MR imaging evaluation of the whole spine is strongly recommended regardless of whether mild initial clinical findings are present. In case of a cervical spine fracture detection, the stabilization procedure is needed, and the standard management includes anterior decompression and combined anterior-posterior stabilization. Anterior approach stabilization alone is not indicated because instability of the posterior column may go undetected in the acute phase of the trauma. Keywords: ankylosing spondylitis, spine fractures, cervical spine trauma. ASPECTE CARACTERISTICE ÎN FRACTURILE COLOANEI CERVICALE DIN SPONDILITA ANCHILOZANTà - PREZENTARE DE CAZ Rezumat:Spondilita anchilopoeticã este o afecþiune sistemicã cronicã ºi o boalã inflamatorie, cu o dezvoltare preponderentã la nivelul scheletului axial. Cel mai frecvent implicat traumatic, la pacienþii cu spondilitã, este segmentul cervical al coloanei vertebrale. Aceºtia sunt supuºi riscului de fracturã, în urma unor traumatisme de intensitate medie sau micã, datoritã cifozei, rigiditãþii ºi osteoporozei existente. Leziunile traumatice sunt localizate cel mai frecvent la nivelul coloanei cervicale distale (C5/C6 ºi C6/C7) ºi la nivelul joncþiunii cervico-toracale. Acestea sunt însoþite foarte frecvent de instabilitate a coloanei vertebrale ºi risc crescut de a dezvolta deficit neurologic, astfel încât, de cele mai multe ori, intervenþia chirurgicalã este o necesitate. În acest articol, exemplificãm particularitatea fracturilor spinale pe fond de spondilitã anchilopoeticã, prezentând cazul unui pacient cu spondilitã, internat în secþia de traumatologie „Casa Austria”, Spitalul Clinic Judeþean de Urgenþã Timiºoara, cu traumatism vertebral cervical mielic ºi tetraplegie. Deoarece aceste leziuni duc de cele mai multe ori la deficit neurologic secundar, evaluarea imagisticã CT ºi RM a întregii coloane este recomandatã, chiar dacã simptomatologia clinicã este minorã. Dacã este prezentã o fracturã cervicalã, este necesarã stabilizarea chirurgicalã a coloanei vertebrale, iar procedura standard este de decompresie ºi apoi, stabilizare combinatã anterioarã ºi posterioarã. Stabilizarea strict anterioarã nu este recomandatã, deoarece o instabilitate a pilonului posterior al coloanei, poate fii de multe ori nedetectatã în fazã acutã. Ana-Maria Maxim 1 , D. Negoescu 2 , Maria Mogoºeanu 1 , Magda Pãscuþ 1 , F. Bîrsãºteanu 1 , D.V. Poenaru 3 Received for publication: 10.03.2009 Revised: 28.04.2009 1.- University of Medicine and Pharmacy „Victor Babeº” Timiºoara, Department of Radiology and Medical Imaging , 2 - Department of Traumatology „Casa Austria”, University County Hospital Timiºoara, 3 - University of Medicine and Pharmacy „Victor Babeº” Timiºoara, Department of Orthopedic Surgery and Traumatology II Journal of Experimental Medical & Surgical Research Cercetãri Experimentale & Medico-Chirurgicale Volume XVI Issue No.2 Year 2009 Pag.143 - 148

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Page 1: CHARACTERISTIC ASPECTS OF CERVICAL SPINE …jmed.ro/articole/12.pdf · characteristic aspects of cervical spine fractures in ankylosing spondylitis – case report 143 ... În fracturile

CHARACTERISTIC ASPECTS OF CERVICAL SPINE FRACTURES IN ANKYLOSING SPONDYLITIS

– CASE REPORT

143

E x p e r i m e n t a l

M e d i c a l S u r g i c a l

R E S E A R C H

J O U R N A L o f

Correspondence to: Ana-Maria Maxim, e-mail: [email protected]

