Surgical Management of Lower Cervical Spine Fracture in Ankylosing Spondylitis

Management of Thoracolumbar Vertebral Fractures and Dislocations in Patients with Ankylosing Conditions of the Spine

Ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) are bone-forming spinal conditions which inherently increase spine rigidity and place patients at a higher risk for thoracolumbar fractures. Due to the long lever-arm associated with their pathology, these fractures are frequently unstable and may significantly displace leading to catastrophic neurologic consequences. Operative and non-operative management are considerations in these fractures. However conservative measures including immobilization and bracing are typically reserved for non-displaced or incomplete fractures, or in patients for whom surgery poses a high risk. Thus, first line treatment is often surgery which has historically been an open posterior spinal fusion. Recent techniques such as minimally invasive surgery (MIS) and robotic surgery have shown promising lower complication rates as compared to open techniques, however these methods need to be further validated.

Traumatic lateral atlantoaxial dislocation combined with a type II odontoid fracture in a patient with ankylosing spondylitis: A case report

RATIONALE

Traumatic lateral atlantoaxial dislocation (AAD) combined with an odontoid fracture is extremely rare. The standards applicable to management of the traumatic lateral AAD are still in flux due to the infrequency of this injury.

PATIENT CONCERNS

We present a unique case of traumatic lateral AAD combined with a type II odontoid fracture in a patient with ankylosing spondylitis (AS).

DIAGNOSIS

Spinal computed tomography showed ankylosis of the entire spine from the sacroiliac joint to the cervical spine. On the cervical X-ray the head was rotated to the right with anterior subluxation of the C1 and odontoid tip relative to C2. The coronal computed tomography (CT) scan also revealed left lateral dislocation of C1 on C2 with a horizontal translation of the odontoid tip. On the axial and sagittal CT scan, the left C1 lateral mass was displaced anteriorly and locked by C2 body.

INTERVENTIONS

We performed occipito-cervical fusion (OCF) after successful manual reduction under general anesthesia.

OUTCOMES

The patient's recovery from surgery was uneventful and without complication. At the 3 year follow-up the patient was asymptomatic and reportedly satisfied with the surgery.

LESSONS

Traumatic AAD with an odontoid fracture is an exceedingly uncommon cervical spine injury. A lateral subluxation with a type II odontoid fracture in a patient with AS is rarer still, so much so that this type of subluxation was not classifiable using any of the previously developed classification systems. In this patient with AS, posterior OCF with internal fixation was necessary to avoid hardware failure, particularly in light of the intensive stress caused by AS.

Classification and Treatment for Cervical Spine Fracture with Ankylosing Spondylitis: A Clinical Nomogram Prediction Study

Objective

Through the follow-up analysis of cervical spine fracture cases with ankylosing spondylitis (AS), a treatment-oriented fracture classification method is introduced to evaluate the clinical efficacy guided by this classification method.

Method

A retrospective analysis was performed on 128 AS patients who underwent comprehensive treatment in the Spine Surgery Department of Qingdao University Hospital from January 2009 to May 2018. Statistics of patient demographic data, distribution of different fractures corresponding to surgical methods, 3-year follow-up outcomes, and summary of objective fracture classification methods were analyzed. A prospective 5-year follow-up study of 90 patients with AS cervical spine fractures from June 2015 to August 2020 was also included. Statistical differences on the distribution of factors such as case information, cervical spine sagittal sequence parameters, and fracture classification were assessed. Correlations between surgical information, American Spinal Injuries Association grade (ASIA), modified Japanese Orthopaedic Association scores (mJOA), and other factors were analyzed to establish a nomogram predictive model for curative effect outcomes. Overall, three major types and the four subtypes of AS cervical spine fractures were evaluated based on the clinical efficacy of the classification and the selection of surgical treatment methods.

