Thoracic vertebral body fracture after total hip replacement in diffuse idiopathic skeletal hyperostosis

Three-Column Spine Fracture After Direct Anterior Total Hip Arthroplasty: A Case Report

CASE

This report describes a case of an unstable spine fracture in the setting of severe degenerative disc disease in a patient who underwent a direct anterior total hip arthroplasty (THA). The patient was positioned supine on a standard operating room table and postoperatively complained of back pain and neurologic deficits. Advanced imaging identified a T12-L1 extension-distraction injury, and the patient ultimately required surgical decompression and spinal fusion.

CONCLUSION

This case outlines a serious complication of THA that can occur in patients with degenerative spine disease and highlights the importance of taking precautions to reduce stress on the spine during surgery.

Lumbar chance fracture after direct anterior total hip arthroplasty

This report describes a patient with ankylosing spondylitis (AS) who underwent total hip arthroplasty (THA) by the direct anterior approach and sustained a L4-5 extension fracture dislocation with neural deficits. A magnetic resonance imaging revealed an epidural hematoma at the site of the fracture causing critical stenosis. The patient was taken to the operating room for a L3-S1 posterior decompression with L2-pelvis posterior spinal fusion. AS and diffuse idiopathic skeletal hyperostosis create a stiff spine that predisposes to fractures because of the larger moment arms experienced than normal spines. The arthroplasty surgeon performing THA should be aware and take precautions to reduce stress on the spine.

Hemoptysis as the Presenting Clinical Sign of a T8-T9 Spine Fracture with Diffuse Idiopathic Skeletal Hyperostosis Changes

Diffuse idiopathic skeletal hyperostosis (DISH) is a noninflammatory degenerative disease that affects multiple spine levels and, in combination with osteoporosis, makes vertebrae more prone to fractures, especially in elderly people. We describe a rare case of thoracic fracture in an ankylosed spine in which hemoptysis was the only clinical sign. The patient (age in the early 80s) presented with chest pain and a cough associated with hemoptysis. The patient had no complaints of back pain and no neurological symptoms. Computed tomography (CT) angiography of the chest revealed changes consistent with DISH, with fractures at the T8 and T9 vertebra as well as lung hemorrhage or contusion in the right lung base. CT and magnetic resonance imaging of the thoracic spine showed similar findings, with a recent T8-T9 fracture and DISH changes. The patient underwent percutaneous pedicle screw fixation from T7 to T11 and remained neurologically intact with an uneventful postoperative course.

Iatrogenic Lumbar Vertebral Fracture during Osteosynthesis for a Trochanteric Fracture of the Femur in Diffuse Idiopathic Skeletal Hyperostosis

Vertebral fractures occur with only slight trauma in patients with diffuse idiopathic skeletal hyperostosis (DISH). However, a lumbar vertebra fracture, due to an intraoperative body position has not been previously reported. An 87-year-old woman with kyphosis sustained a left trochanteric fracture of her femur. The patient was placed in a supine position during the operation. Postoperatively, the patient experienced severe right thigh pain. Magnetic resonance imaging revealed an L4 vertebral fracture. Computed tomography revealed ankylosis from the upper thoracic spine to the sacrum. While in a supine position under general anesthesia, the contact of the patient's lower back with operating table likely created a fulcrum at her lumbosacral spine acting as a long lever arm, bearing the mass of her upper body. We performed L1-S2 posterior stabilization. DISH patients with kyphosis placed in a supine position have an increased risk for lumbar vertebral fracture.

Hyperextension injuries of the thoracolumbar spine in diffuse idiopathic skeletal hyperostosis

STUDY DESIGN

Retrospective study of a consecutive series of patients with thoracolumbar hyperextension injuries (TLHIs) complicated by diffuse idiopathic skeletal hyperostosis (DISH) presenting to a single institution during a 9-year period.

OBJECTIVE

Assess epidemiological data, trauma mechanism, injury characteristics in hyperostotic spines, and short-term outcome.

SUMMARY OF BACKGROUND DATA

An increase in TLHIs complicated by DISH was observed. In current literature, only case reports and small case series touch this topic.

METHODS

All patients with TLHIs in the setting of DISH between January 2002 and December 2010 were reviewed retrospectively. Clinical and radiographical data during hospitalization including computed tomographic scans of all patients were analyzed as to epidemiological issues, trauma characteristics, neurological deficits, and short-term outcomes. Statistical analysis was performed to assess factors related to trauma characteristics.

RESULTS

Twenty patients with 23 TLHIs were analyzed. Twelve injuries involved the thoracic region; 1, the lumbar region; and 10, the thoracolumbar junction. A total of 85.7% of injuries were due to high-energy impact. The distribution of transdiscal and transosseous injuries was almost equal (13/10). Patients with DISH with vertebral body fractures were significantly older than those with transdiscal injuries (78.3 yr vs. 69.8 yr, P < 0.026). Post-traumatic neurological deficit was present in 22.7% patients. Neurological complications did not occur in low-energy injuries. On average, spines were posteriorly stabilized over 2.1 segments. Twenty percent of the patients died within 3 months (average age, 80.7 ± 5.1 yr, range, 76-88 yr).

CONCLUSION

To our knowledge, this is the largest series of TLHIs in DISH-altered spines in literature. The study helps to understand controversial findings in literature about morphological properties of TLHIs in DISH-affected spines. Surgeons should be aware of preexisting alterations in traumatized spines and the impact on therapeutic decisions. Because of the "aging population" and implications of metabolic diseases on an "aging spine," the incidence of TLHIs in DISH will probably rise.