ABSTRACT: Ankylosing spondylitis is a chronic, systemic, inflamatory disease, that affectsespecially the axial skeleton. In patients with spondylitis, the cervical segment of the spine is themost affected in trauma. The fracture risk appears even after a minor or mild traumatic event andthe rigidity of the spine, the kyphosis, the secondary osteoporosis, have a special contribution.The injuries are localized especially on the lower cervical spine, such as segments C5/C6 andC6/C7 and in the cervico-thoracic junction. Traumatic lesions on ankylosing spondylitis spine arecommonly succeeded by spine instability and high risk of secondary neurological deficiency, sothat surgical intervention is the most indicated. In this article, we reveal some of the specialaspects of the spine fractures in ankylosing spondylitis, illustrating a case of a patient withspondylitis, admitted in the department of traumatology „Casa Austria”, University CountyHospital Timisoara, with cervical spine trauma, spinal cord injury and tetraplegia, after a mediumintensity traumatic event. Patients with ankylosing spondylitis are highly susceptible to cervicalfractures, even after a minor or mild trauma. These lesions often lead to secondary neurologicaldeficits, so that CT or/and MR imaging evaluation of the whole spine is strongly recommendedregardless of whether mild initial clinical findings are present. In case of a cervical spine fracturedetection, the stabilization procedure is needed, and the standard management includes anteriordecompression and combined anterior-posterior stabilization. Anterior approach stabilizationalone is not indicated because instability of the posterior column may go undetected in the acutephase of the trauma.Keywords: ankylosing spondylitis, spine fractures, cervical spine trauma.

ASPECTE CARACTERISTICE ÎN FRACTURILE COLOANEI CERVICALE DIN SPONDILITAANCHILOZANTÃ - PREZENTARE DE CAZ

Rezumat:Spondilita anchilopoeticã este o afecþiune sistemicã cronicã ºi o boalã inflamatorie, cuo dezvoltare preponderentã la nivelul scheletului axial. Cel mai frecvent implicat traumatic, lapacienþii cu spondilitã, este segmentul cervical al coloanei vertebrale. Aceºtia sunt supuºi riscului de fracturã, în urma unor traumatisme de intensitate medie sau micã, datoritã cifozei, rigiditãþii ºiosteoporozei existente. Leziunile traumatice sunt localizate cel mai frecvent la nivelul coloaneicervicale distale (C5/C6 ºi C6/C7) ºi la nivelul joncþiunii cervico-toracale. Acestea sunt însoþitefoarte frecvent de instabilitate a coloanei vertebrale ºi risc crescut de a dezvolta deficitneurologic, astfel încât, de cele mai multe ori, intervenþia chirurgicalã este o necesitate. În acestarticol, exemplificãm particularitatea fracturilor spinale pe fond de spondilitã anchilopoeticã,prezentând cazul unui pacient cu spondilitã, internat în secþia de traumatologie „Casa Austria”,Spitalul Clinic Judeþean de Urgenþã Timiºoara, cu traumatism vertebral cervical mielic ºitetraplegie. Deoarece aceste leziuni duc de cele mai multe ori la deficit neurologic secundar,evaluarea imagisticã CT ºi RM a întregii coloane este recomandatã, chiar dacã simptomatologiaclinicã este minorã. Dacã este prezentã o fracturã cervicalã, este necesarã stabilizareachirurgicalã a coloanei vertebrale, iar procedura standard este de decompresie ºi apoi, stabilizare combinatã anterioarã ºi posterioarã. Stabilizarea strict anterioarã nu este recomandatã, deoarece o instabilitate a pilonului posterior al coloanei, poate fii de multe ori nedetectatã în fazã acutã.