Result

The most common type of fracture was type II (30 cases, 33.33%), most of the subtypes were A (37 cases), followed by B (36 cases) and C (17 cases). Twenty-four of 28 patients with type I underwent anterior surgery, and 47 of 62 patients with type II and III underwent posterior surgery. The average follow-up time was 25.76 ± 11.80 months. The results of predicting clinical variables are different but include factors such as fracture type and subtype, type of operation, and age. The predictor variables include the above-mentioned similar variables, but survival is more affected by the fracture type of the patient.

Conclusion

This predictive model based on follow-up information delineation points out the impact of ankylosing spondylitis cervical spine fracture classification on surgical selection and clinical efficacy.

Surgical Treatment for Cervical Spine Fracture in Patients With Ankylosing Spondylitis: Single Posterior Approach or Combined Anterior-posterior Approach?

STUDY DESIGN

A retrospective single-center study.

OBJECTIVE

We aimed to compare the clinical outcomes of cervical spine fracture accompanied with ankylosing spondylitis (ASCSF) treated by single posterior approach (PA) and combined anterior-posterior approach (CA) for patients who were followed up for >1 year.

SUMMARY OF BACKGROUND DATA

For ASCSF patients, surgical treatment has been widely accepted as a recommendable therapeutic option. But the optimal surgical approach is still under controversy, and few studies have focused on the comparison between PA and CA.

MATERIALS AND METHODS

From February 2007 to March 2019, 53 patients were enrolled and divided into the PA group (34 cases) and CA group (19 cases). Their general characteristics and clinical materials were recorded. From the aspects of reduction distance, bone fusion, neurological functional restoration, and postoperative complications, patients' surgical outcomes were evaluated qualitatively and quantitatively.

RESULTS

The reduction degree of dislocation (mean PA=2.05 mm, mean CA=2.36 mm, P=0.94) was close between the 2 groups. Besides, with a similar follow-up period (P=0.10), the rate of bone fusion (both 100%) and neurological functional restoration (PA=31.03%, CA=35.29%, P=0.77) were also without significant difference. The occurrence rate of postoperative complications tended to be higher in the CA group (31.58% vs. 23.53%) but with no significant difference (P=0.52). Nevertheless, the surgical duration time (mean=209.15 min) and blood loss (average=388.91 mL) of PA group were significantly less than CA group (mean duration time=285.34 min, mean blood loss=579.27 mL) (P<0.01).

CONCLUSIONS

Compared with to the CA approach and with the equally significant outcome, surgery by single PA was feasible and should be positively recommended for ASCSF patients, especially for those accompanying with a severe chin-on-chest deformity or poor physical conditions which restrain patients from tolerating a long surgery or major surgical trauma.

Different fixation pattern for thoracolumbar fracture of ankylosing spondylitis: A finite element analysis

The objective of this study is to establish an ankylosing spondylitis (AS) thoracolumbar fracture finite element (FE) model and provide a proper posterior fixation choice from the biomechanical perspective. The ankylosing spondylitis T9-L5 FE model was built and the range of motion (ROM) was compared to previous studies. The L1 transverse fracture was simulated and was separately fixed by five different patterns. The pull force and yielding force of the screws, the von Mises stress of the internal fixation, and the displacement of fracture site were analyzed to evaluate the proper fixation pattern for thoracolumbar fracture of AS. ROM of AS model was obviously restricted comparing to the normal vertebral experimental data. All the fixation patterns can stabilize the fracture. At least four levels of fixation can reduce the von Mises stress of the internal fixation. Four levels fixation has a higher pull force than the six levels fixation. Skipped level fixation did not reduce the stress, pull force and yielding force. The kyphosis correction did not change the biomechanical load. At least 4 levels fixation was needed for AS thoracolumbar fracture. The cemented screws should be chosen in 4 levels fixation to increase the holding of the screws. The skipped fixation has no advantage. The kyphosis correction can be chosen after weighing the pros and cons.

