an occult fracture in a ankylosing spondylitis patient.pdf

8/10/2019 An Occult Fracture in a Ankylosing Spondylitis Patient.pdf

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KISEP Case Reports J Korean Neurosurg Soc 26 146-151, 1997

An Occult Fracture in a Ankylosing Spondylitis Patient

Chang Myong Choi, M.D., Ji Ho Yang, M.D., Il Woo Lee, M.D.,Chul Ku Jung, M.D., Joon Ki Kang, M.D.

Department of Neurosurgery, Taejeon St Marys Hospital,Catholic Universi ty Medical College,Taejeon, Korea

= Abstract =

KEY WORDS

Case Report

A 61-year-old male fell off a 3-m high roof landing on

his head and back. The patient was first treated at a localclinic before transfer to our hospital. In the emergency room

he was stuporous and irritable. Neurological examination

revealed no motor weakness. Cervical spine X-ray showed

hyperlordotic curvature and bamboo spine without fracture.

Brain CT scan showed hemorrhagic hyperdense lesions in

the right frontal region, the cerebellar vermis and the fourthventricle Fig. 1 . Respiration was controlled with intubation

and the man was restrained due to uncooperative irritable

behavior. The patient was treated conservatively with a

course of bed rest, hypertonic solutions, anticonvulsants,

and analgesics. He regained the consciousness alert and his

general condition was improved over next three weeks. He

then, suddenly became paraplegic during wheel-chair am-

bulation with assistance by his family members.

Examination Paraplegia with trace movement to painfulstimuli was observed. No pain or temperature sense below

the T12 dermatome were evident. Anal and bulobocavernous

reflexes were also lost. Neuroradiology Review of T-L spine radiographs de-

monstrated a supspicious transverse linear fracture through

the disc and juxta-end plate region between the T11 andT12 vertebrae with typical findings of ankylosing spondylitis

Fig. 2 . An MRI scan revealed posterior compression of

spinal cord by a bony spicule at the T12 level with signalchange in marrow Fig. 3 .

Operation The patient underwent small laminectomy

and posterior spinal fusion with a rod system. There was a

transverse fracture line extending posteriorly to the laminae

and spinous process. A bony spicule was impinging upon

the dura which exhibited bluish discoloration and swelling.A small amount of epidural hematoma was found. There was

calcification involving apophyseal joints with interspinous

ligaments and ligamenta flava resulting in ossification of

the spaces between the dorsal arches. The small bony spicule

impining upon the dura was removed. A spinal fusion was

performed with rods on two segments above and three

segments below the lesion using sublaminar hooks and

wires. The hook entry site was made by use of an air drill

Fig. 4 .Postoperative Course The patient was nursed on a conve-

ntional hospital bed and turned by log rolling. No significant

improvement was observed in the immediate postoperativecourse. Neurologic symptoms improved gradually and the


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Chang Myong Choi Ji Ho Yang Il Woo Lee Chul Ku Jung Joon Ki Kang

26 1 1997 147

Fig. 1. CT scan obtained on admission shows hemorrage in the right frontal region, cerebell ar vermis, and the fourth ventricle.

Fig. 2. Retrospective examination of films on admission showing suspicious transverse linear fracture line through the ossifieddisc space and juxta-end plate region between the T11 and T12 vertebrae of bamboo spine.


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Fig. 3. CT and MRI examinations taken after paraplegia. Computerized tomography section through the T12 pedicle showsdisruption of the posterior arch. MRI scan demonstrates marrow change and a bony spicule impinging upon cord withincreased signal intensity in the T12 area.

Fig. 4. Postoperative radiograph The fractured spine was fused, two levels above and three levels below the lesion, by a rodsystem with sublaminar hooks and wires.


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patient could walk without assistance approximately 3 months

after the operation. After two years , the independent activities

of daily living ADL were possible, but the patient com-

plained of paresthesia and radiculopathy in both legs.

Discussion

Ankylosing spondylitis Marie-Strmpel arthritis resultsin development of a rigid spinal column bamboo or poker

sign , often severly deformed by exaggerated thoracic

kyphosis and cervical lordosis 25)30) . The ankylosed spine of

a patient with chronic ankylosing spondylitis is more prone

to fracture than the normal spine15)

. Since most afflicted patients remain physically active, the risk of injury causingfracture and spinal contusion is significant 13)14)23)31) . The

trauma which causes the fracture is often minor. Fourteen

of 22 fractures resulted from minor falls in the series of

Thomas et al 27) .

The pathology of ankylosing spondylitis has been des-

cribed in detail elsewhere 8). Although diarthrodial extremities

and spinal joints are frequently involved, the proliferative

process which results in spinal ankylosis predominently

affects ligamentous attachments and intervertebral discs.

Chondroidal metaplasia is followed by calcification andossification involving the apophyseal joints, as well as the

anulus fibrosus, and the anterior, but not always the posterior,

longitudinal ligaments 9). Interspinous ligament and ligam-

entum flavum involvement is not unusual, resulting in

ossification of the spaces between the doral arches. Apo-

physeal joint involvement begins with erosive changes that

progress to cartilage destruction, joint narrowing, and ank-

ylosis. Serial biopsies have demonstrated that inflammatorysynovial proliferation generates a thickened vascularized

fibrous layer which is thought to disrupt adjacent cartilage

and bone 9)11) . P.R. Weintstein et al found 13 of the 20

fractures and destructive vertebral lesions to be located in

the intervertebral discs 21) . This finding suggests a selective

vulnerability of ossified discs to traumatic stress. Disc ossi-fication may be incomplete, with fibrous and cartilaginous

tissue persisting centrally and posteriorly, creating a weaker

structure than the adjacent vertebral bodies. Such transdiscalfractures may be more difficult to visualize radiographically

than fracture lines passing through the bodies or ppedicles.