Ana-Maria Maxim1,D. Negoescu2, Maria Mogoºeanu1, Magda Pãscuþ1, F. Bîrsãºteanu1, D.V. Poenaru3

Received for publication:

10.03.2009

Revised: 28.04.2009

1.- University of Medicine and Pharmacy „Victor Babeº” Timiºoara, Department of Radiology and Medical Imaging , 2 - Department of Traumatology „Casa Austria”, University County Hospital Timiºoara, 3 - University of Medicine andPharmacy „Victor Babeº” Timiºoara, Department of Orthopedic Surgery and Traumatology II

Journal of Experimental Medical & Surgical Research

Cercetãri Experimentale & Medico-Chirurgicale

Volume XVI · Issue No.2 ·Year 2009 · Pag.143 - 148

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INTRODUCTION

Ankylosing spondylitis is a chronic, systemic,

inflamatory disease, that affects especially the axial

skeleton. Usually, sacro-iliitis is the first clinical sign in

spondylitis. The positive diagnosis can be pronounced if a

grade 2, bilateral, or grade 3-4, ipsilateral, sacroiliitis is

present, in association with one of the modified

New-York criteria.

Modified New-York criteria are divided in clinical

criteria and radiological criteria. Clinical criteria: lower

back pain and stiffness for more than 3 months with

improvement after exercise; reduced mobility of the

lumbar spine in the sagittal and frontal axis; restriction of

the chest expansion (age and gender related).

Radiological criteria: sacroiliitis at least grade 2,

bilateral, or grade 3-4, ipsilateral.

It is considered that an autoimmune response

produces fibrosis and ossification of the spine ligaments

and joints, and finally, a fusion of the spinal segments.

One of the ankylosing spondylitis classifications is

described by Hehne and Zielke and is based on

radiographic findings: the presence of syndesmophytes

and the grade of anulus fibrosus and facet joints

ossification.

Ankylosing spondylitis type I (spondylathritis): simple

ossification of the vertebral bodies, without

syndesmophytes.

Type IIa (anulus type): incomplete anular ossification,

especially ventral, with or without lateral

syndesmophytes.

Type IIb (anulus type): complete anular ossification,

with syndesmophytes, that overlapp the vertebral disc

(complete).

Type IIIa (ligament/sub-ligament type): thick and wide

syndesmophytes (with cortical and spongiosa structure),

but not in all segments of the spine (incomplete).

Type IIIb (bamboo-spine): similar with type IIIa, but

multiple vertebral segments are affected (especially on

lumbar and thoracic spine).

The development of kyphosis, spinal rigidity and

secondary osteoporosis leads to biomechanical changes

of the spine. Reduced muscle activity and increased

muscle degeneration produce an overall loss of muscle

strength.

All the pathological changes in ankylosing spondylitis

spine have a special contribution in the characteristic

pattern of traumatic spinal injuries and explain the

fracture development even after a minor trauma

mechanism.

The risk of traumatic injuries increases, especially in

the presence of complete rigidity of the spine, such as in

ankylosing spondylitis type IIb, IIIa and IIIb, by Hehne and

Zielke. In these cases, there is a high rate of neurological

complications.

Although vertebral fractures on ankylosing spondylitis

spine reveal a low prevalence, even in trauma centers

with high case load of spine trauma, these types of

injuries draw a special attention because of the specific

and uncommon fracture pattern, sometimes grotesque,

the high rates of neurological complications and the

challenging surgical management.

The disease prevalence, translated in male to female

ratio is 2,5:1 and the incidence of traumatic spine injuries

is higher in males (1).

In patients with spondylitis, the most affected in

trauma is the cervical segment of the spine. Like we said,

the rigidity of the spine, the kyphosis, the secondary

osteoporosis, that appear in the evolution of the disease,

all have a special contribution in fracture risk (2). The

injuries are localized especially on the lower cervical

spine, such as segments C5/C6 and C6/C7 and in the

cervico-thoracic junction (1). Traumatic lesions on

ankylosing spondylitis spine are commonly succeeded

by spine instability and high risk of secondary

neurological deficiency.

Usually, traumatic injuries of the spine with ankylosing

spondylitis involve all vertebral stability columns, so that

surgical intervention is the most indicated (3).