Management of cervical fractures in ankylosing spondylitis patients: immediate fixation effort via vertebroplasty with one-staged combined anterior and posterior fixation

The ankylosed spine is prone to fracture even as a result of minor trauma due to its changed biomechanical properties. Fractures in ankylosing spondylitis (AS) patients are highly unstable and surgical intervention for fixation is warranted. Implant failure rates are high and combined anterior and posterior fixation is required to enhance the fixation outcome. For fusion, anterior interbody fusion or posterior bone graft fusion is often adopted. Here, we introduce a new method which combines vertebroplasty with anterior and posterior approaches to improve pain control, facilitate the long-term fixation outcome and mechanics, and decrease perioperative risks with prompt stabilization, especially in patients with spine curve deformity. Here, we present two AS cases with cervical spine fracture treated with this new method.

Percutaneous surgery for thoraco-lumbar fractures in ankylosing spondylitis: Study of 31 patients

BACKGROUND

The risk of vertebral fracture is increased 4-fold in patients with ankylosing spondylitis (AS). Diagnostic challenges and the vulnerability associated with AS combine to generate high morbidity and mortality rates. The objective of this study was to assess the outcome of percutaneous thoraco-lumbar fracture surgery in patients with AS, in terms of quality of life, fracture healing, and complications.

HYPOTHESIS

Percutaneous surgery used to treat thoraco-lumbar fractures in patients with AS reliably provides fracture healing, preserves self-sufficiency, and minimises post-operative complications.

METHODS

Two centres included 31 patients with AS who were managed by percutaneous surgery for thoraco-lumbar fractures in 2013-2015. The data were reviewed retrospectively, although admission data were collected prospectively. Clinical outcomes were assessed by comparing the values at baseline and last follow-up of three variables: the Parker score, the visual analogue scale (VAS) pain score, and the EuroQol five dimensions (EQ-5D) quality-of-life score. Computed tomography was performed 1 year after surgery to evaluate bone healing, screw position, and implant loosening. Intra- and post-operative complications were recorded.

RESULTS

The 31 patients had a mean age at surgery of 75.1 years, a mean follow-up of 35.6 months, and a minimum follow-up of 12 months. Three patients died during follow-up. Mean hospital stay duration was 6 days. Cemented screw fixation was used in 18 patients. At last follow-up, all patients had recovered their self-sufficiency; the mean Parker score was 7.14, compared to 6.73 at baseline, the mean VAS pain score was 1.8, and the mean EQ-5D score decrease versus baseline was 0.07 (P=0.02). Bone healing was consistently achieved. Loosening of an uncemented pedicle screw was noted in 1 patient. Of the 228 screws implanted, 6 (2.6%) were improperly positioned, including 1 within the spinal canal in a patient free of neurological manifestations. Asymptomatic cement leakage was noted in 2 patients.

DISCUSSION

Percutaneous fixation of thoraco-lumbar fractures in patients with AS is a reliable method that produces a high healing rate and allows prompt patient mobilisation with preservation of self-sufficiency. The post-operative complication rate is low.

LEVEL OF EVIDENCE

IV, retrospective observational study.

The treatment strategies for spine fractures in patients with ankylosing spondylitis: A case report

PURPOSE

The aim of the study was to explore surgical strategies for effectively treating spine fractures in patients with ankylosing spondylitis (AS) and investigate the postoperative outcomes.

METHODS

We retrospectively analyzed 9 patients with AS that was complicated by spine fractures, who underwent surgery at our spine and spinal cord clinic between 2005 and 2012. The surgical methods included posterior instrumentation and bone grafting, with or without decompression. Fracture healing and neurological function recovery were observed postoperatively. The average follow-up period was 45.1 months (range: 24-60).

RESULTS

The 9 patients included 7 men and 2 women. Eight patients were treated with long posterior fixation. One patient underwent combined long posterior fixation and anterior bone grafting. The neurological function of these patients improved significantly to varying degrees after surgery, and fracture union and segmental instability of the lumbar vertebrae were radiologically confirmed at the 1-month and 2-year follow-up intervals. Severe surgery-related complications were not observed.

CONCLUSIONS

Posterior instrumentation with bone grafting was a satisfying method for treating spine fractures in patients with AS.

