Review Question - QID 215545

Ankylosing Spondylitis QID: 215545 (OBQ20.134)

QID 215545 (Type "215545" in App Search)

A 59-year-old male presents with neck pain after he slipped and fell on black ice. He does not recall hitting his head during the fall. He denies pain elsewhere. On examination, there is 5/5 motor strength in his major muscle groups and there are no sensory deficits. His imaging is shown in figure A. Which of the following statements is true regarding his condition and injury?

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There is rarely a delay in diagnosis of spinal injuries compared to the general population

21/1284

Secondary neurologic deficits are uncommon

47/1284

There are lower mortality and complication rates compared to the general population

15/1284

Long posterior instrumentation and fusion with or without decompression is the recommended treatment

90%

1155/1284

There is a low rate of successful fusion following operative treatment

32/1284

Select Answer to see Preferred Response

The patient is presenting with an unstable C6 vertebral body fracture in the setting of pre-existing ankylosing spondylitis (AS), which is ideally treated with a long-construct posterior instrumented fusion with or without decompression.

AS is a seronegative spondyloarthropathy that results in progressive fusion of the spinal column. Over 90% of patients will have a positive HLA-B27 antigen. This finding combined with bilateral sacroiliitis confirms the diagnosis. Due to the longer lever arm of the spinal column, there is a high incidence of three-column, unstable spinal injuries following trivial falls. These injuries should be treated with a long-construct posterior instrumented fusion with or without decompression.

Rustagi, et al. performed a systematic review of fractures in patients with ankylosing spinal disorders. They reported males over the age of 60 years were most commonly affected and C5-7 were the most commonly injured spinal levels. The authors also reported mortality to be as high as 34% in some studies with complications as high as 84% (most commonly pneumonia, respiratory failure, and pseudoarthrosis). They concluded patients with ankylosing spinal conditions to be at high risk of unstable fractures following trivial falls and recommend surgical fixation despite the presence of osteoporosis.

Westerveld, et al. performed a systematic review, which included 93 articles (400 patients), of spinal fractures in patients with ankylosing spondylitis and DISH. They reported most injuries occurred after low-energy falls with the cervical spine being the most commonly affected region. Additionally, there was a high neurologic deficit rate (67.2% AS and 40% DISH) with progressive deficits being common. The authors concluded fractures in previously ankylosed spines are associated with significantly worse outcomes compared to the general population.

Figure A is a sagittal CT of the cervical spine demonstrating a fracture through the C6 vertebral body with displacement.

Incorrect answers
Answer 1: Due to the low-energy fall mechanism and subtle findings on radiographs, missed or delayed diagnoses are common with spinal injuries in ankylosed spines.
Answer 2: There is a high rate of secondary neurologic deficits following spine injuries in ankylosed spines.
Answer 3: There are high mortality and complication rates following treatment for spinal injuries in ankylosed spines.
Answer 5: Despite there being concerns for fixation failure due to osteoporosis, there are high rates of successful spinal fusion after surgical treatment.