PURPOSE

To portray the special pattern of spine fractures in

ankylosing spondylitis, in this article we present the case

of a patient with cervical spine injuries in ankylosing

spondylitis, after a medium intensity traumatic event.

These lesions affect all anterior and posterior vertebral

structures, with secondary spine column instability.

MATERIAL AND METHODS

The patient R. L. M. (male, 56 years old) came in the

Department of Traumatology „Casa Austria”, University

County Hospital Timisoara, on October 2006 (observation

chart number 14186/30.10.2006). The diagnosis was

cervical spine trauma with spinal cord involvement and

tetraplegia.

The patient suffered a car accident (driver), but the

traumatic stress was of medium intensity. R.L.M. was

known with ankylosing spondylitis diagnosis.

At the arrival in the emergency department, the patient

was conscious, but with tetraplegia, pain in the cervical

144

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region, acute respiratory impairment. On local

examination, edema of the cervical soft tissues, with

latero-cervical bilateral hematoma and bony structures

luxation were evident.

Concerning impaired clinical status, the patient was

investigated imediately to quantify the spinal cord

injuries, post-traumatic lesions of the vessels, ligaments

and adjacent soft tissues, using magnetic resonance

imaging (MRI) of the cervical spine and angio-MRI

technique (General Electric – GE machine, 1 Tesla).

MRI images show burst fracture of C6 vertebrae,

fracture of the C7 vertebrae, loss of the normal alignment

of the cervical vertebral bodies, with anterior

displacement of the distal bony structures, because of a

complete fracture of the cervical spine on C6/C7 level,

anterior listesis of C7 vertebral body on T1.

MRI could also visualize the spinal cord injury along C4

to T1 levels and the compresion of spinal cord at the level

of the complete fracture (Fig. 1, Fig. 2, Fig. 3, Fig. 4). The

anterior and posterior ligamentary structures were

disrupted and a masive hematoma was visible, with

anterior and lateral displacement of adjacent structures.

The angio-MRI investigation shows the absence of

vascular flow on left vertebral artery (Fig. 5, Fig. 6).

145

Fig. 1: MRI image axial plane, T2 FSE sequence, evident -masive cervical medium fascia hematoma, with anteriorand lateral displacement of adjacent structures, spinal cordlesion, absence of vertebral artery flow.

Fig. 2: MRI image axial plane, T2 FSE sequence, evident –bone and adjacent soft tissue traumatic injuries.

Fig. 3: MRI image axial plane, T2 FSE sequence, evident –bone and adjacent soft tissue traumatic injuries.

Fig. 4: MRI image sagital plane, T2 FSE sequence, evident –C6, C7 vertebral fracture, with listesis, tear of the anteriorand posterior longitudinal ligaments, disruption of theposterior ligamentary structures, pre-vertebral hematomawith soft tissue displacement, spinal cord injury along C4 toT1 vertebral bodies and spinal cord compression at C6/C7level

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The pacient is intubated, with assisted ventilation,

hemodynamic equilibration, tracheostomy, but his

clinical status reveals a continuous impairment, until

unresponsive cardiac arrest.

RESULTS AND DISCUSSIONS

Pathological changes in ankylosing spondylitis

(ligament ossification, syndesmophytes, hyper-kyphosis

with rigidity) affect the normal biomechanical

characteristics of the spinal column. The fused spine is

incapable of appropriately dissipating the energy of a

traumatic event and in association with osteoporotic

bones, increase the susceptibility to vertebral fractures,

even after a minor trauma event (1,4).

Some authors made a synthesis of factors that

increase the fracture risk in spine with spondylitis (1).

These factors include: gender (especially males), age,

low body mass index, osteoporosis, disease duration,

degree of syndesmophyte formation, joint involvement,

increased restriction of vertebral column mobility, grade

of kyphosis (4).