Mini-open anterior approach for cervicothoracic junction fracture: technical note

Elderly patients with diffuse idiopathic skeletal hyperostosis are at high risk for falls, and 3-column unstable fractures present multiple challenges. Unstable fractures across the cervicothoracic junction are associated with significant morbidity and require fixation, which is commonly performed through a posterior open or percutaneous approach. The authors describe a novel, navigated, mini-open anterior approach using intraoperative cone-beam CT scanning to place lag screws followed by an anterior plate in a 97-year-old patient. This approach is less invasive and faster than an open posterior approach and can be considered as an option for management of cervicothoracic junction fractures in elderly patients with high perioperative risk profile who cannot tolerate being placed prone during surgery.

Posterior pedicle screw fixation to treat lower cervical fractures associated with ankylosing spondylitis: a retrospective study of 35 cases

Background

The most common site of fractures in patients with ankylosing spondylitis (AS) is the cervical spine, especially the lower cervical spine and cervicothoracic junction. The optimal treatment for cervical spine fractures secondary to AS is controversial. This study aimed to explore the effects of posterior pedicle screw fixation alone on fractures of the lower cervical spine in patients with AS.

Methods

From January 2006 to January 2013, a total of 35 patients with AS and a lower cervical spine fracture were treated using only posterior cervical/thoracic pedicle screw fixation. In this retrospective study, we reviewed the patients’ charts to assess their case histories, operations, neurological outcomes, and complications. We also evaluated their postoperative radiographs to determine the time of bone fusion.

Results

Altogether, 32 (91.4%) of the 35 fractures resulted from an acute injury and 3 (8.6%) from a chronic injury. In 25 cases, the fracture resulted from a low-energy spinal injury and in 8 cases from a high-energy injury. Posterior pedicle screw fixation was successful in all patients, with radiographic fusion confirmed by computed tomography. The average time of bone fusion was 3.6 months (range 3 − 6 months). The surgery improved the American Spinal Injury Association grade in 15 (42.9%) patients. No intraoperative complications occurred. None of the corrections resulted in neurological decompensation. The average postoperative correction was 18°.

Conclusions

Pedicle screw fixation and autologous bone grafting through a single posterior approach to lower cervical spine fractures in AS patients could stabilize the spine, correct kyphosis, and relieve pressure. It is thus reasonable to recommend this surgical strategy for AS-associated fractures of the lower cervical spine.

Trial registration

Not applicable.

Single anterior approach for cervical spine fractures at C5-T1 complicating ankylosing spondylitis

OBJECTIVES

To evaluate the outcomes of anterior approach for cervical spine fractures at C5-T1 in patients with ankylosing spondylitis (AS) and study the problems encountered in diagnosis and treatment.

PATIENTS AND METHODS

Ten patients with AS (all males; mean age 43.7±9.4 years) underwent anterior surgeries to treat fractures at C5-T1. Skull tractions were performed on patients with fracture dislocation preoperatively. After operation, all the patients wore a cervical collar for 3 months. Plain radiographs at follow-up were reviewed. If bone fusion could not be confirmed on plain radiograph, CT scan was employed. The pre- and postoperative neurological statuses were evaluated according to the Frankel grading system. Problems encountered in diagnosis and treatments were analyzed.

RESULTS

The mean follow-up was 41.2±22.7months. After operation, the displacements of fractures were significantly reduced(P<0.05). Bone fusions were observed in 9 patients at final follow-up. Frankel grades improved by 1.0±0.7 grade (P>0.05). Posterior complications occurred in four patients, including implants failure (n=1), subsidence of cage (n=1), hoarse voice (n=1) and pneumonias (n=2). The patient with implants failure required revision surgery and anterior-posterior fixation. Patient with subsidence of the titanium cage achieved bone fusion with prolonged cervical collar immobilization.

