Spinal fractures in patients with ankylosing spinal disorders: a systematic review of the literature on treatment, neurological status and complications

Abstract

The ankylosed spine is prone to fracture after minor trauma due to its changed biomechanical properties. Although many case reports and small series have been published on patients with ankylosing spondylitis (AS) suffering spine fractures, solid data on clinical outcome are rare. In advanced diffuse idiopathic skeletal hyperostosis (DISH), ossification of spinal ligaments also leads to ankylosis. The prevalence of AS is stable, but since DISH may become more widespread due to its association with age, obesity and type 2 diabetes mellitus, a systematic review of the literature was conducted to increase the current knowledge on treatment, neurological status and complications of patients with preexisting ankylosed spines sustaining spinal trauma. A literature search was performed to obtain all relevant articles concerning the outcome of patients with AS or DISH admitted with spinal fractures. Predefined parameters were extracted from the papers and pooled to study the effect of treatment on neurological status and complications. Ninety-three articles were included, representing 345 AS patients and 55 DISH patients. Most fractures were localized in the cervical spine and resulted from low energy impact. Delayed diagnosis often occurred due to patient and doctor related factors. On admission 67.2% of the AS patients and 40.0% of the DISH patients demonstrated neurologic deficits, while secondary neurological deterioration occurred frequently. Surgical or nonoperative treatment did not alter the neurological prospective for most patients. The complication rate was 51.1% in AS patients and 32.7% in DISH patients. The overall mortality within 3 months after injury was 17.7% in AS and 20.0% in DISH. This review suggests that the clinical outcome of patients with fractures in previously ankylosed spines, due to AS or DISH, is considerably worse compared to the general trauma population. Considering the potential increase in prevalence of DISH cases, this condition may render a new challenge for physicians treating spinal injuries.

Evolution of traumatic spinal cord injury in patients with ankylosing spondylitis, in a Romanian rehabilitation clinic

“…Very few papers depicted and analyzed cohorts of patients with AS-associating spine fractures, from a single medical center or region; 17,[21][22][23] other papers were systematic literature reviews. 11,18 Most of these retrospective descriptive papers (about 98%) brought out-similarly with our study-only small series of AS subjects who suffered spine fractures: 18 patients, 24 or 12 cases 25 during a 10-year period and 12 subjects 26 in 6 years. A plausible explanation for the scarcity of the cases consists of the epidemiological pattern of AS (mentioned earlier), making it difficult to establish a consistent cohort of patients in a single medical center.…”

“…[14][15][16][17] In about two third of the cases, the main etiology consists of falls from standing or sitting position, the cervical region being the most frequently injured (in about 81% cases). 18,19 SUBJECTS AND METHODS This observational study aims to depict the clinical profile and functional outcomes of patients with AS who suffered a spinal cord injury (AS-SCI), and to evaluate the incidence of AS-SCI among the cohort of all consecutive subjects with traumatic SCI, admitted in a Romanian rehabilitation clinic.…”

Spinal hyperostosis in humans and companion animals

“…Decreased range of spinal motion and reduced flexibility due to DISH can result in spinal fractures even after minor trauma (Callahan & Aguillera 1993;Belanger & Rowe 2001;Sreedharan & Li 2005). Remarkably, the fracture plane found in patients with DISH is most frequently located through the vertebral body, while in patients with ankylosing spondylitis the fracture plane is most often through the disc (Westerveld et al 2009;Verlaan et al 2011a). These fractures in patients with DISH tend to be unrecognized, unstable, and associated with treatment delays and permanent neurologic deficits (Callahan & Aguillera 1993;Belanger & Rowe 2001).…”

“…Westerveld et al (2009) described in their systematic review a high percentage (51.2%) of hyperextension fractures in patients with DISH compared to the percentage (0.2%) described by Magerl et al (1994) in a group of 1445 spine fractures. Considering the potential increasing prevalence of DISH in western society, this disorder may render an emerging challenge for physicians working with spinal injuries (Westerveld et al 2009). …”

Surgical Treatment After Spinal Trauma in Patients with Ankylosing Spondylitis

“…The diffuse paraspinal ossification and inflammatory osteitis of advanced AS creates a fused, brittle spine that is susceptible to fracture (De Peretti et al, 2004;Einsiedel et al, 2006;Hanson and Mirza, 2000;van der Horst-Bruinsma, 2006;Taggard ans Traynelis, 2000;). Patients suffering from AS may undergo a fracture with minimal (Graham and Van Peteghem, 1989;Hanson and Mirza, 2000;Trent et al, 1988;Whang et al, 2009), or even no history of injury (Olerud et al, 1996;Westerveld et al, 2009;Yau and Chan, 1974).…”