The most frequent injury mechanism implicated in

spine fractures related with ankylosing spondylitis is

flexion with hyperextension. The torsion mechanism is

rare, but if present, the traumatic lesions developed are

unstable (1).

The incidence of spinal cord injuries after trauma in

patients with spondylitis is higher (84% of all spinal cord

lesions) than spinal cord injuries in general population

(55%) (4).

Because of the special pattern (atypical and complex)

of vertebral fractures in the rigid spine, the classical

classification of these lesions is hardly applicable.

Cornefjord et al. consider that cervical spine fractures

on ankylosing spondylitis changes are due to

hyperextension on a rigid and distorted vertebral column.

The fracture line could pass through the calcified

intervertebral discus or through the vertebral body, but

more frequent are those through discal space. The rate of

associated neurological complications, including

complete paraplegia, is high. After a minor trauma, the

injuries could be localized only at the anterior structures

of the spine, but with a permanent risk of secondary

extension in the posterior column structures (1).

Frequently, in patients with ankylosing spondylitis, the

detection of cervical fractures is delayed, therefor the risk

of secondary neurological impairment is higher. Also, the

neurological complications often develop over time. The

delayed fracture detection could be due to the minor pain

(usually, minor trauma event), grotesque changes of the

spine in spondylitis (5). So, the recommendation is of a

concise and proper radio-imaging evaluation of the spine

(1).

The first option imaging procedure is the plain film of

the cervical spine, in at least two views. Sometimes,

additional views are required – for occipito-cervical and

cervico-thoracic junctions (1,6). The execution of

radiograms is difficult by reason of spine rigidity and the

visualization of the fracture lines is also difficult because

of the osteoporosis.

Finfelstein et al. showed some of the causes of missed

fractures on conventional radiogram: pathological

changes in the normal anatomy of the spine, extra-bone

formation, ligament ossification, osteoporosis, minor

146

Fig. 5: Angio-MRI image axial plane, 3DTOF SPGRsequence, evident - absence of vascular flow on leftvertebral artery.

Fig. 6: Angio-MRI image axial plane (lower cervical sectionthan in Fig. 5), 3DTOF SPGR sequence, evident - absence of vascular flow on left vertebral artery

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trauma, no displacement, difficult visualization of the

cervico-thoracic junction.

The plain film can visualize fractures of the anterior

column of the spine (exception – occult fractures),

rupture of the anterior longitudinal ligament

(consequence of calcification), fractures of the cervical

spinous processes. Fractures of the posterior column of

the spine, fractures of the facet jonts, ruptures of the

posterior longitudinal ligament and soft tissues injuries

are difficult to see on the plain film.

Before the use of MRI, the diagnosis of spinal fractures

on ankylosing spondylitis was difficult, in the absence of

neurological damage (6).

MRI has a special contribution in imaging evaluation of

the ligaments, intervertebral discs and the spinal cord.

MRI could visualize the bone edema – an indirect sign of

an occulte fracture (1,6); intraspinal bleeding

(hematoma) – usually seen in these cases because of the

solid fixation of epi- and peridural veins with the fibrotic

or ossified tissue (1).

Diagnostic MRI images could be obtained using a

flexible multipurpose coil if the use of standard coil is

impossible due to a excessive kyphosis or a rigid collar

(7).

In comparison to MRI, CT of the spine requires shorter

scanning time and is of better quality in evaluation of

detailed bony injuries and fragment displacement (6). The

new-generation of CT scanners, with multiplanar

reconstruction posibility (3D-CT), offer a high quality

imaging evaluation of spinal fractures (extent of the

lession and details).

Multislice-CT (MDCT), with slice thickness of 2 mm

and multiplanar reconstruction ability, is helpfull for the

visualization of the fine fracture lines (1,6,8).

Frequently discussed by literature are the multi-level

spine fractures, asymptomatic or with minimal clinical

appearence. In consequence, often comes the indication

of imaging evaluation of all the spine (CT or/and MRI) –

because of associated lesions on different spinal levels

(for example, the association of cervical segments

traumatic injuries with lombar spine injuries) (5).