CONCLUSION

The diagnosis and treatment of cervical spine fractures at C5-T1 in AS patients are challenging, with high risk of neurological compromise and postoperative complications. The single anterior approach followed by postoperative immobilization with a cervical collar can yield acceptable results if the cases are properly selected.

Cervical spine surgery in ankylosing spondylitis: Review and current concept

Ankylosing spondylitis of the cervical spine is associated with stiff kyphosis and increased risk of transversal unstable fracture. A spine surgeon may be involved mainly in the management of trauma cases, but in some situations, corrective surgery of a kyphotic cervical deformity is needed. Both types of cases carry specific aspects and rely on principles that differ from those associated with more common cervical surgery. This paper is a review of the literature regarding cervical surgery in cases of ankylosing spondylitis. It addresses practical technical questions.

Multiple noncontiguous spinal fractures and occipitocervical dislocation in a patient with ankylosing spondylitis treated with a hybrid open and percutaneous spinal fixation technique: a case report

BACKGROUND CONTEXT

Spinal fractures occur with a greater frequency in ankylosing spondylitis (AS) patients. Treatment of these fractures is complicated because of a higher incidence of medical comorbidities, higher rate of neurologic deficits, and higher risk of neurologic deterioration.

PURPOSE

To report a case report of a novel, combined open and percutaneous surgical techniques used for the treatment of multiple noncontiguous spinal fractures in a patient with AS.

STUDY DESIGN/SETTING

We describe the surgical treatment and the outcome of a patient with AS that sustained an occipitocervical dislocation and two noncontiguous three-column extension injuries using a hybrid technique with open occipital to T3 fusion and percutaneous T5-L1 instrumentation at a tertiary care facility.

PATIENT SAMPLE

A 77-year-old man with multiple comorbidities and newly diagnosed AS.

OUTCOME MEASURES

Two-year clinical and radiographic outcome of a patient treated surgically for multiple spine injuries in the setting of an ankylosed spine.

METHODS

The patient was treated with a hybrid approach using both open fusion and percutaneous instrumentation techniques.

RESULTS

At 2 years postoperatively, the patient had recovered ambulatory ability and had a good clinical outcome.

CONCLUSIONS

We describe a unique case of noncontiguous spinal trauma in a medically complex patient with AS treated with a hybrid open and percutaneous technique to minimize surgical insult and blood loss, with a good clinical and radiographic outcome 2 years postoperatively.

Percutaneous dorsal instrumentation for thoracolumbar extension-distraction fractures in patients with ankylosing spinal disorders: a case series

BACKGROUND CONTEXT

Thoracolumbar extension-distraction fractures are rare injuries mainly restricted to patients suffering from ankylosing spinal disorders. The most appropriate surgical treatment of these unstable spinal injuries remains to be clarified.

PURPOSE

To report on a cohort of 10 patients treated with closed reduction and percutaneous dorsal instrumentation.

STUDY DESIGN

Case series.

PATIENT SAMPLE

Ten consecutive patients with ankylosing spinal disorders and thoracolumbar extension-distraction fractures (Type B3 according to the AOSpine Thoracolumbar Spine Injury Classification System).

OUTCOME MEASURES

Postoperative reduction, alignment, and implant position were analyzed by computed tomography. Loss of reduction was assessed on lateral radiographs by using the Cobb technique. Ambulation ability and pain were assessed at follow-up.

METHODS

Minimally invasive dorsal percutaneous instrumentation was performed in 10 consecutive patients (3 men, 7 women) with a mean age of 81.5 (range 72-90) years between May 2010 and December 2012. The mean postoperative follow-up time was 7.9 (range 4-28) months.

RESULTS

All 10 patients were treated with closed reduction and dorsal instrumentation; in no case was conversion to an open approach required. The mean operation time was 60.2 (range 32-135) minutes. None of the patients presented neurologic deficits. Cement-augmented screws were implanted in two cases. Sufficient radiographic correction was achieved in all patients; no case of loss of reduction was noted at final follow-up. In one case, complete hardware removal was performed 9 months after the index operation because of persistent back pain at the level of the implant. One patient died of postoperative inferior vena cava obstruction. At discharge, all patients were able to ambulate without the need for crutches or opioid analgesics. At final follow-up, all patients ambulated with full weight bearing; four patients reported persistent back pain.

