Treatment of fracture and complication of cervical spine with ankylosing spondylitis

Abstract

A 43-years old male su ered a fracture of his cervical spine at C 5/6 followed by tetraplegia below C 5. At the time of the accident his spine was a ected by ankylosing spondylitis which had been present for several years. Decompression was done in a regional hospital with fusion between cervical vertebrae 5 and 6 (bonegraft) and stabilization between 5 and 7 (Codman-plate) by a ventral approach. In addition dorsal fusion was performed with wires and bone-chips. He developed aspiration pneumonia and arti®cial ventilation was necessary via a tracheal stoma. After transfer to the Spinal Cord Injury Center we found some pills and a tooth in the lungs. Several attempts were necessary to remove them by bronchoscopy. After ®nishing ventilation, radiological exploration demonstrated a severe dislocation of the fracture. Screws and implant had been torn o . Because of infection of the stoma we performed stabilization in a Halo-®xator with body-jacket and extended the cervical spine some millimeters every day until we obtained a nearly correct position. Meanwhile the patient was mobilized with physio-and occupational therapy. Eight weeks after the accident the ®xator could be removed and the fracture was stable. The patient developed a 3 to 4 cm diameter pressure sore localized to the left shoulder and this was treated conservatively. Removing of the dislocated material is planned because of pressure to the oesophagus.Conclusion: We believe this procedure avoids infection of the implant by open stoma in case of a new stabilizations approach. First opinionFractures of the ankylosing spine (Bechterew's disease) always lead to an instability in all directions (¯exion, extension and rotation) which means that surgical procedures must compensate in every direction of instability bearing in mind that the bone density in these patients is poor due to the accompanying osteoporosis. This type of spinal fracture resembles fractures of the long bones. As mobility of the spine does not have to be considered, long plating distances can be chosen; at least two, sometimes more segments above and below the lesion with screws in each vertebral body. The primary surgeons used the 4th and 7th cervical body to anchor the plate, but did not screw additional bodies and missed penetrating the posterior wall. As angular stability between plate and screw was not provided, secondary angulation and pull out was a potential problem despite posterior sublaminar wiring by titanium cables. Wiring in osteoporotic bone is not advisable, as the wires cut through, so that a transarticular plating for a combined reconstruction should be used.It is not known at which time the re-dislocation occured exactly, as this was only noted after treatment in the intensive care unit. Possibly the repeated bronchoscopies under di cult conditions in an ankylotic spine were the reason for the dislocation.Despite the tracheostomy I would have revised the dislocation surgically removing the dislocated plate and screws, and reducing the dislocation again, then using an ante...

Posterior fixation of subaxial cervical spine fractures in patients with ankylosing spondylitis

“…Several treatment obstacles have to be surmounted. The ossified spine in ankylosing spondylitis is more easily susceptible to fractures than non-ossified spines, due to changed biomechanics with long lever arms, pre-existing kyphotic deformity and often severe osteoporosis [12,32]. The cervical spine is the most common site of spine fractures in patients with ankylosing spondylitis, accounting for about 75% of the spinal fractures in these patients [22].…”

“…In several series, using anterior plating or lateral mass screws, screw-loosening and screw pull-out have been demonstrated [8,12]. The Olerud cervical fixation system (OC) (Anatomica AB, Askim, Sweden), with cervical pedicle screws and rods, gives an opportunity to create a more rigid and biomechanically stable osteosynthesis than the previously mentioned methods [33].…”

“…However, disadvantages and complications have been demonstrated with all these methods [8,12,22,40].…”

Management of cervical spine fracture in patient with advanced ankylosing spondylitis using SOMI brace

“…The displacement occurs mostly in hyperextension, which is most dangerous with regard to spinal cord compression. 6,9,16,17,20,23 Injured AS spine should be immobilised in the position it typically presents in. Modification of standard technique, such as elevation of the head with sandbags on each side, as well as halo cast immobilisation with kyphotic bars will assist in safely immobilising the patient.…”

Fractura transdiscal y subluxación C5-C6 en paciente con espondilitis anquilopoyética

“…En los estudios de RM efectuados no se realizaron secuencias postcontraste, aunque sí secuencias de supresión grasa; se ha demostrado que ambas son de gran utilidad en la evaluación del espacio dural y epidural 22 . La terapéutica de este tipo de fracturas es controvertida 6,3 . La literatura actual promueve tanto medidas conservadoras como quirúrgicas.…”