Mostoften the posterior elements are fused and fracture

lines extend posteriorly to the lamina and spinous process31)

.Ankylosis of the spine results in biochemical alterations

that predispose the patient to serious spinal injury. Alth-

ough the degree of precipitating trauma may be small, the

ensuing damage to the spine and spinal cord may be exten-

sive 12) . Fractures through the cervical spine in ankylosing

spondylitis have been well documented in the literature,usually occurring through the ossified disc space or ver-

tebral body and extending posteriorly through the posterior

elements 3)19)20)31) . The existence of similar fractures in thethoracic and lumbar spine has not been emphasized as clearly,

probably because of confusion with inflammatory changes

as well as the lack of serious neurologic impairment. Lower

thoracic fractures are also quite unstable, and even minor

mechanical stresses may cause dangerous dislocation of thefracture margins 6). In the ankylosed spine where compen-satory disc and facet joint movement in response to load is

prevented, it seems likely that bony deformation and, the-

refore, stress fractures would tend to occur most frequently

at the thoracolumbar and lumbosacral junctions 2)7)10)17)29)32) .

Once a fracture has occurred, the long rigid lever arm

represented by the ankylosed spine tends to concentrate

stress and deformation at the fracture site. This may contribute

subsequently to the formation of pseudoarthrosis. Disc space

or end plate horizontal fractures with associated posterior

element involvement are common in long-standing ankylosisspondylitis and reflect the bio-mechanical effect of trauma

or subclinical stress on a rigid spine 20) .

An occurrence of minor spinal trauma can lead to problems

in diagnosis. Fractures in ankylosing spondylitis can be

overlooked because ligamentous and disc ossification fre-

quently obscure transverse and oblique fractures on plain

radiographs 21) . In our case, the delay in diagnosis was due

to the associated severe head injury which caused the failureof physicians to detect subtle spinal lesion during initial

evaluation. When a patient is represented to a physician

who is unfamiliar with this type of problem, the diagnosis

of spinal fracture may not be considered, or it may be

dismissed readily when radiographs fail to demonstrate a

spinal fracture. The difficulty in radiographic visualizationof these fractures is a potentially serious problem 15)27) . A

delay in correct radiographic diagnosis at emergency room

can result in subsequent development of spinal cord damage.Delayed onset of neurologic deficit due to instability was

found to be present in 2 cases out of 13 patients 21). Fractures

can frequently occur as a result of even minimal trauma

and may be associated severe neurologic deficits. Fracturesthat occur in ankylosing spondylitis are potentially lethal


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and associated with severe spinal cord injury. Although the

majority of fractures occur in the lower cervical spine, they

may occur at any levels and often result in quadriple-

gia1)13)17)27)29) . Radiographically, the fractures most commonly

occur through the intervertebral disc space. However hori-zontal fractures through the vertebral bodies adjacent to the

vertebral endplate, similar to the Chance or seat belt fra-

cture, with extension through the posterior elements mayalso occur 21) .

The ankylosed spine fractures like a long bone, and if

the fracture is through and through involving the posterior

elements of the spine, it is considered to be unstable due to

the loss of ligamentous support3)4)15)27)

. The loss of normalspinal segmental flexibility and the accompanying osteo-

porosis predispose the ankylosed spine to injury 22)31) . It is

essential that this borne in mind during the initial handling

of the patient and during the period of fracture healing. The

importance of careful immobilization can not be stressed

too highly. All patients with known ankylosing spondylitis

should be warned by their physicians of the inordinate

susceptibility to spinal fractures. These patients after trauma,

or even if they note spontaneous back pain associated with

a jerking or grating sensation, should immobilize themselves

and immediately seek medical attention, as recommended by Osgood et al. This is most imperative with cervical and

lower thoracic sensations 18) .

Radiographic recognition in the patient presenting sudden

focal pain and tenderness is important for selection of proper

therapy. If bony irregularity and sclerosis begin to develop,

a pseudoarthrosis rather than a pyogenic or granulomatous

infection should be suspected and rigid internal fixation

and surgical fusion may be required 20)24) . Fractures of thethoracic and lumbar spine in ankylosing spondlyitis generally

have fewer neurologic complications than cervical fractures

and heal with moderate immobilization. Conservative treat-

ment with external support by a brace is associated with a

high rate of fracture union and a low rate of complications

and mortality. Surgical intervention may be indicated fortreatment of incomplete or evolving neurologic lesions, and

in the management of fractures that can not be stabilized

by nonopera tive means 5) . We think that this case report presents a challenge to physicians for management of brain-

injury associated ankylosing spondylitis where thorough

examination of radiographs are mandatory in the initial

evaluation.

Conclusion

Although complications are uncommon from minor spinal

trauma in patients with ankylosing spondylitis, they should be kept in mind, especially in head injured patients. Thorough

clinical and roentgenographic examination of the entire ver-

tebral column is recommended in patients with ankylosingspondylitis who have sustained injury.

References

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