CONCLUSIONS

In fragile patients with ankylosing spinal disorders and thoracolumbar extension-distraction fractures, closed reduction and percutaneous dorsal instrumentation provide a satisfying midterm functional outcome while minimizing perioperative risks compared with conventional dorsoventral procedures.

Surgical treatment of lumbar hyperextension injury in ankylosing spondylitis

Ankylosing spondylitis (AS) is a chronic systemic and inflammatory rheumatic disease with a variable course of the axial skeleton. Spinal involvement may accompany ossification of the ligaments, intervertebral disc, end-plates and apophyseal structures, and seems to be "bamboo spine". Because of these natures of the spine in AS, a spinal fracture can be occurred with minor trauma or spontaneously. The fracture of the AS can cause neurological complications extremely high, so special attention to prevent neurological deterioration. Operative management of the injured spine with AS is difficult, and associated with a high complication rate. Extreme care must be taken for surgery to prevent secondary neurological deterioration.

Surgical experience of neglected lower cervical spine fracture in patient with ankylosing spondylitis

The management of lower cervical fractures in patients with ankylosing spondylitis (AS) differs from normal cervical fractures. Patients with AS are highly susceptible to extensive neurologic injuries and spinal deformities after cervical fractures from even minor traumatic forces. These injuries are uniquely complex, require careful imaging assessment, and aggressive surgical management to optimize spinal stability and functional outcomes.

Acute cervical fractures in ankylosing spondylitis: an opportunity to correct preexisting deformity

STUDY DESIGN

A new technique for the management of traumatic cervical fracture in patients with chin-on-chest deformity in ankylosing spondylitis is presented. OBJECTIVE.: To present a new surgical technique for acute deformity correction through cervical fractures in the setting of kyphotic deformities.

SUMMARY OF BACKGROUND DATA

Cervicothoracic kyphotic deformity in ankylosing spondylitis is currently treated with extension osteotomy in an elective setting. In elective extension osteotomies, the surgeon manipulates the head to generate osteoclasis, temporarily producing an unstable cervical fracture. Cervical fractures in ankylosing spondylitis are highly unstable and frequently associated with neurologic compromise. Most reports describe either no reduction and fixation in situ or reduction in preoperative traction followed by fixation.

METHODS

A 60-year-old man with chronic ankylosing spondylitis and profound kyphotic deformity suffered a traumatic lower cervical spine fracture. He was treated with an acute cervical spine extension osteotomy through the fracture site using an anterior lengthening bar modification to a halo vest. The anterior lengthening bar allows controlled extension of the neck without manual manipulation by the surgeon.

RESULTS

This patient presented with a chin-brow angle of approximately 90 degrees and was corrected to approximately 5 degrees to 8 degrees . No immediate or delayed complications were seen. After halo vest treatment for 3 months, an excellent postural correction was obtained.

CONCLUSION

Surgical extension osteotomy in the lower cervical spine through the fracture site using the anterior lengthening bar-halo extension brace seems to be a safe method for correcting spine flexion deformity in ankylosing spondylitis after traumatic fracture.

A revisitation of distractive-extension injuries of the subaxial cervical spine: a cadaveric and radiographic soft tissue analysis

STUDY DESIGN

A biomechanical cadaveric and radiographic analyses.

OBJECTIVE

To identify and elaborate on specific anatomic soft tissue structures that are injured during various stages of a distractive-extension (DE) injury of the lower cervical spine and their role in angulation and posterior translation.

SUMMARY OF BACKGROUND DATA

Two DE stages (DES) of injury to the cervical spine have been described as follows: DES-1 and DES-2. However, the role of the soft tissue structures involved in such injuries has not been clearly defined. Furthermore, the importance of the facet capsules in DES injuries has not been well-addressed.