Concerning treatment procedures, both non-operative

and operative management are accepted. Indications of

surgical intervention treatment include: instability of the

spine, incorrect posture, pain and neurological deficit.

The surgical procedure is aimed on spine stabilization and

single posterior or a combined anterior-posterior

approach are preferred (1).

Due to the traumatic injuries on the spine with

ankylosing spondylitis, that have a high prevalence of

instability, the recommendation of non-operative

treatment strategies is controversial (5).

Some authors are considering that adequate

stabilization and realignment of the cervical spine with

spondylitis is obtained with surgical fixation, the

approach being in correlation with fracture localization:

anterior intervention – the injury is localized anteriorly;

posterior – in posterior localized lesions and 360 degree

fixation – if all vertebral stability pylons are damaged.

The acute traumatic lesions, without spinal

deformities, could be managed by anterior or posterior

fusion, depending on fracture location.

Patients with spinal post-traumatic deformities and

tears/deformities developed over time, are therapeuticaly

managed applying a fracture reduction procedure and

realignment of the vertebral bodies, using traction

maneuvers. If the reduction is obtained, but the spinal

deformity stil exists, posterior and, possibly, anterior

fusion are indicated. If a pronounced spinal deformity

(such as chin on chest) persists, the cervical traction

maneuver is prolonged (several days, with low traction

weight) and/or an anterior wedge release via osteotomy

is indicated and restoring of cranio-cervical alignment

with posterior spinal fusion.

The posterior spinal fusion uses lateral masses

approach and iliac bone fusion graft, for safety fixation

(9). Some authors, recommend the use of a special

cement for fusion (5).

In the majority of cases, a high rate of instability is

present, on account of injured posterior elements of the

spine and tearing of the interspinal ligament, so that

posterior stabilization is needed and must encompass a

sufficient number of vertebral segments. Implants for

posterior instrumentation include hook-based plates,

wire loops, and internal fixation devices like flexible

internal fixators or plates.

If the surgical management consists of combined

anterior and posterior stabilization, the decision of

performing the intervention in one session or two,

depends on the individual case and surgeon’s standard

procedure. Laminectomy could be performed on cases

without instability (1).

The decision and the type of surgical management

procedure in patients with ankylosing spondylitis

depends on fracture localization, if one or more spinal

levels are affected, if the injury is acute or chronic, if the

instability is present, evidence of displacement, degree of

spinal cord damage (6).

However, the anterior-posterior stabilization becomes

the procedure of choice in cases of trauma on ankylosing

spondylitis spine, with marked column instabilities (5).

147

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The literature based evidence shows that clinical

evolution of the patients with ankylosing spondylitis and

spine fractures is less positive than in patients with

normal spine fractures (10). Regardless the surgical

procedure, patients with spondylitis cumulate a higher

risk of surgical procedure’s complications (1,9). The

following have been reported: high risk of epidural

hematoma and bleeding (6,9), implant failure (40%-50%

cases) (5), septic problems (30%) (1,5) and death

(30%-75%) (4,5).

In conclusion, we can state that patients with

ankylosing spondylitis are highly susceptible to cervical

fractures, even after a minor or mild trauma. These

lesions often lead to secondary neurological deficits, so

that CT or/and MRI imaging evaluation of the whole spine

is strongly recommended, regardless of whether mild

initial clinical findings are present.

In case of a cervical spine fracture detection, the

stabilization procedure is needed, and the standard

management includes anterior decompression and

combined anterior-posterior stabilization. Anterior

approach stabilization alone is not indicated because

instability of the posterior column may go undetected in

the acute phase of the trauma. Further follow-up imaging

studies are necesary (1).

Any patient with new complaint neck or back pain,

with or without neurologic deficit, should be treated as if

he/she has an unstable spine fracture, until proved

otherwise (6).

148

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