METHODS

A total of 15 adult cadaveric motion segments of the lower cervical spine were isolated and tested. Motion segments were mounted, with the cervical spine in extension, such that a distractive load was applied through the cephalad body. Anatomic supporting structures were serially sectioned from anterior to posterior to simulate varying degrees of soft-tissue disruption as occurring with the DE mechanism. Specimens were loaded at each stage of injury and measurements of angulation and posterior translation were recorded from fluoroscopic images by 2 independent observers.

RESULTS

A strong correlation was noted between the 2 sets of independent measurements. A statistical significant difference was noted between the degree of soft-tissue injury to the change in angulation and posterior translation (P < 0.001). The mean change in angulation and posterior translation was significantly greatest following sectioning of the anterior aspect of the facet capsules and to a lesser extent following sectioning of the posterior longitudinal ligament (PLL) (P < 0.001). A greater mean percent change between sequential sectioning of soft tissue structures was largely associated with posterior translation rather than angulation.

CONCLUSION

Sequentially greater angulation and posterior translation was seen after serial sectioning of the anterior facet capsule and to a lesser degree the PLL. This suggests that there are in fact 2 main "tethers" to angulation and posterior translation in the DE injury model, with the anterior facet capsule being the major stabilizer and to a lesser degree the PLL. Thus, based on our findings, it would appear that an expansion of the DE injury classification may be warranted, based on angulation and posterior translation, and regarded as DES-1, DES-2A, DES-2B, and DES-3. Such categorization based on the degree of angulation and posterior translation may prove advantageous in designing appropriate treatment strategies to address DE injuries of the lower cervical spine; however, further studies are needed to validate the clinical applications of such categorization.

Pitfalls and complications in the treatment of cervical spine fractures in patients with ankylosing spondylitis

Patients with ankylosing spondylitis are at significant risk for sustaining cervical spine injuries following trauma predisposed by kyphosis, stiffness and osteoporotic bone quality of the spine. The risk of sustaining neurological deficits in this patient population is higher than average. The present review article provides an outline on the specific injury patterns in the cervical spine, diagnostic algorithms and specific treatment modalities dictated by the underlying disease in patients with ankylosing spondylitis. An emphasis is placed on the risks and complication patterns in the treatment of these rare, but challenging injuries.

Use of hinged rods for controlled osteoclastic correction of a fixed cervical kyphotic deformity in ankylosing spondylitis

✓Cervical kyphosis in patients with ankylosing spondylitis (AS) can be severely disabling. Surgical treatment of this disorder is technically demanding, however, with a considerable risk of neurological and vascular injuries. The extension osteotomy is a well-described posterior treatment for this condition, but this approach presents the risk of acute subluxation and spinal column translation during the reduction. In this paper, the authors report the novel use of a hinged posterior cervical rod for controlled correction of cervical kyphosis. After sustaining a traumatic spinal fracture, a 57-year-old man with AS developed a delayed cervical flexion deformity. The patient was neurologically intact, but suffered from disabling impairment in horizontal gaze and activities of daily living, and from neck pain. The patient subsequently underwent surgical correction via a posterior cervical extension osteotomy at C7–T1 with manual extension of the neck for osteoclastic reduction of the cervical kyphosis. Controlled correction was performed by using a hinged rod affixed to posterior cervical and thoracic screws, allowing for free sagittal correction while restricting translational forces. Once the desired angle of correction was achieved, the hinge connector was locked, transforming the rod into a rigid device for permanent internal fixation. The use of hinged rods in cervical kyphosis correction provides a controlled method for reduction at the osteotomy site, decreasing the risk of neurological injury.

A treatment algorithm for the management of cervical spine fractures and deformity in patients with ankylosing spondylitis

Object

Patients with ankylosing spondylitis (AS) who present with cervical spine fractures represent a unique challenge to spine surgeons. These injuries often result in neurological deficits that necessitate early and aggressive surgical management with posterior and/or anterior fixation. The authors introduce a clinical problem-solving algorithm to assist in the surgical management of instability and deformity in this exigent patient population.

Methods

Thirteen patients with AS and fractures of the cervical spine were radiographically evaluated to determine if spinal realignment was obtainable with cervical manipulation or traction. Seven patients had flexible deformities that were stabilized with either anterior or posterior fixation only, and 6 patients had fixed deformities and required circumferential anterior–posterior instrumentation. All patients were observed for neurological outcome, radiographic evidence of bone fusion, and complications.

Results

With the use of the authors' treatment algorithm, all patients were able to achieve satisfactory spinal realignment and bone fusion; 92% of patients achieved postoperative stability or improvement in Nurick and modified Japanese Orthopaedic Association scale scores. One patient experienced neurological deterioration following surgery, and 1 patient died at an acute rehabilitative facility following discharge.

Conclusions

Patients with AS are highly susceptible to extensive neurological injury and spinal deformity after sustaining cervical fractures from even minor traumatic forces. These injuries are uniquely complex in nature and require considerable scrutiny and aggressive surgical management to optimize spinal stability and functional outcomes. The authors' clinical problem-solving algorithm will assist spine surgeons in providing optimal care in this difficult population.

Considerations for airway management for cervical spine surgery in adults

Surgery on the cervical spine runs the gamut from minor interventions done in a minimally invasive fashion on a short-stay or ambulatory basis, to major surgical undertakings of a high-risk, high-threat nature done to stabilize a degraded skeletal structure to preserve and protect neural elements. Planning for optimum airway management and anesthesia care is facilitated by an appreciation of the disease processes that affect the cervical spine and their biomechanical implications and an understanding of the imaging and operative techniques used to evaluate and treat these conditions. This article provides background information and evidence to allow the anesthesia practitioner to develop a conceptual framework within which to develop strategies for care when a patient is presented for surgery on the cervical spine.

Successful nonoperative treatment of a three-column thoracic fracture in a patient with ankylosing spondylitis: existence and clinical significance of the fourth column of the spine

STUDY DESIGN

A case report.

OBJECTIVE

To report the successful nonoperative management of a patient with progressive ankylosing spondylitis who sustained a three-column flexion-distraction injury of the upper thoracic spine with an intact sternal-rib complex, thereby emphasizing the existence and clinical relevance of the fourth-column concept in such patients.

SUMMARY OF BACKGROUND DATA

Three-column injuries of the cervical and lumbar spine are typically unstable and require surgical stabilization. Patients with ankylosing spondylitis are at an increase risk to sustain three-column injuries of the spine due to their progressive inflammatory disease, a state that renders the spine brittle and alters its biomechanical function. A fourth-column model of the thoracic spine has been proposed and incorporates the sternal-rib complex; however, such a model has rarely been addressed in the literature and its role regarding three-column upper thoracic spine injury with an intact sternal-rib complex in patients with ankylosing spondylitis is unknown. METHODS.: A 68-year-old white man with ankylosing spondylitis and Pickwickian body habitus sustained a three-column flexion-distraction injury at T5 following a ground-level fall. The patient complained of midthoracic back pain; however, he was neurologically intact and ambulated without aids.

RESULTS

Because of the patient's numerous active medical issues that substantially increased his perioperative risks combined with symptomatic improvement of his pain, the patient refused surgical stabilization. In addition, because of the patient's body habitus and pulmonary issues, external brace immobilization was not tolerated. At 17 months of follow-up, the patient remained neurologically intact, ambulated well, his midthoracic back pain had subsided, and no progressive kyphosis was noted.

CONCLUSIONS

This case confirms the existence and clinical relevance of the fourth column of the thoracic spine and its role in providing added spinal stability in the patient with ankylosing spondylitis. As such, it is still possible to achieve a favorable clinical outcome in a select subpopulation of patients with ankylosing spondylitis that sustain three-column flexion-distraction injuries who are neurologically intact and are not candidates for surgical stabilization.